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Ann Thorac Surg 2000;70:1970-1973
© 2000 The Society of Thoracic Surgeons

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Original article: cardiovascular

Right thoracotomy for mitral reoperation: analysis of technique and outcome

^a Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA

Accepted for publication June 21, 2000.

Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, 719 ZRB, 703 S 19th St, Birmingham, AL 35294-0007
e-mail: wholman{at}its.uab.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. This report describes technical details of the right thoracotomy approach for mitral surgery, and analyzes our experience with this procedure for patients with a prior sternotomy. Three methods for myocardial management (hypothermic cardioplegic arrest, beating heart, and fibrillating heart) are compared.

Methods. Records were abstracted of patients who had a right thoracotomy between January 1, 1992 and July 1, 1999 for mitral surgery after at least one prior sternotomy. Demographic, operative, and outcome data were collected for analysis. Telephone follow-up was used to measure postoperative New York Heart Association functional status.

Results. Eighty-four patients (mean age 60 ± 15 years) had reoperative mitral surgery via a right thoracotomy. Myocardial management included ventricular fibrillation in 10 patients, operation on the beating heart in 58 patients, and hypothermic blood cardioplegia arrest in 16 patients. The mean time in the operating room was 185 ± 73 minutes, and the mean duration of cardiopulmonary bypass was 63 ± 56 minutes. There were no perioperative strokes and the prevalence of death for patients who received cardioplegic arrest was significantly higher than the prevalence of death for patients who had mitral surgery with perfused fibrillating or beating heart techniques (p = 0.007; Fisher’s exact test comparing risk-unadjusted mortality).

Conclusions. Right thoracotomy provides efficient exposure for reoperative mitral surgery. Mitral valve procedures on the fibrillating or beating heart are feasible in most patients and are at least as safe as surgery using cardioplegic arrest.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The right thoracotomy approach for isolated mitral valve reoperation minimizes dissection of adhesions, avoids injury to the right ventricle, and prevents damage to arterial and venous coronary bypass grafts [1–4]. Our study retrospectively analyzes an institutional experience with the right thoracotomy approach for mitral valve procedures in patients with prior surgery performed via a median sternotomy. Included in this analysis are a description and comparison of three methods for myocardial management during the procedure (cardioplegic arrest, fibrillating heart, and beating heart), and an analysis of patient outcome.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patient population and analysis methodology
There were 84 patients (44 men and 40 women; mean age 60 ± 15 years) who had a mitral valve procedure performed via a right thoracotomy in this study. All of these patients had at least one prior operation that had been performed via a median sternotomy. These mitral operations were performed between January 1, 1992 and July 1, 1999. Data were abstracted from hospital and clinic charts. Follow-up was conducted by telephone interview, which included a structured questionnaire to evaluate New York Heart Association functional class. Variables were chosen to describe patient demographics, operative procedure, and outcome.

The prevalence and frequency distribution of variables were calculated. Means are displayed in the tables ± standard deviation. The prevalences of risk-unadjusted death were compared according to the method of intraoperative myocardial management using Fisher’s exact test (SAS-PC; Cary, NC). This study was approved by the Institutional Review Board for the University of Alabama at Birmingham.

Technical description of mitral procedure
After induction of anesthesia and placement of a single lumen endotracheal tube, the patient is placed in the lateral decubitus position with the right side up and the right groin vessels exposed by rolling the hips to the patient’s right. Transesophageal echocardiography is used in all cases, and external defibrillation patches are positioned before draping. Cardiopulmonary bypass is usually conducted via femoral-femoral bypass. However, if the patient has important atherosclerotic disease of the femoral or iliac arteries, the aorta is cannulated via the thoracotomy incision. If femoral venous return is inadequate, or the venous cannula cannot be passed to the level of the right atrium, cannulation of the right atrium or vena cavae is used. Femoral venous return is augmented by a centrifugal pump (Medtronic Biomedicus; Eden Prairie, MN). Bypass is conducted at mild to moderate hypothermia.

After initiating cardiopulmonary bypass, the lungs are allowed to collapse. The lateral walls of the atria are exposed. If ventricular fibrillation is used, the patient is placed in Trendelenberg position prior to inducing ventricular fibrillation. Ventricular fibrillation is induced either with electrical stimulation or brief perfusion of the heart at a cold temperature. The external patch electrodes are used for defibrillation at the completion of the procedure, so that dissection of the ventricles for placement of internal paddles is unnecessary. This procedure is performed with the aorta vented.

If the procedure is performed in the beating heart, the patient is placed in Trendelenberg position and rotated to elevate the left atrium relative to the left ventricle. The aorta is vented. At the end of the procedure, the mitral valve is made incompetent while the heart is filled with blood. Ventilation of the lungs is resumed until no air is seen coming from the left atriotomy. The blood lost from the atriotomy during de-airing is recovered with the cardiotomy suction. Transesophageal echocardiography is used to assure thorough de-airing before left atrial closure is completed and left ventricular ejection is allowed to resume.

Cardioplegic arrest is currently reserved for situations in which backflow of blood through an incompetent aortic valve makes visualization of the mitral region difficult. If cardioplegia is used, the cardioplegia delivery catheter is placed in the aortic root, and sufficient aorta is dissected for cross-clamp placement. The proximal anastomoses of aorto-coronary artery grafts are visualized, if possible, so that the cross-clamp can be placed above them. If the grafts cannot be visualized, the aorta is dissected out and clamped as close to the innominate artery as possible.

