TY - JOUR
AU - Berretta, Paolo
AB - Abstract Aortic valve replacement (AVR) via a median sternotomy approach has been largely reported to be safe and long-term efficacious, and currently represents the ‘gold standard’ approach for aortic stenosis treatment. However, aortic valve surgery has undergone continuous development over the last years, involving less invasive techniques and new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Indeed, minimally invasive AVR and transcatheter aortic valve replacement caseload have steadily increased leading to a paradigm shift in the treatment of aortic valve disease. In this setting, we have established a multidisciplinary minimally invasive programme to treat patients who require AVR. Herein, we present our approach including (i) reduced chest incision (through a J ministernotomy), aiming to reduce the traumatic impact of the surgical procedure, to decrease blood loss, postoperative pain and wound complications and to increase patient’s satisfaction; (ii) rapid-deployment AVR, to reduce operative times, to facilitate minimally invasive approach and to improve haemodynamic outcomes; (iii) minimal invasive extracorporeal circulation system, to improve end-organ protection, to decrease systemic inflammatory response and to promote fast-track anaesthesia and (iv) ultra fast-track anaesthesia, to decrease the rate of postoperative complications and assure better and earlier recovery. Minimally invasive valve surgery , Rapid-deployment valve , Minimally invasive extracorporeal circulation , Fast-track anaesthesia INTRODUCTION Aortic valve replacement (AVR) through a median sternotomy approach has been largely reported to be a safe and long-term effective treatment for aortic valve diseases [1, 2]. Over the last years, with the increasing adoption of less invasive techniques and new technologies, aortic valve surgery has been greatly refined [3]. Indeed, an increasing number of surgeons treat aortic valve diseases through reduced chest incisions aiming to both decrease the ‘invasiveness’ of the surgical procedure and improve clinical and cosmetic outcomes. We believe that the concept of minimally invasive aortic valve replacement (MIAVR) should be broader than simply reducing the length of the surgical incision. In fact, by increasing the technological content of our surgical procedures, the patient’s global trauma may be further decreased by adding the use of (i) more sophisticated valve prostheses capable of reducing operative times and providing excellent haemodynamics, (ii) advanced cardiopulmonary bypass (CPB) circuits effective in minimizing inflammatory response and (iii) anaesthetic protocols with rapid table extubation promoting early physiotherapy and recovery. To reach this target, we have established a multidisciplinary approach involving all health professionals embroiled in the perioperative management of the patient: surgeons, anaesthesiologists, perfusionists, nurses and physical therapists. Herein, we present our ultra fast-track (UFT) multistep minimally invasive approach to treat patients who require AVR, which involves the following: 1. Reduced chest incision [through an upper J ministernotomy (MS)], 2. Rapid-deployment AVR (RD-AVR) using the EDWARDS INTUITY Elite™ valve (Edwards Lifesciences, Irvine, CA, USA), 3. Minimal invasive extracorporeal circulation (MiECC) system and 4. Ultra fast-track anaesthesia. SURGICAL TECHNIQUE Premedication with morphine (0.10–0.15 mg/kg) and/or diazepam (0.1–0.3 mg/kg) is given 30 min before surgery. After induction of anaesthesia with Fentanyl (5 μg/kg) and Propofol 1% (1, 5–2, 5 mg/kg) or using target infusion technology system (Propofol 2%–Remifetanil 50 μg/ml), a short-acting volatile agent (Sevoflorane) is used to maintain anaesthesia before and after CPB. Cisatracurium (induction dose 0.15 mg/kg; maintenance dose 0.1–0.4 mg/kg) or Rocuronium (induction dose 0.45–0.6 mg/kg; maintenance dose 0.1–0.2 mg/kg) are used for neuromuscular block. Following a 5-cm skin incision, started at the angle of Louis, an upper ‘J’ MS extended to the 3rd or 4th right intercostal space is performed. The pericardium is opened, and the surgical field is exposed using 6 pericardial stay sutures. Systemic heparinization is achieved according to the individual patient’s response to heparin estimated by the Hepcon/HMS system (Medtronic Inc., Minneapolis, MN, USA). A low-dose anticoagulation protocol with a targeted activated clotting time of 300–350 is employed. The ascending aorta and the right atrium are cannulated for CPB institution using a standard technique. A double-purse string suture is placed to the venous cannulation site to minimize air leakage, and minimally invasive CPB is performed using the ROCSafe™ hybrid perfusion system (Terumo, Ann Arbor, MI, USA) (Fig. 1). For minimizing haemodilution, the MiECC circuit is retrogradely primed with patient’s blood, placing the operating table in the Trendelenburg position to increase venous return. The right superior pulmonary vein is cannulated for left ventricle venting. A cell saver system (Dideco Electa, Sorin Group, Saluggia, Italy) is used to preserve the red cell mass. After normothermic CPB institution, with an empty heart, a subxiphoid spiral drain is placed, to continuously inflate carbon dioxide into the pericardial cavity. The ascending