Hundred plus Minimally Access Cardiac Surgery: Our Experience

Background: Minimally invasive procedures lead to less scarring resulting in better cosmetic outcomes. This has resulted in increased patient interest in such procedures and this has motivated surgeons to pursue newer and improved techniques for Minimally invasive cardiac surgery (MICS). Obviously, with the advent of MICS the techniques to achieve it also needed to be changed and upgraded which includes access for cannulation for cardiopulmonary bypass (CPB). Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels with minithoracotomy/ministernotomy proves to be a safe and effective tool in patients with body weight of above 20 kg for minimally access cardiac surgery. We use this technique for Atrial septal defect (ASD) closure, aortic valve replacement (AVR), redo Tricuspid valve replacement (TVR) and mitral valve replacement (MVR). Here, we describe our experience with minimally invasive approach using total peripheral cannulation and an anterior mini-thoracotomy (6 cm or less) incision for ASD closure, AVR, TVR and MVR. Methods: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive ASD closure, AVR, TVR and MVR with total peripheral cannulation were collected and analyzed. Results: Between May 2014 to May 2019 we performed minimally invasive closure of atrial septal defects, AVR, TVR and MVR with total peripheral cannulation in 103 patients. There were 64 females and 39 males Mean age was 25 years (range 8 - 58 years), Spectrum of procedures include ASD closure in 81 patients (78.6%), AVR via minithoracotomy in 13 patients (12.6%) and AVR via ministernotomy in 3 patients (2.9%), redo TVR in 5 (4.8%), MVR in 1 patient (0.97%). Average cardiopulmonary bypass (CPB) time was 46 minutes (range 22 - 78 min) and average aortic cross-clamp time (AoX) 26 min (range 12 - 45 min) in ASD closure group. In AVR group average CPB time was 91 min (range 72 - 120 min) and AoX time 76.5 min (range 65 - 109 min). In TVR group average CPB time 54 min (range 45 - 67 min) on beating heart. Only one MVR done in this period and CPB time was 82 min and AoX time was 65 min. The mean length of stay in intensive care unit was 1.8 days in ASD closure, 2 days in AVR group when in TVR group 3.5 days, and hospital stay was 3 days in ASD closure group, 4 days in AVR group and 7 days in TVR group. The only one patient who underwent MVR died in 12th post operative day from sepsis. There was one late mortality in AVR group after reoperation for prosthetic valve endocarditis at 3 months from first operation. Conclusion: ASD closure, AVR, TVR and MVR with mini invasive approach is safe with very few manageable preoperative complications and good patient satisfaction.

Cosmetic outcome of femtosecond laserassisted pterygium surgery

Background:To examine the cosmetic outcome of femtosecond laser-assisted pterygium surgery(FLAPS)with conjunctival autograft(CAG)and its potential predictive factors.Methods:This Was a prospective interventional case series(NCT02866968).We included 29 patients(29 eyes)with primary pterygium who underwent FLAPS.Cosmetic outcome was graded by two graders(an ophthalmology resident and an experienced ophthalmologist)using Hirst classification system(1-4:excellent-poor).Weighted Cohen's kappa analysis was performed to examine the intra-and inter-rater reliability.The relationship between cosmetic outcome and various factors were determined by Spearman's correlation coefficients(r).Results:The preoperative severity of pterygium(Tan grading system)was mild/atrophic(7%),moderate/intermediate(62%),and severe/fleshy(31%).An ultrathin CAG(mean thickness of 74.5±9.8μm)was fashioned intraoperatively.An excellent cosmetic outcome of FLAPS(median±IQR)was observed at 3 months(1.0±1.0)and remained similar at 6 months(1.0±0.0)and 12 months(1.0±0.0)postoperatively.At final fllow-up,27(93%)patients achieved good-to-excellent cosmetic outcome,with 1(3%)patient having a poor outcome due to incomplete pterygium removal.Weighted kappa analysis of Hirst grading system showed excellent intra-rater(k:0.86-0.95)and inter-rater reliability(k:0.84-0.88).There was a weak and borderline significant correlation between good cosmetic outcome and reduced postoperative CAG thickness(r=0.38,P=0.06)but not with age,gender,preoperative pterygium severity,or intraoperative CAG thickness.Conclusions:FLAPS can result in an excellent cosmetic outcome,which may be attributed to the beneficial effect of an ultrathinCAG.Trial registration:ClinicalTrials.gov,NCT02866968.Registered in July 2016.

Cosmetic outcome of femtosecond laserassisted pterygium surgery

Background:To examine the cosmetic outcome of femtosecond laser-assisted pterygium surgery(FLAPS)with conjunctival autograft(CAG)and its potential predictive factors.Methods:This was a prospective interventional case series(NCT02866968).We included 29 patients(29 eyes)with primary pterygium who underwent FLAPS.Cosmetic outcome was graded by two graders(an ophthalmology resident and an experienced ophthalmologist)using Hirst classification system(1-4=excellent-poor).Weighted Cohen’s kappa analysis was performed to examine the intra-and inter-rater reliability.The relationship between cosmetic outcome and various factors were determined by Spearman’s correlation coefficients(r).Results:The preoperative severity of pterygium(Tan grading system)was mild/atrophic(7%),moderate/intermediate(62%),and severe/fleshy(31%).An ultrathin CAG(mean thickness of 74.5±9.8μm)was fashioned intraoperatively.An excellent cosmetic outcome of FLAPS(median±IQR)was observed at 3 months(1.0±1.0)and remained similar at 6months(1.0±0.0)and 12months(1.0±0.0)postoperatively.At final follow-up,27(93%)patients achieved good-to-excellent cosmetic outcome,with 1(3%)patient having a poor outcome due to incomplete pterygium removal.Weighted kappa analysis of Hirst grading system showed excellent intra-rater(κ=0.86-0.95)and inter-rater reliability(κ=0.84-0.88).There was a weak and borderline significant correlation between good cosmetic outcome and reduced postoperative CAG thickness(r=0.38,P=0.06)but not with age,gender,preoperative pterygium severity,or intraoperative CAG thickness.Conclusions:FLAPS can result in an excellent cosmetic outcome,which may be attributed to the beneficial effect of an ultrathin CAG.