Immediate extubation in the operating room (OR) following cardiac surgery remains controversial. In 2021, our institution implemented a fast-track protocol that incorporated ultra-fast extubation (ORE) for minimally invasive heart valve surgery. We retrospectively evaluated outcomes and cost-effectiveness in comparison to standard extubation in the ICU (ICE). We retrospectively reviewed 615 minimally invasive valve surgeries performed between 2019 and 2023. Among these, 228 patients were extubated in the ICU, if possible, within 6 h as per current guidelines, while 387 patients underwent immediate ultra-fast extubation in the operating room (ORE) at the end of the surgery. Baseline variables were compared, and case-control matching was performed based on significantly different factors: Age, BMI and cross clamp times, resulting in two matched groups of 122 each. After matching, baseline variables were comparable between groups. Patients who underwent ORE had shorter ICU and hospital stays, were less likely to require ventilation for more than 24 h, and had significantly less often respiratory failure. Rates of repeat intubation did not differ significantly between groups. In multivariate logistic regression analysis, ORE, aortic cross clamp time, and EuroSCORE II were independent predictors of prolonged ventilation (> 24 h). However, conversion to sternotomy, previous cardiac surgery, gender, and history of smoking were not significantly associated with prolonged ventilation. ORE also led to reduced costs (Standard mean difference: 10 247€, p = 0.03). Ultra-fast extubation after minimally invasive valve surgery was associated with improved respiratory outcomes and lower costs compared to standard extubation in the ICU, with no increase in re-intubation rates. These findings support the clinical feasibility and safety of OR extubation in selected patients at experienced centers.

Background: Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation. Methods: Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger’s technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis. Discussion: To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

The use of bioprostheses is increasing in younger patients, but it is associated with the risk of later valve deterioration, especially in the mitral position. A new bioprosthesis for mitral valve replacement offers possible longer-term durability and improved hemodynamics. Objectives: Here, we report the implantation of the novel Edwards MITRIS RESILIA mitral valve (Edwards Lifesciences Inc., Irvine, CA, USA) through microinvasive fully endoscopic access as an innovative surgical approach based on a series of twelve patients. Methods: Contrast-based ECG gated CT was preoperatively performed in all patients to determine the intravascular calcifications and vascular parameters, as well as to assess noticeable problems during the operation. CT software for cardiac interventions (3Mensio Medical Imaging BV) was used to simulate surgical prostheses digitally inside the native annulus. With this, a digital LVOT and neo LVOT was created, and the difference between the valve prostheses was measured. Implantation of the MITRIS RESILIA valve was performed in 12 patients according to the instructions for use through microinvasive access in a fully endoscopic fashion using 3D visualization. Results: The mean patient age was 56.50 years, and 7/12 (58.33%) were redo procedures. All patients survived the first 30 days after the procedure, the mean aortic cross-clamp time was 40.17 ± 13.72 min. and mean postoperative transvalvular gradient was 4.45 ± 1.74 mmHg. The neo LVOT in the CT-based simulation was measured with an average area of 414.98 ± 88.69 mm². The average difference between the LVOT and neo LVOT area was 65.35 ± 34.99 mm². There was no case of paravalvular leakage or obstruction of the left ventricular outflow tract. Conclusions: The novel MITRIS RESILIA valve is a promising new bioprosthesis for mitral valve replacement that offers improved features as compared to other prostheses. The ease of implantation is increased by this prosthesis by the improved pliability of the sewing cuff and the inward folding of the struts, which was confirmed by short operative times in our series.

Objectives: Iatrogenic injury to the circumflex artery (CX) during mitral valve (MV) surgery occurs in 0.3%-1.8% of cases. This study analysed the CX’s anatomical relationship to the mitral annulus using advanced imaging to predict peri-operative risk in patients undergoing endoscopic MV surgery. Methods: A CT analysis using 3mensio software was performed in 315 patients (2019-2023) undergoing minimally invasive MV surgery. A prediction index (PI) for CX injury was calculated to identify at-risk individuals. Results: CX anatomy was assessable in all patients (n = 315). The mean age was 62.84 ± 11.34 years; median annulus area was 12.97 ± 5.69 cm2. The mean distance between the left CX and mitral annulus was 6.97 ± 3.85 mm. A critical distance <4 mm was observed in 23.5% (74/315), among whom circumflex obstruction occurred in 2.71% (2/74), compared to 0% in those with ≥4 mm distance (P = .05). Percutaneous coronary intervention was required in 0.32% (1/315). A low injury PI (≤0.2) was found in 27.31% (86/315), correlating with male sex, larger annular dimensions, and elevated injury risk. Conclusions: Preoperative CT-based measurement of the CX’s distance from the mitral annulus is feasible and may identify patients at elevated risk for iatrogenic injury. A distance ≤4 mm or injury PI ≤0.2 indicates increased risk. Routine CT imaging, combined with coronary angiography, is recommended for risk stratification before MV surgery.