aorta is gently clamped using a specifically designed clamp for minimally invasive interventions (Cygnet® Flexible Clamps, Vitalitec, Plymouth, MA, USA). Blood cardioplegia is delivered in antegrade fashion via the aortic root or directly into the coronary arteries. A ‘hockey-stick’ aortotomy crossing the sinotubular junction is performed, and the aortic valve is exposed. The aortic cusps are removed, and the annulus is accurately decalcified. The aortic annulus is measured, and a properly sized EDWARDS INTUITY Elite rapid-deployment valve is selected. Rapid-deployment valve implantation is performed as previously described (Fig. 2) [5], and the aortotomy is closed using standard technique. Before releasing the aortic clamp, 2 pacing wire electrodes are sutured to the right ventricle. The operation is then completed as usual. Figure 1: View largeDownload slide Type IV MiECC system [4]. (A and B) The Terumo ROCSafe™ hybrid perfusion system. (C) The Terumo FX 15 oxygenator. (D) Venous bubble trap. Figure 1: View largeDownload slide Type IV MiECC system [4]. (A and B) The Terumo ROCSafe™ hybrid perfusion system. (C) The Terumo FX 15 oxygenator. (D) Venous bubble trap. Figure 2: View largeDownload slide The EDWARDS INTUITY Elite™ valve implantation. Three guiding sutures are placed at the nadir of each coronary cusp (A) and then passed through the sewing ring of the INTUITY Elite valve at the black markers (B). The valve is parachuted down into the aortic annulus (C), and the guiding sutures are snared with a tourniquet (D). The balloon catheter is advanced distally until the catheter snapped into place, and the stent is expanded within the left ventricular outflow tract by inflating the balloon catheter with sterile water to the appropriate pressure for 10 s (E). After balloon deflation, the snares and the delivery system are removed, proper seating of the valve is checked and the guiding sutures are tied (F). Figure 2: View largeDownload slide The EDWARDS INTUITY Elite™ valve implantation. Three guiding sutures are placed at the nadir of each coronary cusp (A) and then passed through the sewing ring of the INTUITY Elite valve at the black markers (B). The valve is parachuted down into the aortic annulus (C), and the guiding sutures are snared with a tourniquet (D). The balloon catheter is advanced distally until the catheter snapped into place, and the stent is expanded within the left ventricular outflow tract by inflating the balloon catheter with sterile water to the appropriate pressure for 10 s (E). After balloon deflation, the snares and the delivery system are removed, proper seating of the valve is checked and the guiding sutures are tied (F). Local anaesthetic infiltration (Ropivacaine 10 ml + Lidocaine 10 ml) of suture and drains sites is used for immediate postoperative pain relief. Few minutes before surgery completion, the inhalational agent is stopped, and alveolar recruitment is achieved using a temporary 10 cmH2O positive end-expiratory pressure. At the end of the surgery, the neuromuscular blockade is reversed with Sugammadex (2–4 mg/kg) or neostigmine (0.07 mg/kg). Table extubation is performed once usual extubation criteria are fulfilled. They include patient responsive and co-operative, satisfactory ventilation parameters (respiratory rate between 12 and 15 breaths per minute, end-tidal CO2 <45 mmHg, SpO2 >95% using FiO2 <60% and tidal volume 4–6 ml/kg), stable haemodynamics with adequate heart rate control and absence of major bleeding. After extubation, the patient is transferred to the intensive care unit with 50% FiO2 oxygen supplementation through a facemask. Postoperative analgesia is provided with Tramadol 4–8 μg/kg/min for 24 h or with morphine (continuous intravenous infusion 10–20 mg/24 h). Continuous analgesia infusion is stopped after 24 h (if pain visual analogue scale <1). Mobilization and respiratory therapy as well as oral feeding are started 4–12 h after surgery and, if no complications occur, the drains are removed and the patient is transferred to the ward (Fig. 3) [5]. Figure 3: View largeDownload slide Early rehabilitation therapy. Our protocol aims to improve the overall patient’s functional capacity by timely re-establishing the respiratory and physical independence and reducing the risk of bed-rest-related complications. (A) Breathing exercises + active upper and lower limb movements (4–12 h after surgery). (B) Bed and chair sitting (12–24 h after surgery). (C) Standing and ambulation (36–48 h after surgery). Figure 3: View largeDownload slide Early rehabilitation therapy. Our protocol aims to improve the overall patient’s functional capacity by timely re-establishing the respiratory and physical independence and reducing the risk of bed-rest-related complications. (A) Breathing exercises + active upper and lower limb movements (4–12 h after surgery). (B) Bed and chair sitting (12–24 h after surgery). (C) Standing and ambulation (36–48 h after surgery). Inclusion and exclusion criteria All adult patients with severe aortic valve stenosis who require isolated AVR are eligible for UFT rapid-deployment MIAVR programme. Exclusion criteria are (i) severe haemodynamic instability requiring high doses of inotropic drugs, (ii) severe heart failure [New York Heart Association (NYHA) IV, ejection fraction <30% and intra-aortic balloon