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Eur J Cardiothorac Surg 1998;14:S111-S114
© 1998 Elsevier Science NL

Is the femoral cannulation for minimally invasive aortic valve replacement necessary? ¹

Division of Cardiac Surgery, Juan Canalejo Hospital, 15006 La Coruna, Spain

^* Corresponding author. Tel.: +34 81 178186.

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

 
Introduction: Minimally invasive cardiac surgery through a small transverse sternotomy is a new promising technique that can be considered an alternative in most cases to aortic valve replacement thus reducing surgical trauma and subsequent time of hospitalization. The need to avoid the risks associated with femoro–femoral bypass has lead to the interest in aortic valve replacement (AVR) operations without femoral vessels cannulation. We want to emphasize a few important points of our technique, which differs somewhat from the one applied by Cosgrove and associates. Objective: This study details the approach to the minimally invasive AVR as first described by. Cosgrove et al. without standard femoral cannulation and points out our preliminary clinical experience. Patients and methods: From October 1996 to May 1997 we have operated on 25 patients using minimally invasive AVR (MI-AVR) In 23 cases, access through transverse sternotomy as described by Cosgrove et al., was performed. In two additional cases the chest is opened via a mini-median sternotomy with an `L'-shape extending from the sternal notch to the superior edge of the third interspace. Twenty-three patients underwent AVR through transverse sternotomy. The male/female ratio was 13:10. The mean age was 67 years (range 45–78 years). Seventy-four percent of the patients were over 65. Predominantly, in 43% of cases aortic valve stenosis and in 25% of cases aortic valve regurgitation isolated is presented. In 19 cases, a 10-cm transverse incision is performed over the second interspace. Likewise, in four cases over the third interspace according to the thorax morphology and length of the ascending aorta assessed by chest X-ray films. By convention, cannulation of the ascending aorta and right atrial appendage was performed as usual. In contrast, in one patient (5.5%), cannulation was placed in the superior vena cava and right common femoral vein into the inferior vena cava. In the present series, 15 mechanical prostheses and eight bioprostheses whose used sizes were 19, 21,23, and 25 mm in diameter were placed in four, nine, nine, and one of the cases, respectively. All patients underwent AVR electively and a transesophageal echocardiography probe is made. Results: During surgery, conversion to median sternotomy was not required in any patient. Mean aortic cross-clamp time was 68 min (range 38–90 min). Mean total bypass time was 87 min (range 50–120 min). Mean postoperative bleeding was 434 ml. (range 200–850 ml). Perioperative blood transfusion was required in 17% of the patients. Mean mechanical ventilation time was 7.3 h (range 3–24 h), with a mean ICU stay of 18 h. Mean postoperative hospital stay was 4.5 days (range 3–10 days). In all cases, transthoracic and transesophageal echocardiography were performed postoperatively Prosthetic valve dysfunction was not observed. On the other hand, just one patient (4%) died 5 days after operation due to sudden cardiac death. Further, in two patients (8%), during follow-up, pericardial effusion is detected. In one case, cardiac tamponade with hemodynamic instability required a pericardial window procedure. In addition, in two patients (8%), non-infectious sternal dehiscence required reinforced sternal closure. Conclusions: Minimally invasive AVR surgery without femoral vessel cannulation is a safe procedure with less surgical aggression. After a learning curve, benefits on fast-track programs will be accomplished.

Key Words: Minimally invasive cardiac surgery • Transverse sternotomy • Aortic valve replacement • Cardiac surgery

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

 
Aortic valve surgery has been traditionally performed via a median sternotomy with direct aortic and right atrial cannulation for cardiopulmonary bypass. Recently, the use of a partial sternotomy approach minimizes the potential for wound infection and blood loss, postoperative pain, which generally means comfortable to patients without jeopardizing surgical results.

The original and best-known technique is the minimally invasive Sortie valve replacement cardiac surgery popularized by Cosgrove and associates in 1996 [1–6]. The procedure can be performed through a 10-cm transverse incision in the second intercostal space. In his series, femoral artery cannulation was performed on 86% of cases. Initially, 98% (20 cases) were reported compared with 18% (20 cases) later on. Femoral vein cannulation was performed on 34% of cases.

As has been previously stated, femoro–femoral cannulation can be troublesome in the early post-bypass period. In support of this attitude, we use standard techniques for cannulation and cardiopulmonary bypass, using anterograde blood cardioplegia. It has yielded excellent results in these twenty-three consecutive cases, with no patients being returned to the operating room for bleeding.

