A single center experience with minimally invasive approaches in congenital cardiac surgery

Abstract

Background: Cardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved. Methods: We performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range). Results: Between September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14-47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7-37.8) than those who were not (24.2, 20.8-29.3) (P=0.009). Conclusions: Minimally invasive approaches for congenital cardiac conditions require a team approach.Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.

Minimally Invasive Approach for Cardiac Hemangioma Resection in a Teenager

“…In our experience, patients with a body mass index <35 kg/m 2 , fewer than 3 prior median sternotomies, no prior conduit placement, and no evidence of dextrocardia or mesocardia are potential candidates. 5 Theoretical benefits of the LAMI approach include a smaller incision, avoidance of sternal precautions, and improved cosmesis. Early outcomes continue to mirror those performed through median sternotomy.…”

“…4 We have demonstrated its utility by applying it to fibroelastoma resection, banding of the dilated pulmonary annulus for landing transcather valves, and for pulmonary artery translocation for treatment of anomalous aortic origin of a coronary artery. 5 Our previously described technique has even been successfully adopted by other groups, demonstrating its translatability. 6 We now consider LAMI for all patients requiring operations of the RVOT or pulmonary valve.…”

Whole-Chest Three-Dimensional Modeling Aids Hybrid Pulmonary Valve Replacement Following Double Switch Operation

“…3D imaging has allowed for proper surgical approach and decision making prior to procedures, especially important for surgical incision placement when accessing the heart in minimally invasive approaches. 7 Previous reports of 3D imaging for pulmonary valve replacements have focused on the anatomy of the right ventricular outflow tract and valve landing zone to improve procedural success. However, in hybrid per-ventricular approaches, surgical sheath placement is paramount for procedural success and can be difficult in patients with abnormal ventricular looping anatomy.…”

Minimally invasive cardiac surgery: in the pursuit to treat more and hurt less

“…It is somewhat expected that besides unroofing, many of the other proposed repaired techniques, for example coronary reimplantation or pulmonary translocation, would have a high degree of difficulty to be applied through a mini-incision due to their complexity. In the article of Nellis et al (7), this justifies the relevant conversion rate (36%) to the conventional method, as well as the continuous increase on the graphical representation of cardiopulmonary bypass time (CPB) for subsequent AAOCA procedures.…”

“…These approaches in CHD patients have to overcome several other barriers besides the learning curve, such as patient size (in small pediatric patients), and limitations in manufacturing surgical instrumentation (6) approaches in CHD patients continues to grow and it is encouraging that more data come to light supporting the safety and the applicability of these techniques along with the comparable mortality, the expedited recovery and the reduced LOS. Such an article we come across in the current issue of the journal by Nellis and coworkers (7). In this single institution retrospective review, the authors report on their initial experience from a 3-year program focused in MICS in CHD patients.…”