Minimally Invasive Autopericardial Neocuspidization with Thoracoscopic Pericardial Harvesting

Aim: to compare outcomes of autopericardial neocuspidization (AVNeo) of the aortic valve performed via J-shaped ministernotomy with thoracoscopic pericardial harvesting versus conventional full median sternotomy.

Materials and methods: we retrospectively analyzed 64 patient records: 20 undergoing AVNeo via J-shaped ministernotomy with thoracoscopic harvesting (Group 1) and 44 receiving conventional sternotomy (Group 2). The groups were matched for comorbidities and concomitant cardiac pathology. In Group 1, cardiopulmonary bypass (CPB) was established via femoral vein-femoral artery (70%) or femoral vein-aorta (30%) cannulation. Thoracoscopic pericardial harvesting was performed on the arrested heart (mean duration: 29.2±4.2 min) through port access, yielding comparable pericardial patch sizes between groups. The ministernotomy level (3rd/4th intercostal space) was determined by preoperative MSCT.

Results: J-shaped ministernotomy was associated with significantly increased mean CPB time and aortic cross-clamp time (175.5±11.6 min and 102.5±7.8 min in Group 1 vs. 114.4±40.6 min and 84.4±19.9 min in Group 2, p>0.001 for both comparisons). The minimally invasive approach demonstrated reduced blood loss (576±114.7 mL in Group 1 vs. 763.6±446.7 mL in Group 2, p=0.027). All Group 1 patients were discharged successfully, while Group 2 had two deaths (4.5% mortality). Postoperative mechanical ventilation duration was shorter in Group 1 (2.85±2.3 hours vs. 5.18±3.9 hours in Group 2, p>0.001). Group 1 also showed lower VAS pain scores (p >0.001) and reduced postoperative hospital stay (7.1±3 days vs. 13.9±5.5 days in Group 2, p>0.001). No significant differences were found in procedural effectiveness between the approaches.

Conclusion: thoracoscopic pericardial harvesting allows using less traumatic approach to perform AVNeo procedure. Minimally invasive autopericardial neocuspidization of the aortic valve is a safe and effective procedure.

1. Duran C.M. Pericardium in valve operations. Ann ThoracSurg. 1993; 56(1): 1-2. DOI:10.1016/0003-4975(93)90393-v

2. Ozaki S., Kawase I., Yamashita H. et al. Midterm outcomesafter aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg. 2018 Jun;155(6):2379-2387. DOI: 10.1016/j.jtcvs.2018.01.087

3. Dedeilias P., Baikoussis N.G. et al. Aortic valve replacementin elderly with small aortic root and low body surface area; the Perceval S valve and its impact in effective orifice area. J Cardiothorac Surg. 2016; 11(1): 54. DOI: 10.1186/s13019-016-0438-7

4. Ozaki S. Ozaki Procedure: 1,100 patients with up to 12 years of follow-up. Turk Gogus Kalp Damar Cerrahisi Derg. 2019; 27(4): 454. DOI: 10.5606/tgkdc.dergisi.2019.01904

5. Li A.E., Fishman E.K. Evaluation of complications after sternotomy using single- and multidetector CT with three-dimensional volume rendering. AJR Am J Roentgenol. 2003;181(4):1065-70. DOI: 10.2214/ajr.181.4.1811065

6. Čerle M., Černý D., Sedláčková E. et al. Vitamin D for prevention of sternotomy healing complications: REINFORCE-D trial. Trials. 2020; 21(1):1018. DOI: 10.1186/s13063-020-04920-z

7. Heilmann C., Stahl R., Schneider C. et al. Wound complications after median sternotomy: a single-centre study. Interact Cardiovasc Thorac Surg. 2013; 16(5): 643-8. DOI: 10.1093/icvts/ivs554

8. Rao PN, Kumar AS. Aortic valve replacement through rightthoracotomy. Tex Heart Inst J. 1993; 20(4): 307-8

9. Komarov R.N., Ognev O.O., Ismailbaev A.M. et al. ModernApproaches to Minimally Invasive Aortic Valve Surgery. Pathology of Circulation and Cardiac Surgery. 2022;26(3):31-40 [In Russ] DOI: 10.21688/1681-3472-2022-3-31-40

10. Jahangiri M., Hussain A., Akowuah E. Minimally invasivesurgical aortic valve replacement. Heart. 2019; 105(Suppl 2):s10-s15. DOI: 10.1136/heartjnl-2018-313512.

11. Rosseikin E.V., Kobzev E.E., Bazylev V.V. OZAKI Procedurevia Mini-Access. Angiology and Vascular Surgery. 2019; 25 (3): 142-155 DOI: 10.33529/ANGIO2019319

12. Nguyen D.H., Vo A.T., Le K.M. et al. Minimally Invasive Ozaki Procedure in Aortic Valve Disease: The Preliminary Results. Innovations (Phila). 2018; 13(5): 332-337. DOI: 10.1097/IMI.0000000000000556

13. Mikus E., Calvi S., Campo G. et al. Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference? Ann Thorac Surg. 2018; 106(6): 1782-1788. DOI: 10.1016/j.athoracsur.2018.07.019

14. Wu Y., Jiang W., Li D., et al. Surgery of ascending aorta withcomplex procedures for aortic dissection through upper ministernotomy versus conventional sternotomy. J Cardiothorac Surg. 2020; 15(1): 57. DOI: 10.1186/s13019-020-01095-1

15. Kirmani B.H., Jones S.G., Malaisrie S.C., et al. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev. 2017; 4(4): CD011793. DOI: 10.1002/14651858

16. Burdett C.L., Lage I.B., Goodwin A.T., et al. Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery. Interact Cardiovasc Thorac Surg. 2014; 19(4): 605-10. DOI: 10.1093/icvts/ivu196

17. Yousuf S. M., Hamilton H., Rahman I. et al. Mini-sternotomy vs right anterior thoracotomy for aortic valve replacement. J Card Surg. 2020; 35(7): 1570-1582. DOI: 10.1111/jocs.14607

18. Lamelas J., Sarria A., Santana O. et al. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg. 2011; 91(1):79-84. DOI: 10.1016/j.athoracsur.2010.09.019

19. Nguyen T.C., Thourani V.H., Pham J.Q. et al. Traditional Sternotomy Versus Minimally Invasive Aortic Valve Replacement in Patients Stratified by Ejection Fraction. Innovations (Phila). 2017; 12(1): 33-40. DOI: 10.1097/IMI.0000000000000338

20. Phan K., Xie A., Di Eusanio M. et al. A meta- analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg. 2014; 98(4): 1499-511. DOI: 10.1016/j.athoracsur.2014.05.060