Objectives: The HOSTILE score was developed to assess femoral access challenges in transcatheter valve therapy. Similar vascular issues arise in femoral cannulation for minimally invasive valve surgery, making CT-based planning essential. We adapted the score for surgical use (MOD-HOSTILE) and evaluated its association with neurological and adverse outcomes. Methods: In this single-center retrospective study, the MOD-HOSTILE score (0–11 points) was calculated for 364 patients undergoing minimally invasive heart valve surgery from 2019 to 2023. Patients were stratified into low (0–2), mild (>2–5), and high (>5–11) score categories. Outcomes included 30-day stroke, other neurological events, and perioperative complications. Results: High MOD-HOSTILE patients were significantly older (70 [64.7–73.0] vs. 61 [60.0–63.0] years; p < 0.01) and had higher surgical risk (EuroSCORE II 1.79 [1.26–2.16] vs. 0.83 [0.75–0.94]; p < 0.01). Neurological complications were more frequent in the high MOD-HOSTILE group, including stroke (8.7% vs. 0.9%; p = 0.02) and hemiplegia (13.0% vs. 0.9%; p < 0.01). Axillary cannulated patients had higher MOD-HOSTILE scores than femoral cannulated patients. Stroke risk was highest in patients with high MOD-HOSTILE score undergoing axillary cannulation (high vs. low MOD-HOSTILE, 18.2% vs. 0%; p = 0.04). Thirty-day mortality was comparable between groups (p = 0.09). MOD-HOSTILE predicted stroke with an AUC of 0.78 (95% CI 0.73–0.82) and OR 1.4 per point (95% CI 1.1–2.0). Conclusions: The MOD-HOSTILE score identifies vascular and neurological risk in minimally invasive valve surgery, with scores ≥5 indicating elevated risk of stroke and delirium. Patients with high scores may benefit from alternative surgical strategies.

Background/Objectives: Transcatheter mitral valve-in-valve (ViV) and valve-in-ring (ViR) procedures have emerged as alternative treatment options for failed mitral valves following prior bioprosthetic replacement or ring annuloplasty. However, redo surgical mitral valve replacement (redo-MVR) remains the standard therapy despite its perceived higher procedural risk. This study aimed to descriptively compare short- and long-term outcomes of ViV/ViR and redo-MVR. Methods: We retrospectively included patients older than 60 years who underwent treatment of failed mitral valve bioprostheses or repairs between 2000 and 2022 (n = 30; ViV/ViR cohort: 2008–2022). Patients treated with ViV/ViR (n = 15) were compared with those undergoing redo-MVR (n = 15). Endpoints were reported according to Mitral Valve Academic Research Consortium (MVARC) criteria. Technical, device, and procedural success were defined according to the MVARC criteria and applied identically to both groups. Owing to the small sample size and substantial baseline differences, this study is descriptive and hypothesis-generating. Results: Patients in the ViV/ViR group were significantly older than redo-MVR patients (76.9 ± 5.8 vs. 68.0 ± 8.4 years, p < 0.001). EuroSCORE II did not differ significantly between groups. Thirty-day mortality was comparable, with one death in the ViV/ViR group and none after redo-MVR (6.7% vs. 0%, p = 1.00). Device success at 30 days was significantly higher after redo-MVR compared with ViV/ViR (86.7% vs. 40.0%, p = 0.02). Neurological events were rare and similar between groups. Degenerated bioprostheses were more frequent in the ViV/ViR group (86.6%), whereas prior annuloplasty ring implantation predominated in redo-MVR patients (80.0%, p < 0.01). Pre-procedural and discharge mitral valve gradients were higher in ViV/ViR patients. Implanted valve size was smaller in the ViV/ViR cohort (28.2 ± 1.4 vs. 29.5 ± 1.8 mm, p = 0.03). Conclusions: In this small, retrospective, single-center cohort with substantial baseline differences (e.g., age), 30-day mortality was low in both groups. Device success was higher after redo-MVR, mainly because of higher postoperative gradients after ViV/ViR. These findings are descriptive and hypothesis-generating and do not constitute evidence of comparative treatment effectiveness. Both approaches may be considered complementary options guided by a multidisciplinary heart team.