This study details the approach to the minimally invasive AVR as described by Dr. Cosgrove without standard femoral cannulation and points out our preliminary clinical experience.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

 
2.1 Patient population (Table 1 )
From October 1996 to May 1997, two surgeons (J.C. and A.J.) have operated on twenty-five consecutive patients using MI-AVR. In Twenty-three cases (92%), access through transverse sternotomy as described by Cosgrove et al. is performed. In two additional cases the chest is opened via a mini-median sternotom with an `L'-shape extending from the sternal notch to the superior edge of the third intercostal space. In this way, ligation of the internal mammary arteries was not required.

2.2 Surgical technique (Table 2 )
All patients underwent AVR electively and a transesophageal echocardiography probe is placed to assist in removing air from the heart before removal of the aortic clamp. Defibrillation pads `Fast-patch' (Physio-control, Redmond, WA) are placed on the patient's back and anterior left chest.

After systemic heparinization, routine cannulation of the ascending aorta is performed with an annulated arterial cannulas 21 or 24 Fr. (Stockert, Munich, Germany), depending upon the patient's body surface area and venous drainage via a dual cannula TR 36–51 Fr. (Research Medical, Midvale, UT), placed in the right atrial appendage is performed as usual. In contrast, in just one case (4%) cannulation was placed in the superior venal cava and right femoral vein into the inferior venal cava due to unallowable access through right atrial appendage.

After cardiopulmonary bypass is instituted, the aorta is crossclamped and for myocardial protection cold intermittent blood anterograde cardioplegia is given directly into the aortic root of the coronary ostia after the aortotomy is performed, and warm blood cardioplegia reperfusion into the aortic root is administered. Additionally after transverse aortotomy three traction sutures placed at the tip of the commisures improved exposure of the aortic valve. The aortic valve is replaced. For Patients over 70 years without atrial fibrillation or chronic anticoagulation, bioprostheses implantation is indicated. The aortotomy is closed with double-line suturing technique.

Before and after Sortie cross-clamp removal, routine deairing of the heart by left atrial and left ventricular aspiration following passive filling and by needle aspiration of the ascending aorta was performed. Adequacy of deairing is assessed by transesophageal echocardiography. Temporary pacing wires are placed on the right atrium appendage and right ventricle with exteriorization through the next upper interspace under cardiopulmonary bypass.. Likewise, before weaning from bypass and decannulation, an intrapericardial drainage tube via the subxiphoid process is placed.

At the time of closure, standard vertical sternal wires (usually two, are placed as in routine cases. Then, the bone is approximated, and two additional vertical wires are placed on each side of the sternum or upper and lower intercostal space in order to decrease tension strength which allows good sternal osteosynthesis. The wound was closed in layers.

2.3 Statistical analysis
All data are presented as mean+standard deviation and/or percentages. The paired Student t-test was used to compare variables. A P<0.05 was regarded as statistically significant.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

 
3.1 Operative results (Table 2)
In our present study, 23 patients had valve replacement. Of these, 15 mechanical prostheses (13 carbomedics; 2 Bjork-Monostruct) and eight bioprostheses (seven Carpentier–Edwards; 1 Hancock II) were implanted. Moreover, because of less patient body surface area, the used prostheses sizes were 19 mm in four cases; 21 mm in nine cases; 23 mm in nine cases, and 25 mm in just one case. The mean acetic cross-clamp time was 69±18.1 min (range 38–90 min). The mean total bypass time was 87±15.4 min (range 50–120 min). The mean operation time was 180 min (range 120–240 min). In 1995, at our institution 45 patients underwent Sortie valve replacement through median sternotomy with the same cardiac surgery team. The mean aortic crossclamp time was 60±15.6 min, which means a comparative increase regarding the mean operative time. The result of the analysis showed that there was no significant statistical differences between both groups.