The thoracotomy incision is made as small as possible to provide adequate exposure. A section of rib is removed posteriorly to minimize uncontrolled rib fractures. However, no other special pain control measures, such as postoperative placement of an epidural catheter or intercostal nerve blocks, were used in these patients.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Of the 84 patients in this analysis, 56 patients had one prior operation via a sternotomy, 20 patients had two prior procedures, and 8 patients had three or more prior procedures. The prior cardiac procedures included a variety of operations for ischemic, valvular, and congenital cardiac diseases. There were 3 patients who had extensive resections of the anterior chest wall prior to a mitral valve operation (2 patients with sternectomy for radionecrosis after mastectomy and 1 patient with prior sternectomy for postoperative mediastinitis). The mean time between the initial operation and the first reoperation was 9.1 ± 0.9 years (range 0.1 to 30.7 years). The mean time between the first and second reoperation was 8.7 ± 7.7 years (range 0.03 to 22.4 years), and the mean time between the second and final reoperation was 7.9 ± 6.5 years (range 0.01 to 16.2 years). The mitral valve procedures included 16 native valve repairs, 41 native valve replacements, six repairs of para-valvular leaks, and 21 prosthetic mitral valve replacements. Mitral valve endocarditis was the indication for surgery in 6 patients (four native valve and two prosthetic valve). Two of the operations were performed on an emergent basis. The intent was to perform mitral valve replacement via a right thoracotomy in all patients. However, 1 patient had dense vascular pleural adhesions in the right hemithorax, thus the mitral valve was replaced via a median sternotomy. All other operations were completed via the planned right thoracotomy approach.

Intraoperative myocardial management changed during the time period under review, as shown in Figure 1. The techniques used during the period under review included ventricular fibrillation at a perfusion temperature of 25° to 28°C in 10 patients, operation on the beating heart at a perfusion temperature of 32° to 34°C in 58 patients, and hypothermic blood cardioplegia arrest in 16 patients. Use of the beating heart technique versus the fibrillating heart technique after 1993 was primarily due to surgeon preference. Cardioplegic arrest was the only method used until 1993, when operation on the beating or fibrillating heart was introduced. After 1993, cardioplegic arrest has mainly been used to decrease blood flow through an incompetent aortic valve that obscured visualization of the mitral valve.

View larger version (27K): [in this window] [in a new window]   Fig 1. Myocardial management methods used for mitral valve operations via thoracotomy. (CP = cardioplegia; VF = ventricular fibrillation.)

The time and mode of postoperative death are summarized in Table 4. Death data were collected from hospital and clinic records, interviews with family members and referring physicians, and Social Security databases. Postdischarge follow-up mortality information is available for 77 patients, with 7 patients lost to follow-up.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Right thoracotomy provides a time-efficient exposure for reoperative mitral valve surgery. The right ventricle and bypass conduits are away from the operative field, and were not injured in any of our patients. In this series, we did not find that a dual lumen endotracheal tube was necessary. Cannulation for cardiopulmonary bypass was typically via the femoral vessels. Yet the aorta, cavae, and right atrium were in the operative field and were easily accessible when they were needed for cardiopulmonary bypass, insertion of a retrograde cardioplegia cannula, or a tricuspid valve operation.

We found that the prevalence of death for patients who received cardioplegic arrest was significantly higher than the prevalence of death for patients who had mitral surgery in the perfused fibrillating or beating heart. The heterogeneity of this relatively small group of patients with regard to demographics, prior surgery, preoperative cardiac function, and co-morbid conditions makes risk adjustment impossible, so we cannot conclude that one technique for myocardial management is superior to another. It can, however, be stated that mitral valve procedures in the fibrillating or beating heart appear to be at least as safe as procedures performed under cardioplegic arrest, provided that appropriate precautions are taken to avoid air embolization. None of the patients in this series suffered an intraoperative stroke, nor was massive ejection of air from the left ventricle seen by echocardiography. Operation on the perfused heart, rather than the heart under cardioplegic arrest with cross-clamping, avoids the problems associated with dissection around the aorta from a right thoracotomy approach. The beating heart technique also eliminates the additional rewarming time that is necessary if a lower temperature is used to maintain fibrillation or as an adjunct to hypothermic cardioplegic arrest.

Durations of the operation and hospitalization were determined. These data can be used as a benchmark. They can also be compared to the results obtained with other techniques, including video-assisted mitral valve surgery. It appears, based on published data [5–8], that a video-assisted approach for reoperative mitral valve surgery will entail a substantially longer operative time, including a longer time on bypass and a longer cross-clamp time. Moreover, it will offer little benefit over the open technique in terms of length of hospitalization or intensive care unit stay.

In summary, the right thoracotomy approach provides a time-efficient exposure for mitral valve surgery in patients with prior operations performed via a sternot-omy. Technical details, including methods for operating on the fibrillating or beating heart, were presented that may be of use to others. Reoperative mitral valve procedures on the fibrillating or beating heart are feasible in most patients and are at least as safe as surgery using cardioplegic arrest.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We gratefully acknowledge the contribution of Timothy J. Ness, MD, Macy C. Smith, Jr, Todd Weiss, MPH, MSPH, and Robert N. Brown, BS to the collection and analysis of the data in this study.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William L. Holman David C. McGiffin James K. Kirklin Albert D. Pacifico Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Holman, W. L. Articles by Pacifico, A. D. Search for Related Content PubMed PubMed Citation Articles by Holman, W. L. Articles by Pacifico, A. D.