Objective: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. Methods: From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. Results: Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. Conclusions: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly. #

Background-Ventricular restraint is a nontransplantation surgical treatment for heart failure. The effect of varying restraint level on left ventricular (LV) mechanics and remodeling is not known. We hypothesized that restraint level may affect therapy efficacy. Methods and Results-We studied the immediate effect of varying restraint levels in an ovine heart failure model. We then studied the long-term effect of restraint applied over a 2-month period. Restraint level was quantified by use of fluid-filled epicardial balloons placed around the ventricles and measurement of balloon luminal pressure at end diastole. At 4 different restraint levels (0, 3, 5, and 8 mm Hg), transmural myocardial pressure (P tm ) and indices of myocardial oxygen consumption (MV O 2 ) were determined in control (nϭ5) and ovine heart failure (nϭ5). Ventricular restraint therapy decreased P tm and MV O 2 , and improved mechanical efficiency. An optimal physiological restraint level of 3 mm Hg was identified to maximize improvement without an adverse affect on systemic hemodynamics. At this optimal level, end-diastolic P tm and MV O 2 indices decreased by 27% and 20%, respectively. The serial longitudinal effects of optimized ventricular restraint were then evaluated in ovine heart failure with (nϭ3) and without (nϭ3) restraint over 2 months. Optimized ventricular restraint prevented and reversed pathological LV dilatation (130Ϯ22 mL to 91Ϯ18 mL) and improved LV ejection fraction (27Ϯ3% to 43Ϯ5%). Measured restraint level decreased over time as the LV became smaller, and reverse remodeling slowed. Conclusions-Ventricular restraint level affects the degree of decrease in P tm , the degree of decrease in MV O 2 , and the rate of LV reverse remodeling. Periodic physiological adjustments of restraint level may be required for optimal restraint therapy efficacy.

Conversion to a full sternotomy occurs infrequently during minimal-access cardiac surgery. Upper hemisternotomy conversions are usually urgent after crossclamp removal and are often associated with serious morbidity and mortality. Conversely, lower hemisternotomy conversions are performed electively in the prebypass period because of poor exposure and are not associated with complications.

Axillary intra-aortic balloon pump therapy provides excellent support for selected patients as a bridge to transplant. The majority of the patients were successfully bridged to transplant and discharged. Although this therapy has been described in previous studies, this is the largest series to incorporate a regimen of aggressive ambulation with daily measurements of distances walked.