3.2 Postoperative course (Table 3 )
The mean baseline hematocrilevel was 44±6.3% (range 41–50%), after CPB was 32±4.6% (range 25–35%). The mean postoperative bleeding was 434±187 ml (range 200–850 ml). Perioperative blood transfusion was required in 17% of patients. The mean mechanical ventilation time was 7.3±5.6 h (range 3–24 h) with a mean ICU stay of 18±8.2 h. The mean postoperative hospital stay was 4.5±2.6 days (range 3–10 days). Anticoagulation was controlled with the patient in a ambulatory rule. Moreover, in all cases. transthoracic and transesonhacea echocardiography was performed postoperatively. Prosthetic valve dysfunction was not observed.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

In this regard, also preferred by many as the primary surgical technique approach transversal sternotomy has been used in 23 cases at our institution. As first described by Cosgrove. et al. there is some concern about the sacrifice of the internal mammary arteries and the need for femoral vessels cannulation.

In 1989, the Cleveland Clinic Foundation reported a large series of 1689 patients who underwent aortic valve replacement. At a mean 8.6 years of follow-up, 21 patients (1,6% in total) required coronary artery bypass grafting, most commonly the saphenous vein. Of these, eight patients (0.6%) reoperation for ischemic heart disease was indicated. It seems apparent, therefore, based on this finding, that the internal mammary artery plays a minor role in all patients over 60 years with normal coronary arteries confirmed by angiography at the time of surgical intervention. In fact, the mini-median sternotomy approach has been performed on young patients.

In a series reported by Cosgrove et al. in 1996, femoral artery cannulation was performed on 86% of cases. Initially, 98% (20 cases) were reported compared with 18% (20 cases) later on. Femoral vein cannulation was performed on 34% of cases. Occasionally, femoro–femoral bypass may lead to related problems such as infection, lymphoid fistula, venous thrombosis, arterial wall dissection, and often insufficient venous return. Therefore, a potentially serious complication of prolonged cannulation is distal limb ischemia. Thereby, we suggested not to leave much doubt about the need for standard cannulation. In our present study, 17 of the 23 patients underwent the transversal sternotom approach through second interspace. Notwithstanding, in some instances, we found it difficult to perform standard cannulation. In one patient (4%), a superior venal cava and femoral vein cannulation into the inferior venal cava was required. In light of this, more recently, six patients underwent the transversal sternotomy approach to take into account the thorax morphology and total length of the ascending aorta assessed by chest X-ray films. On these, in four patients a transversal incision exposing the third intercostal space is made suggested by ascending aorta size whereas two patients required access through second interspace. Femoral connulation was not required in any patient.

In the present study, we found there are basically just three postoperative complications for patients who really need medical care. First, a few patients had prolongated hospital stay because of atrial fibrillation presented in 17% of cases. Amiodarone was being used in converting atrial fibrillation to sinus rhythm. Second, in two patients (8%) non-infectious sternal dehiscence was present. As we have already described, a surgical technique for sternal osteosynthesis is used. Third two patients (8%) were admitted at our institution for evaluation of pericardial effusion. Late cardiac tamponade was recorded and pericardial window procedure was carried out.

	5. Conclusion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

 
Our on-going experience indicates that, with proper selection of patients and with more experience with different techniques, minimally invasive aortic replacement surgery without femoral vessels cannulation is safe and cost-effective. Undoubtedly, the procedure is technically more demanding and there is a learning curve, even so, we have experienced lower morbidity.

We believe that this operation will have its place among the techniques of aortic valve replacement. Concomitantly, it may become a viable option for the management of fast-track programs.

	Footnotes

 
¹ Presented at the World Congress on Minimally Invasive Cardiac Surgery, Paris, May 30–31, 1997.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusion References

 

1. Banta HD. Minimally invasive surgery. Implications for hospitals, health workers and patients. BMJ 1993;307:1546-1549.[Medline]
2. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
3. Rodriguez JE, López MJ, Carrascal Y, et al. Susutitución valvular Pórtico par miniesternotomía. Rev Esp Cardiol 1996;49:928-930.[Medline]
4. Lyme B, Cosgrove D, Taylor P, et al. Primary isolated aortic valve replacement. Early and late results. J Thorac Cardiovasc Surg 1989;97:675-694.[Abstract]
5. Lytle B. Minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 1996;111:554-555.[Medline]
6. Gates J, Bichell D, et al. Thigh ischemia complicating femoral vessel cannulation for cardiopulmonary bypass. Ann Thorac Surg 1996;61:730-737.[Abstract/Free Full Text]

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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): Vicente Campos Jose M Herrera Alberto Juffe Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cuenca, J. Articles by Juffe, A. Search for Related Content PubMed PubMed Citation Articles by Cuenca, J. Articles by Juffe, A.