HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David H. Adams Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Adams, D. H. Search for Related Content PubMed Articles by Adams, D. H.

Ann Thorac Surg 1999;68:2213-2214
© 1999 The Society of Thoracic Surgeons

---

Invited Commentaries

^a Division of Cardiac Surgery, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA

e-mail: dhadams{at}bics.bwh.harvard.edu

Invited commentary

Widespread interest in minimally invasive direct access cardiac valve surgery has led to numerous reports in the literature over the past few years. This unrandomized and retrospective review by Szwerc and associates has further clarified the utility of a limited-sternotomy approach to replacement of the aortic valve. It has been previously established that this approach is safe and reproducible, with potential benefit in terms of improved patient satisfaction and earlier return to normal activity [1]. This report again demonstrates that the aortic valve can be safely replaced with limited exposure. Surprisingly, it can be replaced in the same timely fashion as a full sternotomy. So the question is should a limited-sternotomy approach be the gold standard for aortic valve replacement? Additional data provided in this study suggest not. The authors have described three morbidities that occurred with greater frequency in the partial sternotomy group which deserve emphasis. They noted an increased need for post-operative inotropic therapy in the small incision group and noted that limited exposure of the heart may have compromised their myocardial protection because of their inability to topically cool, emphasizing concern regarding right ventricular dysfunction. Echocardiographic documentation of specific wall motion abnormalities would have strengthened this argument, but their finding is still important given the significance of a potential compromise in protection, especially in patients with aortic stenosis and myocardial hypertrophy. The increased incidence of pleural and pericardial effusions in the partial sternotomy group suggests that perioperative drainage of the thoracic cavity may be compromised with a smaller incision and special care should be taken when placing drains in these patients. Finally, their observation of superficial wound inflammation in several smaller incisions, presumably due to traction induced dermal ischemia, suggests that adding incision length may in fact decrease the morbidity of the procedure.

The information provided in this manuscript should help surgeons select appropriate patients for minimally invasive aortic valve surgery and provide them with a warning regarding potential complications in these selected patients. We are continuing to refine our selection criteria for the hemi-sternotomy approach and are in agreement with the authors that younger patients concerned with cosmetics and facing a poten-tial future reoperation are the most logical group that might benefit. We share their concern about myocardial protection and now specifically avoid the small incision in the setting of decreased ventricular function or severe hypertrophy. We are also more likely to avoid the hemi-sternotomy approach in elderly or other high risk patients, including those with respiratory or renal dysfunction because we do find the overall operative time is generally increased. One additional group, not mentioned by the authors, that might benefit from the partial sternotomy approach to aortic valve replacement are patients with patent coronary bypass grafts. We have found this group to have shorter overall operative times and less complications such as bleeding and transfusion requirement compared to patients undergoing repeat full sternotomy [2].

References

1. Cohn L.H., Adams D.H., Couper G.S., et al. Minimal invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 1997;226:421-428.[Medline]
2. Byrne JG, Aranki SF, Couper GS, Adams DH, Allred EA, Cohn LH. Reoperative aortic valve replacement: minimal-invasive vs. conventional approach. J Thorac Cardiovasc Surg 1999; in press.

This article has been cited by other articles:

				R. Sharony, E. A. Grossi, P. C. Saunders, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, P. Ursomanno, F. G. Baumann, A. C. Galloway, and S. B. Colvin Minimally Invasive Aortic Valve Surgery in the Elderly: A Case-Control Study Circulation, September 9, 2003; 108(90101): II-43 - 47. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David H. Adams Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Adams, D. H. Search for Related Content PubMed Articles by Adams, D. H.