Research
Minimally invasive endoscopic beating mitral valve surgery with cardiopulmonary support
By Abdelrahman Abdelbar, Palanikumar Saravanan, Joseph Zacharias
In this video, the authors demonstrate the advantage of minimally invasive endoscopic beating mitral valve surgery with cardiopulmonary support in complex redo cases. This technique can simplify the procedure in the hands of experienced teams with minimally invasive surgery, especially with patients deemed to be at high risk for redo-sternotomy. The authors have moved to performing beating heart mitral surgery even for first time cases.
How to start a minimal access mitral valve program
By Mr S Hunter BMedSci BM BS FRCS FRCS(CTh)
The seven pillars of governance established by the National Health Service in the United Kingdom provide a useful framework for the process of introducing new procedures to a hospital. Drawing from local experience, the author present guidance for institutions considering establishing a minimal access mitral valve program. The seven pillars of governance apply to the practice of minimally invasive mitral valve surgery, based on the principle of patient-centred practice. The author delineate the benefits of minimally invasive mitral valve surgery in terms of: “clinical effectiveness”, including reduced length of hospital stay, “risk management effectiveness”, including conversion to sternotomy and aortic dissection, “patient experience” including improved cosmesis and quicker recovery, and the effectiveness of communication, resources and strategies in the implementation of minimally invasive mitral valve surgery. Finally, the author have identified seven learning curves experienced by surgeons involved in introducing a minimal access mitral valve program. The learning curves are defined as: techniques of mitral valve repair, Transoesophageal Echocardiography-guided cannulation, incisions, instruments, visualization, aortic occlusion and cardiopulmonary bypass strategies. From local experience, the author provide advice on how to reduce the learning curves, such as practising with the specialised instruments and visualization techniques during sternotomy cases. Underpinning the NHS pillars are the principles of systems awareness, teamwork, communication, ownership and leadership, all of which are paramount to performing any surgery but more so with minimal access surgery, as will be highlighted throughout this paper.
Report on Unilateral pulmonary oedema following minimal invasive mitral valve surgery
By Mr S Hunter BMedSci BM BS FRCS FRCS(CTh)
This report will discuss the findings of a survey conducted by The British and Irish Society of Minimal Invasive Cardiac Surgery (BISMICS) of 19 centres in GB, Ireland and included 3 large volume centres in Europe. This totalled over 9000 cases. This will also consider the evidence from a literature search of unilateral pulmonary oedema and will discuss possible mechanisms and conclude with a best practice of prevention.
Minimally Invasive Totally Endoscopic Beating Mitral Valve Repair
By Abdelrahman Abdelbar and Joseph Zacharias
The authors present their experience with totally endoscopic beating mitral valve surgery by presenting this case of mitral repair. They recently moved to beating mitral surgery due to the shortage of the endo-balloon aortic clamp which was their preferred method of myocardial protection. Their team does not feel very comfortable using the external clamps (Chitwood Clamp). Since last year, the authors started performing most of their endoscopic mitral and/or tricuspid endoscopic surgeries on a beating heart with favorable outcomes. This video presents their technique and pitfalls.New Paragraph
Propensity-matched analysis of minimally invasive approach versus sternotomy for mitral valve surgery
Stuart W Grant,1 Graeme l Hickey, Paul Modi, Steven Hunter, Enoch Akowuah, Joseph Zacharias
Objective
The objective of this multicentre study was to compare short-term and midterm outcomes between sternotomy and minimally invasive approaches for mitral valve surgery.
Methods
Data for all mitral valve procedures with or without concomitant tricuspid atrial fibrillation surgery were analysed from three UK hospitals between January 2008 and December 2016. to account for selection bias between minimally invasive approach and sternotomy, one-to-one propensity score calliper matching without replacement was performed. the main outcome measure was midterm reintervention free survival that was summarised by the Kaplan-Meier estimator and compared between treatment arms using the stratified log-rank test.
Download the complete articles here
The UK Mini Mitral Trial
A multi-centre randomised control trial on Minimally invasive thoracoscopically-guided right minithoracotomy versus conventional sternotomy for mitral valve repair. The UK wide trial is being led by South Tees Hospitals NHS Foundation Trust with Mr Enoch Akowuah, Consultant Cardiac Surgeon and Karen Ainsworth, Lead Research Nurse as clinical leads.
