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Ann Thorac Surg 2002;74:43-45
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Minimally invasive tricuspid operation using port access

^a Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA

* Address reprint requests to Dr Glower, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710, USA
e-mail: glowe001{at}mc.duke.edu

Presented at the Video Session of the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Port-access techniques performed through a right mini-thoracotomy have been extensively described for both the mitral and aortic valves. However, reports of tricuspid valve operations using the port-access approach are rare. A technique for minimally invasive tricuspid valve operation using port access is described.

Methods. Port-access approach was applied to 33 consecutive patients undergoing tricuspid valve repair or replacement.

Results. Twelve percent (4 of 33) underwent tricuspid replacement and 88% underwent repair (28 of 33). Perioperative mortality was 6% (2 of 33) and conversion to median sternotomy was 3% (1 of 33).

Conclusions. Port-access tricuspid operations are both feasible and safe with a low conversion rate to conventional median sternotomy.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The minimally invasive port-access approach to cardiac valvular operation uses a small right thoracotomy, cardiopulmonary bypass, with or without endovascular aortic occlusion. Reports from various institutions demonstrate the efficacy of this approach when dealing with aortic or mitral pathology [1–3]. In contrast, reports of tricuspid valve operations using the port-access approach are rare [4]. Because several reports have suggested potential advantages to port-access as an approach for mitral operations [5, 6], the port-access approach to the tricuspid valve may have similar advantages over sternotomy including cosmesis, earlier patient mobilization, lower infection and sepsis, and possibly less bleeding and transfusion. We describe our technique and report on our initial experience of 33 patients with port-access tricuspid valve operations.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients were positioned supine with the right shoulder elevated. After intubation with a dual lumen endotracheal tube, a 6-cm right anterolateral thoracotomy was performed over the fourth intercostal space. The fourth intercostal space was entered. As necessary, the right fourth rib was divided medially at the costochondral junction to facilitate aortic exposure. A reusable chest retractor (Cardiovations, Somerville, NJ) provided upward lift on the third and fourth ribs. The pericardium was opened vertically from the diaphragm to the base of the innominate artery exposing the ascending aorta, staying 1 to 2 cm anterior to the phrenic nerve. Lateral retraction sutures were placed on the posterior pericardial edge, and the patient was heparinized.

In the initial series, a 4 to 5 cm groin incision was used to expose the femoral artery and vein which were cannulated as previously reported after screening the aorta for arteriosclerosis by aortography or transesophageal echocardiography, or both [5, 6]. After 1998, venous access was obtained by passing a percutaneous wire from the right femoral vein into the superior vena cava using transesophageal echocardiography. A 25-French venous catheter (QD-25; Cardiovations, Somerville, NJ) was passed over the wire into the femoral vein using serial dilators. The venous cannula was placed in the right atrium using palpation and transesophageal echocardiography.

A 16-gauge needle was passed through the first intercostal space in the midclavicular line with the needle directed toward the chosen aortic cannulation site 1 to 1.5 cm proximal to the base of the innominate artery. An 11.5 mm port was then inserted along the path of the 16-gauge needle after withdrawing it. When inserted through the port, the aortic cannula and introducer (DF-K-24 or SS-23; Cardiovations, Somerville, NJ) should point directly at the chosen cannulation site. Two concentric pursestrings of pledgeted 2-0 polyester were placed at the aortic cannulation site. Using a retractable blade incorporated into the aortic cannula introducer, the cannula was passed through the port into the pursestring and the aorta. The aortic cannula was secured with plastic tourniquets that were brought through the 11.5 mm port.

After cardiopulmonary bypass was started, vacuum assist was used to provide total drainage of the atrium. Any mitral valve procedure was performed first using either cardioplegic arrest (17 patients) or ventricular fibrillation (16 patients). Cardiac arrest was achieved by external aortic cross clamp applied directly to the ascending aorta below the arterial cannulation site in 1 patient. In this patient, antegrade cardioplegia was delivered through a 4-0 polypropylene pursestring in the ascending aorta, and then the cannula was removed from the field. In 16 patients, initial antegrade cardioplegia was given directly through an endoclamp (EC-65; Cardiovations, Somerville, NJ), which was passed through the aortic cannula and positioned by transesophageal echocardiography. In 12 patients, retrograde cardioplegia was delivered through a coronary sinus catheter and placed either percutaneously (6 patients) or through the thoracotomy into the right atrium (6 patients).