pump (IABP)], (iii) severe renal failure/dialysis or severe hepatic disease, (iv) previous cardiac surgery, (v) bleeding >100 ml/h, (vi) prolonged CPB time (> 120 min) and (vii) hypothermia (central temperature <36°C). Relative exclusion criteria involve emergency surgery, severe pulmonary hypertension and history of stroke or major neurological dysfunction. DISCUSSION Reduced chest incisions MIAVR with reduced chest incisions was popularized in the 1990s and has gradually been recognized as a less traumatic approach when compared with median sternotomy [6, 7]. Currently, the upper MS and the right anterior minithoracotomy are the most common approaches for MIAVR. Although both techniques are associated with similar excellent clinical outcomes, MS represents our favourite approach. Minithoracotomy is a more technically demanding operative approach when compared with MS and requires specialized techniques, dedicated surgical instruments, accurate patient selection and defined preoperative planning. Conversely, AVR through a MS approach is extremely similar to the conventional AVR, both from the surgical and the anaesthesiologist viewpoint. In fact, MS needs only a minimal learning curve and is associated with reduced operative times when compared with minithoracotomy [8]. Moreover, MS allows easy and safe conversion to full sternotomy in case of unexpected complications or unpredicted technical problems. In recent years, minimally invasive incisions, regardless of the type of approach, have been increasingly desired, and often requested, by surgical patients for the attractiveness of an improved cosmesis and a potential for reduced pain and faster recovery. Indeed, MIAVR and transcatheter aortic valve implantation caseload have steadily increased over the last years, leading to a paradigm shift in the treatment of aortic valve disease [3]. Nevertheless, the widespread adoption of MIAVR still remains controversial within the surgical community. Critics of MIAVR sustain that potential advantages (reduced surgical chest trauma, faster functional recovery and improved cosmesis) are offset by longer cross-clamp and CPB times (due to greater operative complexity) and that the resulting increased operative times may translate into inferior clinical outcomes. However, a growing body of evidence has shown that MIAVR provides equivalent outcomes when compared with conventional AVR in terms of both operative mortality and major postoperative complications [6, 7, 9]. Additionally, a number of studies have reported that MIAVR is associated with reduced transfusion incidence, postoperative renal failure, intensive care unit and hospital length of stay, and total hospital costs [6, 7, 9]. In the near future, further improvements in minimally invasive surgery may occur by implementing MIAVR with the latest technological developments allowing for further mitigating of the disparities in operational CPB and cross-clamp durations (RD-AVR) and reducing the deleterious effects of CPB (MiECC system) [4, 10]. We support that the synergistic effects of minimally invasive RD-AVR and MiECC, coupled with a fast-track anaesthetic management, focused on promoting early recovery, and further reducing postoperative complications [11, 12] may finally provide more robust clinical benefits with MIAVR over conventional AVR. Rapid-deployment aortic valve replacement RD-AVR facilitates remarkably a minimally invasive approach [13, 14]. During MIAVR, the passage and tying of sutures through narrow working space may be challenging and time consuming when compared with the standard approach. When compared with conventional AVR, RD-AVR, not requiring the placement and the tying of the numerous sutures, may simplify the prosthesis implantation technique, shorten operative times and improve surgical outcomes. Several studies showed significantly shorter procedural times of RD-AVR when compared with conventional AVR in both standard sternotomy and MIAVR approaches [13–15]. Recently, Borger et al. [9], in a prospective multicentric randomized trial comparing results in patients undergoing minimally invasive RD-AVR with patients undergoing conventional full sternotomy AVR, reported a significant cross-clamp time reduction in patients undergoing RD-AVR (41.3 vs. 54 min), despite the minimally invasive approach. RD-AVR has also indicated better haemodynamic performance when compared with conventional AVR, with reduced transvalvular gradients and greater effective orifice areas [14, 16, 17]. At 1 year, the INTUITY Elite valve was associated with a significantly increased effective orifice area and a decreased peak transvalvular gradient when compared with conventional valves. Moreover, RD-AVR showed a trend towards lower mean transvalvular gradients and a reduced rate of patient–prosthesis mismatch when compared with conventional AVR [17]. The current evidence suggests that RD-AVR may have the potential to become the new gold standard treatment for MIAVR by facilitating minimally invasive approaches, providing superior haemodynamic results and allowing for shorter operative times. However, the perfect aortic valve substitute should have a well-established track record with regard to long-term outcomes and durability, but today robust RD-AVR long-term data are still lacking, and randomized studies and registry data are