For patients diagnosed with mitral regurgitation, a form of mitral valve disease, the traditional approach to treatment is open heart surgery involving a sternotomy, where the heart is accessed by cutting the breast bone. More recently there have been developments in the area of minimally invasive surgery and an operation called a mini-thoracotomy to treat mitral valve disease. This treatment involves accessing the heart through a small incision on the side of the chest, a much less invasive approach.
The UK Mini Mitral Trial has been developed to help answer the question, which treatment is better for patients and for the NHS and what effect each surgery has on patients following their treatment. The trial is currently underway and hopes to recruit around 400 adult NHS patients from across England and Scotland who are randomly selected for either a sternotomy or a mini-thoracotomy. Each patient is monitored over the course of their treatment and for 12 months after surgery to assess how quickly they returned to their normal activities
Isolated Endoscopic Tricuspid Valve Surgery
Isolated tricuspid regurgitation has been increasingly diagnosed amongst the population (1). Intracardiac devices and the prevalence of atrial fibrillation (AF) are now the most common causes of AF (2).
Morbidity and mortality from tricuspid regurgitation can be significant (3). However, surgery for isolated tricuspid valve regurgitation is still believed to be under-performed compared to the number of patients diagnosed. This rarity exists despite the clear guidelines to intervene in cases of severe symptomatic tricuspid regurgitation (4). The main reason for this under-performance is the reported high mortality following conventional sternotomy (5). Also, referral for surgery is often delayed until patients develop intractable right-sided heart failure. Recently, a few centers reported endoscopic minimal access tricuspid surgery with better results compared to standard sternotomy (6). In this video, the authors present a single-center experience with this type of surgery and seek to promote more surgical treatment for tricuspid valve pathologies.
References:
- Arsalan M, Walther T, Smith RL, Grayburn PA. Tricuspid regurgitation diagnosis and treatment. Eur Heart J.2017; 38:634–638.
- Chang JD, Manning WJ, Ebrille E, Zimetbaum PJ. Tricuspid valve dysfunction following pacemaker or cardioverter-defibrillator implantation. J Am Coll Cardiol. 2017 May 1;69(18):2331-2341.
- Fender EA, Zack CJ, Nishimura RA. Isolated tricuspid regurgitation: outcomes and therapeutic interventions. Heart. 2018;104:798–806.
- Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017 Aug 26;38(36):2739-2791.
- Rankin JS, Hammill BG, Ferguson TB Jr, Glower DD, O’Brien SM, DeLong ER, et al. Determinants of operative mortality in valvular heart surgery. J Thorac Cardiovasc Surg. 2006 Mar 1;131(3):547-557.
- Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg. 2009 Dec 1;88(6):1845-1850.
- Mr Zacharias is a proctor for Edwards Lifesciences, Abbott, and Cryolife.
2017 Best Oral Presentation Award
Sara Abou Sherif BMBS MScFY1 Doctor Imperial College London Healthcare Trust
Having carried out an MSc in cardiovascular research, for my intercalated degree during medical school, I was keen on further exploring my interest in the field of cardiac surgery. Under the supervision of Mr Ahmed Ishtiaq, a cardiac surgeon at the Royal Sussex County Hospital, I underwent a variety of research projects. Subsequently, I was warmly invited to attend and present our work at the British & Irish Society for Minimally Invasive Cardiac Surgery (BISMICS) 2017 annual meeting in London, where I was awarded with the best oral presentation prize. As part of this prize, I was delighted to be granted funding by the BISMICS to attend the 2019 International Society’s annual meeting (ISMICS) taking place in New York.
This was a fantastic opportunity to present my poster on the outcomes of patients undergoing minimally invasive aortic valve replacement versus those undergoing a full sternotomy, at an international level. The conference provided a stimulating environment to share discussions around my work with distinguished worldwide experts as well as gain advice on career planning and development. Amongst the wide range of talks on cutting edge research and technology in minimally invasive cardiothoracic surgery, I was particularly interested by the debate sessions; these were run by a panel of world-renowned professionals addressing the challenges around the translation of surgical research in answering important clinical questions.
The conference was also conveniently located in Times Square, right in the heart of New York city; providing an excellent opportunity for exploring. I am extremely grateful for this invaluable learning experience and would like to thank the BISMICS in supporting me to attend.