The periareolar access has been the preferred technique used at our institution for minimally invasive cardiac surgery since 2006. The surgical approach consists of video-assisted minithoracotomy in the 4th right intercostal space, through a periareolar incision. Initially, the technique was restricted to minimally invasive mitral valve surgeries but, due to its feasibility and safety, was soon incorporated as an ideal access for other cardiac pathologies such as tricuspid valve disease, atrial septal defect, atrial fibrillation, and pacemaker leads endocarditis. The technique was performed in 214 patients, and it is associated with excellent aesthetic and functional results, with low morbimortality and no reoperations at long-term follow-up. Here, we describe and support the use of periareolar access as a routine surgical technique for correction of several cardiac pathologies, especially in women.
Background: Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci ® robotic system was performed in LatinAmerica. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil.Methods: From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy.Results: The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term.Conclusions: Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra-and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.
Mitral valve reconstruction techniques using polytetrafluoroethylene sutures are associated with high repair rates and excellent durability but are dependent on accurate neochordae length estimates. Current strategies to determine the appropriate length of artificial neochordae commonly rely on nonphysiologic saline testing on the arrested heart, with erroneous lengths resulting in residual mitral regurgitation. We present a guide for reproducible and accurate neochordae reconstruction based upon transesophageal echocardiographic measurements, which simplifies mitral repair for most patients with degenerative mitral regurgitation and can be used in conventional or minimally invasive approaches.
Surgical treatment of infective endocarditis remains a challenge, with concerns of optimal prosthesis selection and risks of recurrent infection remaining paramount. The pulmonary autograft has unique features which may make it the ideal aortic valve substitute, especially in infectious endocarditis. We describe strategic considerations and technical details in performing a Ross procedure in a young patient with acute aortic valve endocarditis.
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