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Ann Thorac Surg 1998;65:1535-1538
© 1998 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Address reprint requests to Dr Cosgrove, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation (F25), 9500 Euclid Ave, Cleveland, OH 44195
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.
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Abstract |
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Methods. From January 1996 through July 1996, 115 patients underwent primary isolated valve procedures. One hundred (85%) patients underwent the operation through a right parasternal incision.
Results. There was one hospital death secondary to a stroke on the fifth postoperative day. Three patients (two with aortic valve operations and one having a mitral valve procedure) required conversion to sternotomy. Mean aortic occlusion time was 71 minutes; mean cardiopulmonary bypass time was 93 minutes. Mean stay in the intensive care unit was 27 hours and mean hospital postoperative stay was 5.7 days. Seventy-seven percent of the patients did not receive blood transfusions. Comparison with median sternotomy demonstrated a reduction in both postoperative length of stay and direct hospital costs.
Conclusions. We conclude that this minimally invasive approach is safe for a variety of valve procedures and is effective in reducing surgical trauma and cost.
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Introduction |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentAddendumDiscussionReferences |
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Results |
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The duration of postoperative respiratory support was short. The percentage of patients extubated in less than 6 hours and the mean duration of respiratory support are shown in Table 5.
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Comment |
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The small amount of bleeding that occurred with the minimally invasive incision was a surprise to us. This may be the result of the smaller incision, which lessens the potential for bleeding. It is possible to stop bleeding from a minimally invasive incision during entry, whereas sternal bleeding from a standard sternotomy continues throughout the operative procedures and shed blood is retrieved from the pericardial sac. It is recognized that contact with a pleural pericardial surface depletes fibrinogen [3]. By avoiding this bleeding and contact with the pleuropericardial surface, the clotting cascade is not activated during the surgical procedure. It is suspected that a sternotomy will continue to bleed into the mediastinum, even after it has been reapproximated. A combination of these two factors likely accounts for the diminished bleeding and transfusion requirements with the minimally invasive approach.
Another potential advantage of the minimally invasive approach is that the pericardium is not opened over the right ventricular outflow tract. This is the site that is most commonly injured during reoperation. Reoperation should be considerably easier and safer if the pericardium in this area has not been interrupted. The potential for an easier reoperation may influence the surgeon’s choice of prosthesis. If morbidity and mortality of a reoperation are substantially reduced, the willingness of patient and surgeon to consider a bioprosthesis at the time of the initial procedure may increase.
The potential disadvantages of this procedure have also been considered. It is a fact that the incision over the dome of the left atrium sacrifices the sinoatrial node artery in 100% of patients. This raises the question of conduction abnormalities. Recently Kumar and associates [4] compared the incidence of conduction abnormalities found after vertical transseptal atriotomy, as described by Guiraudon and colleagues [5], with that encountered after conventional atriotomy. Kumar and coworkers noted that transient junctional rhythm was common in the early postoperative period. Masuda and colleagues [6] noted an increased incidence of early transient nodal rhythm; however, they found a similar incidence of late postoperative cardiac arrhythmias regardless of the type of incision used. Our observation is similar and we find no long-term differences between the two types of incisions when comparing the incidences of conduction abnormalities.
The second concern expressed was the sacrifice of one or two internal thoracic arteries. The importance of the internal thoracic artery as a conduit for coronary revascularization is well recognized. To justify this decision, we investigated the incidence of a second surgical intervention for coronary artery disease in patients who had isolated valve surgery. This topic was addressed by Lytle and associates [7]. Lytle and associates reviewed 1,317 patients undergoing primary isolated aortic valve replacement between 1972 and 1983. Mean follow-up on these patients was 8.6 years and there were 11,328 patient-years of follow-up available for analysis. In this group of patients, only 21 (1.6%) underwent reoperation for coronary artery disease. Of these, less than 25% had the internal thoracic artery used at reoperation. Although it is impossible to predict the potential for reoperation for coronary artery disease in a patient with isolated valve disease, it appears to be relatively low. With the knowledge that several other arterial conduits are available, the advantage of an intact pericardium at reoperation must be weighed against the loss of the internal thoracic artery.
Concern has also been expressed about the stability of the anterior chest wall. In the majority of cases, there is a slight bulging of the chest wall during coughing. This becomes stable over several months and has not required any reoperations or caused significant disability to patients.
Surgeons have been concerned about the potential for cerebrovascular accidents secondary to the inability to carefully remove air from the left ventricle. There is no indication that this is a major factor. We have carefully monitored the left ventricle for air using transesophageal echocardiography, which provides invaluable information. This approach, coupled with a vent in the ascending aorta and a partial clamp on the ascending aorta to trap air, seems to avoid this complication.
The main impediment to adoption of any new surgical approach is that it requires the learning of a new technique. Resistance to this is always significant; however, patients are resistant to procedures requiring median sternotomy. This lesson was driven home by the widespread patient acceptance of percutaneous transluminal coronary angioplasty. Rather than undergo surgical revascularization, patients were virtually unanimous in their willingness to accept the alternative of percutaneous transluminal coronary angioplasty, which carries a risk similar to that of coronary artery bypass grafting, a higher requirement for additional procedures, no long-term cost or survival advantages, and less relief of angina. The major advantage of percutaneous transluminal coronary angioplasty is avoiding the sternotomy. Ultimately, we must listen to our patients and strive to provide the same quality of care and outcome with less morbidity.
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Addendum |
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To optimize exposure and avoid the disadvantages noted with the parasternal incision, we have experimented with several other small incisions. Currently, our incision of choice is a ministernotomy extended into the fourth interspace on the right. We have found that this enables us to cannulate centrally and preserve the internal mammary artery, and that it provides excellent exposure for aortic, mitral, and tricuspid valves. This incision has been associated with excellent wound healing, and has the advantage of minimal trauma.