The tricuspid operation was done after completion of any mitral procedure to decrease clamp time and to allow rewarming in patients for whom aortic clamping was not possible and for whom systemic hypothermia was the only option to maintain ventricular fibrillation (because of a scarred mediastinum or open grafts, or both). A 28-French angled venous cannula was placed in the superior vena cava through a pursestring at the base of the superior vena cava. The femoral venous cannula was retracted into the inferior vena cava after placing tourniquets around the superior and inferior vena cava. The tricuspid operation was done during normal cardiac rhythm in all patients to avoid left ventricular distension from ventricular fibrillation and to avoid prolonged aortic clamping. The right atrium was opened with a linear vertical atriotomy, and the right atrium was held open by a dedicated atrial retractor passed through the chest wall (Cardiovations, Somerville, NJ). Standard tricuspid valve repair or replacement techniques were used (Fig 1).

View larger version (122K): [in this window] [in a new window]   Fig 1. Surgeon’s view of the tricuspid valve after repair. Note the excellent visualization of the valve through the mini-thoracotomy. (AC = aortic cannula; SN = snares around the inferior and superior vena cava; SVC = superior vena caval cannula.)

A right pleural chest tube was placed through a separate stab incision. A silicone elastomer sump catheter was placed through the right pleura into the pericardium and brought out through a separate stab incision as well. The pericardium was loosely closed. The thoracotomy incision was closed in a standard fashion using a figure eight, number four sternal wire to repair the fourth rib if divided. The chest tube was removed in 12 hours, and the silicone elastomer drain was removed in 3 to 4 days.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Between 1997 and January 2002, this approach has been used successfully in 33 patients at our institution and remains our first choice in applicable patients. Average age of this group was 62 ± 10 years. Sixty-one percent of patients (20 of 33) were female. Mean ejection fraction was 45% ± 11%. The most common tricuspid pathology was annular dilation, which was seen in 29 of 33 patients (88%). Tricuspid procedures were replacement in 4 of 33 patients (12%), annuloplasty alone in 25 of 33 (76%), and more complex repairs in 4 of 33 (12%). One replacement patient had carcinoid disease, and the other 3 had long-standing rheumatic disease with irreparable tricuspid leaflet scarring in all 3, and mild tricuspid stenosis in 1. Seventy-nine percent of patients (26 of 33) underwent concurrent mitral valve procedures and 18 of 33 (55%) patients had undergone prior cardiac operations.

Femoral arterial cannulation was used in the first 9 patients, and the subsequent 24 patients had central aortic cannulation. Mean aortic cross clamp time was 56 ± 63 minutes with mean cardiopulmonary bypass times of 251 ± 80 minutes. Median chest tube output was 600 mL (range, 114 to 940 mL). The aorta was not clamped in 17 of 33 patients (52%). Median hospital length of stay was 10 days (range, 4 to 82). Mortality and related morbidity is documented in Table 1. There was 1 patient who required a conversion to median sternotomy because of a left ventricular tear resulting from adhesions to a previous left thoracotomy. Stroke occurred in 3 patients who all had femoral arterial cannulation and were all among the earliest cases. Stroke was significantly associated with femoral arterial cannulation (3 of 9 vs 0 of 24; p = 0.03).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Tricuspid valve procedures traditionally have been associated with high operative mortality and morbidity due to the presence of multivalvular disease, systemic disease, and prior cardiac procedures [7, 8]. The conventional median sternotomy carries the risk of bleeding and cardiac injury in the reoperative patient. Obese patients and diabetics are particularly prone to sternal infection and instability. The minimally invasive thoracotomy approach described here may have several advantages over median sternotomy, as have been suggested for minimally invasive thoracotomies of single aortic and mitral valve operations [6, 9, 10]. These potential advantages include avoidance of prior sternotomy incision, better cosmesis, quicker return to normal activity, less incisional pain, less blood loss, and less wound infections [6, 9, 10–12].

Mortality (6%) and morbidity were comparable to that described in other reports [7, 8] using the more conventional approach of median sternotomy. The port-access approach did not compromise the ability to repair the tricuspid valve. The 12% incidence of tricuspid replacement is not significantly different from other large series of tricuspid valve procedures by sternotomy [7]. Indeed excellent results have been reported from very complex mitral repairs using port access [13].

Although the observed 9% stroke rate may seem high, the incidence of stroke after tricuspid valve operation has never really been reported [7, 8]. Previous authors have focused on right-sided events and have not mentioned left-sided complications. Indeed tricuspid surgical patients all have many other risk factors for stroke like chronic atrial fibrillation, severe left atrial enlargement, and often a prior stroke. Moreover, in the current series stroke was associated with femoral arterial cannulation, which is now used more selectively.