required to adequately assess the durability of RD-AVR. Minimal invasive extracorporeal circulation system The concept of ‘MiECC system’ was recently introduced to create a system that integrates all contemporary technologies with recognized benefits, in one closed CPB circuit [10]. The purpose of the MiECC system, which implicates a pooled strategy including surgical, anaesthesiological and perfusion management techniques, is to achieve a more physiological perfusion during CPB and to minimize the side effects of extracorporeal circulation. Current evidence shows that the MiECC system is associated with (i) reduced red blood cells transfusion rate, due to decreased haemodilution and postoperative bleeding; (ii) improved end-organ protection; (iii) decreased incidence of postoperative atrial fibrillation and (iv) less cerebral gaseous microembolisms with better neurological outcomes [10]. Furthermore, (v) MiECC seems to limit the systemic inflammatory response syndrome by reducing the blood–air contact and using more biocompatible surfaces with complete heparin coating of the circuit [10, 18]. Indeed, in CABG patients, MiECC systems have been associated with superior patients' survival [19] and earlier recovery using fast-track anaesthetic management [20]. Such favourable observation is lacking in valvular patients. We advocate MiECC systems in combination with minimally invasive chest incisions, and rapid-deployment aortic valve prostheses may have the potential to maximize clinical benefits and, as a result, to further valorize surgical (MI)AVR. Ultra fast-track anaesthesia In a recent meta-analysis of randomized controlled trials comparing fast-track anaesthesia versus conventional (not fast-track) care in patients at low to moderate risk, Wong et al. [21] reported that both methods were similarly safe and effective (comparable mortality and major postoperative complications rates). However, fast-track management shortened time to extubation and reduced intensive care unit stay. Prolonged ventilation time is a well-known risk factor for increased postoperative respiratory morbidity [22], extended use of sedative drug [23], protracted intensive care unit stay [21], delayed rehabilitation therapy [24] and augmented hospital costs [25]. Growing evidence has proved that fast-track (≤6–8 h) and UFT (table) extubation can be safely achieved in patients undergoing cardiac surgery [11, 21]. Nevertheless, fast-track anaesthesia is not merely a method to reduce the time to tracheal extubation; rather, it has emerged as a multidisciplinary clinical pathway for patient care including all procedures aimed at refining and facilitating postoperative recovery and enhancing patient comfort by decreasing the rate of postoperative complications and shortening intensive care unit and hospital stay [11, 12]. An effective fast-track programme should include low-dose opioid-based anaesthesia, aggressively normothermic temperature management, time-directed extubation protocol and, very importantly, timely rehabilitation programmes with a dedicated team of respiratory and motor therapists. The value of early rehabilitation therapy in the intensive care unit has been widely determined by the observation in patients receiving aggressive rehabilitation programmes, in patients with decreased respiratory complications and loss of muscle strength and in patients with superior clinical outcomes [26–28]. This seems of particular importance in high-risk elderly patients who often present with multiple age-related comorbidities. Moreover, implementing a fast-track programme with a specialized postanaesthetic care unit may further improve postoperative results. When compared with standard postoperative intensive care unit care, UFT management with direct admission to an anaesthesia-managed postanaesthetic care unit could lead to earlier extubation and faster discharge to a step-down unit, without compromising patient safety [29]. Obviously, because of the overall minimally invasive nature of our surgical approach, patients undergoing mini RD-AVR using MiECC system may represent a very appealing cohort for UFT anaesthesia concepts. UFT management combined with the advanced surgical and perfusion techniques may help improve patient clinical outcomes and reduce hospital costs, particularly in elderly and high-risk patients. However, no robust evidence is still available in this setting. CONCLUSIONS By reducing the overall surgical stress, we advocate that our multidisciplinary and multistep minimally invasive approach [(i) reduced chest incision, (ii) RD-AVR, (iii) MiECC system and (iv) UFT anaesthesia protocol] may be associated with faster recovery, increased patient comfort and finally superior patient outcomes when compared with conventional AVR. However, further clinical trials are needed to effectively assess early and late results in these patients. Conflict of interest: none declared. 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TI - Ultra fast-track minimally invasive aortic valve replacement: going beyond reduced incisions
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1093/ejcts/ezx508
DA - 2018-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/ultra-fast-track-minimally-invasive-aortic-valve-replacement-going-7O0DNuXiTb
SP - ii14
EP - ii18
VL - 53
IS - suppl_2
DP - DeepDyve
ER -