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Discussion |
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Our results basically agree with Dr Cosgrove’s that the advantages of this approach are not in a dramatic reduction in the patient’s length of stay in the hospital, but what we have found has been a more rapid trajectory in the rate of recovery in the 1 to 3 weeks after the operation. So my first question would be to ask Dr Cosgrove about the relative recovery of these patients versus those with median sternotomy.
The other question I have has to do with arrhythmias. Because this particular approach to the mitral valve is not typical for most of us and has been associated in the past with sinus node dysfunction and bradycardias, I wonder whether the rate of arrhythmias is at all increased, whether pacing is required, and whether this is a long-term problem.
Second, the incidence of stroke in the mitral group, which comprised 2 patients, or 4%, seemed somewhat elevated, and I wonder if these are at all a result of deairing, because those who have not done minimally invasive procedures have been concerned about the ability to deair the heart with this approach.
Next, the durability of the procedure was not described, as this report does not give us long-term follow-up. I wonder if any of these patients have required reoperation at any time.
Finally, the patients presented here are a group of patients with relatively good risk, and some surgeons have touted the benefits of minimally invasive operations as allowing even higher risk patients to go through the operations with less morbidity. I wonder at this point, having seen the feasibility of this approach, whether patients with renal insufficiency or respiratory dysfunction now are done with the minimally invasive approach and can safely go through these operations less traumatically.
DR LARS G. SVENSSON (Burlington, MA): I also rise to congratulate Dr Cosgrove on an excellent study and also for introducing these novel and innovative techniques. He has also introduced the important principle of tailoring the minimal access incision for the operative site that requires operation. For some patients in whom we have needed a bit more exposure (for example, composite valve grafts, reoperations, and where the hemiarch has needed to be fixed), we have used a J incision, starting either in the first intercostal space or the sternal notch, and then coming down to the third or fourth intercostal space on the right side. We have found this to be a useful incision that has not required ligation of the mammary artery.
What we have noticed in some of our patients is that when the pericardium is tented up the right-sided pressures increase and left ventricular dysfunction occurs. Furthermore, when one comes off pump, the anesthesiologists are very keen to start giving a whole lot of inotropic agents. We have taken the course of releasing the sutures and allowing some time for the heart to recover, and with that the problem has resolved. I was wondering if you could comment on what you think the reasons are for this. Is this a left ventricular filling dysfunction or a type of cardiac tamponade, and how do you manage it?
Finally, we have looked at our patients, because of this, with some concern about left ventricular protection and have noticed that on transesophageal echocardiography, measurement of creatine kinase-MB levels, and electrocardiographic studies, there is no evidence of left ventricular dysfunction or injury. We think this is a temporary problem, and I was wondering if you could comment on this. Congratulations once again on a fine study.
DR RICARDO J. MORENO-CABRAL (San Diego, CA): I rise to congratulate Dr Cosgrove for his outstanding results and to suggest an alternative approach that may be more appealing to surgeons familiar with the midline sternotomy and also to some female patients.
About 3 years ago, we used a T-shaped lower sternotomy for coronary bypass grafting in a patient with a permanent tracheostomy. This incision extended from the side of the xiphoid to the second or third intercostal space without cutting the manubrium.
We have now used this incision in about 20 patients, not only for mitral and aortic valve replacement or repair, but also for repair of septal defects and for coronary bypass grafting including the internal mammary. Exposure is enhanced by placing an internal mammary retractor. By lifting the manubrium, it is easier to cannulate the ascending aorta directly. We have had some difficulty obtaining satisfactory exposure in patients with a barrel chest, but in general this incision has provided satisfactory exposure and easy access for myocardial protection and deairing. In your experience, have you encountered difficulty with exposure in patients with a barrel chest when you used the transverse or parasternal incision, and how have you managed these patients?
DR COSGROVE: Our entire experience in 1966 was 236 procedures, of which 116 were on mitral valves, 94 were on aortic valves, and the remainder were on various combinations of valves, coronary arteries, atrial septal defects, ascending aortas, tricuspid valves, and others. The operative mortality rate was 0.9%.
Conversion to sternotomy was required in 6 patients. Patients who have pectus excavatum present the greatest problem. Very often the heart lies completely in the left chest and it is very difficult to approach the mitral valve through this incision. Pectus excavatum and reoperations are our current contraindications.
Recovery in patients undergoing minimally invasive procedures was significantly more rapid. The hospital length of stay was shortened, as was the rapidity with which these patients returned to full activity. No long-term follow-up is available in these patients, although 2 of the 236 patients required reoperation, 1 for mitral insufficiency and the other for an atrial septal defect.
The Guiraudon incision passes through the sinoatrial node artery in 100% of the cases. Transient nodal rhythm occurred in many of these patients, requiring atrial pacing for approximately 24 hours. There were no increased incidences of pacemaker requirements or nodal rhythm. This is confirmed by three reports in the literature that show exactly the same result.
A study performed by our cardiologists comparing patients with this incision with patients with other incisions shows a lower incidence of atrial fibrillation in the postoperative period. The reasons for this are not clear.
Doctor Svensson raises an interesting point regarding the compression of the right ventricle and low cardiac output afterwards. It is important that one release the traction sutures on the pericardium, as one can compress the heart against the posterior sternum by tension on those.
Finally, I would like to add that these smaller incisions are not the final word. We have learned that cardiac surgeons have tremendous imaginations and that they will learn to make an incision that is appropriate for the operation. With this, we will find a more rapid recovery for our patients and fewer complications associated with the perioperative period.
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References |
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TopAbstractIntroductionMaterial and methodsResultsCommentAddendumDiscussionReferences |
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