Relative contraindications to the port-access approach to the tricuspid valve include the need for coronary bypass grafting, severe pectus excavatum, and aortic diameter greater than 4 cm. Disadvantages to port access in tricuspid valve patients may include the longer learning curve associated with it, the cost of required additional hardware, and the relatively long cardiopulmonary bypass time seen in this study. The mean pump time (251 ± 80 minutes) greatly exceeded the clamp time (56 ± 63 minutes), because in combined mitral and tricuspid procedures (26 of 33 patients [79%]) the tricuspid procedure is performed on a beating heart. These redo combined mitral and tricuspid patients with open grafts, indeed could have had a shorter clamp time and shorter pump time with a redo sternotomy, but at the risk of injury to open grafts or injury to the dilated and scarred right heart. Partial inferior sternotomy, partial superior sternotomy, and right parasternal incision are additional options for the tricuspid patient, but all include the disadvantage of sternal or chest wall deformity from rib excision.

Thoracotomy has been used as an alternative approach to access the tricuspid valve, particularly in patients with previous sternotomy [14]. The majority of previous thoracotomies for tricuspid operations have used a full right anterolateral thoracotomy with standard cardiac cannulation and no aortic endoclamp. Data from reoperative mitral valve patients suggest that this standard thoracotomy may carry significantly more morbidity and perhaps more mortality than that of the smaller right thoracotomy with port access [11].

In conclusion, port access is a recent alternative approach to the tricuspid valve in patients not requiring coronary artery bypass grafting or aortic or pulmonary valve procedures. The results presented herein demonstrate the safety and technical feasibility of this approach.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Mohr F.W., Falk V., Diegeler A., Walther T., Van Son J.A.M., Autschbach R. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:567-576.[Abstract/Free Full Text]
2. Galloway A.C., Shemin R.J., Glower D.D., et al. First report of the port access international registry. Ann Thorac Surg 1999;67:51-58.[Abstract/Free Full Text]
3. Glower D.D., Siegel L.C., Frischmeyer K.J., et al. Predictors of outcome in a multicenter port-access valve registry. Ann Thorac Surg 2000;70:1054-1059.[Abstract/Free Full Text]
4. Robin J., Tronc F., Verdinne C., Champsur G. Video-assisted tricuspid valve surgery: a new surgical option in endocarditis on pacemaker. Eur J Cardiothorac Surg 1999;16:243-245.[Abstract/Free Full Text]
5. Colvin S.B., Galloway A.C., Ribakove G., et al. Port-access mitral valve surgery: summary of results. J Card Surg 1998;13:286-289.[Medline]
6. Glower D.D., Landolfo K.P., Clements F., et al. Mitral valve operation via port access versus median sternotomy. Eur J Cardiothorac Surg 1998;14(Suppl 1):S143-S147.[Abstract/Free Full Text]
7. McGrath L.B., Gaonzalez-Lavin L., Bailey B.M., Grunkemeier G.L., Fernandez J., Laub G.W. Tricuspid valve operations in 530 patients: twenty-five year assessment of early and late phase events. J Thorac Cardiovasc Surg 1990;99:124-133.[Abstract]
8. Glower D.D., White R.D., Smith R., et al. In-hospital, and long-term outcome after porcine tricuspid valve replacement. J Thorac Cardiovasc Surg 1995;109:877-884.[Abstract]
9. Walther T., Falk V., Metz S., et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67:1643-1647.[Abstract/Free Full Text]
10. Grossi E.A., Galloway A.C., Ribakove G.H., et al. Impact of minimally invasive valvular heart surgery: a case-control study. Ann Thorac Surg 2001;71:807-810.[Abstract/Free Full Text]
11. Cohn L.H., Adams D.H., Couper G.S., et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 1997;226(4):421-426.[Medline]
12. Grossi E.A., Galloway A.C., Ribakove G.H., et al. Minimally invasive port access surgery reduces operative morbidity for valve replacement in the elderly. Heart Surg Forum 1999;2:212-215.[Medline]
13. Glower D., Landolfo K., Kypson A., et al. Is port-access applicable to complex mitral valve repair?. Heart Surgery Forum 2001;4:S73.
14. Berreklouw E., Alifieri O. Revival of right thoracotomy to approach atrioventricular valves in reoperations. Thorac Cardiovasc Surgeon 1984;32:331-333.[Medline]

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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): Alan P. Kypson Donald D. Glower Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kypson, A. P. Articles by Glower, D. D. Search for Related Content PubMed PubMed Citation Articles by Kypson, A. P. Articles by Glower, D. D. Related Collections Valve disease