Eur J Cardiothorac Surg 1998;14:S126-S129
© 1998 Elsevier Science NL
Minimally invasive aortic valve replacement without sternotomy. Experience with the first 50 cases 1
Carmine Minale*,
Hans J Reifschneider,
Edgar Schmitz,
Frank P Uckmann
Department of Cardiothoracic and Vascular Surgery, Witten-Herdecke University Wuppertal, Wuppertal, Germany
* Corresponding author. Klinikum Wuppertal, Heusner Strasse 40, 42283 Wuppertal, Germany. Tel.: +49 202 8962629; fax: +49 202 8962146.
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Abstract
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Objective: The method of replacing the aortic valve via a mini-thoracotomy has been reported in the recent literature. Although this strategy has clear advantages, further refinements of the process make the procedure even less invasive. Methods: Aortic valve replacement was performed in 50 patients whose age ranged between 49 and 82 years, averaging 68±8.3 years. As access route, a right parasternal mini-thoracotomy of about 8 cm, without rib resection was used. Cardiopulmonary bypass was connected through the same access. Standard surgical techniques and equipment were employed. In all patients a mechanical prosthesis was implanted. Results: There were neither intraoperative complications nor hospital death. All patients could be discharged home at an average of 10±3 days postoperatively. Cardiopulmonary bypass time, aortic cross-clamp time, total operation time averaged 118±32, 70±21, 180±45 min, respectively. Four patients could be extubated in the operative theater, the others on the intensive care units at an average of 12±6 h, postoperatively. One patient with a very thin aortic wall sustained a severe bleeding from the aortic cannulation site during an hypertensive crisis, just after extubation. He had to be re-entered immediately via a median sternotomy. A second patient, who was initially operated on because of a floride aortitis, had a limited periprosthetic leak 2 months postoperatively. The leak was repaired via a median sternotomy. Drainage lost and blood substitution averaged 751±400 and 274±390, respectively. Conclusions: The advantages of the present method include further reduction of hospital trauma, preservation of chest wall integrity, early mobilization and rehabilitation of the patient. Surgical technical improvements include avoidance of groin cannulation, simpler equipment, and an easy access in case of reoperation.
Key Words: Aortic valve • Surgery • Minimally invasive
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1. Introduction
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During recent years, minimally invasive techniques are gaining popularity in all surgical disciplines. In cardiac surgery, myocardial revascularisation through mini-thoracotomy is now, considered a standard procedure, while mitral valve replacement through port-access is still under consideration, and clinical experience is limited to a few institutions. To our knowledge, up to the time of preparation of this manuscript there has only been two reports from the same group in the literature in which a new approach has been proposed to replace the aortic valve via a mini-thoracotomy [1, 2]. The approach described by the authors includes two accesses: a right parasternal incision with resection of two costal cartilages, and a groin incision for femoral connection of the extracorporeal circulation. We have made a few technical modifications to the original procedure to make it simpler and even less invasive. We now perform the operation via a single access and we maintain the anatomical integrity of the chest wall. In the present article we report on our approach along with early results in a series of patients.
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2. Material and methods
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From October 8, 1996 to May 15, 1997, a series of 50 consecutive patients with a severe aortic valve disease underwent aortic valve replacement with a mechanical mini-thoracotomy at our institution. Anagraphic and preoperative data are listed in Table 1
Table 2
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Patients were given total endovenous anesthesia and ventilated via a left double-lumen endotracheal tube. As access route, a right parasternal mini-thoracotomy without rib resection was used. A skin incision 8 cm long was made along the right sternal border (Fig. 1
). In females, a curved incision was made for cosmetic reasons. The pectoral muscle was divided vertically along its insertions to the ribs, close to the sternal border, and undermined up to the mammilla. The thorax was opened via the 3rd intercostal space. The internal mammary artery was double-ligated and severed. The 3rd and 4th costal cartilages were cut close to the sternum and retracted on top of the adjacent ribs by means of a self-retaining retractor. The pericardium was opened longitudinally and suspended with stay sutures. Cardiopulmonary bypass was connected through the same access. The ascending aorta was pulled down with a vessel band inserted between the aorta and pulmonary artery. A 24-Fr. flexible aortic arch cannula (Sarns, 3M Health Care, Ann. Arbor, MI) was then inserted through a purse-string suture on the anterior aortic wall, close to the origin of the common trunk. A standard double-step cannula 36–50 Fr. (Stockert Instruments, Munich, Germany) was inserted through a purse-string suture around the right atrial appendage in the first 25 patients. In the following 25 patients the atrial cannula was replaced by a single-step cannula 40 Fr. (Stockert).
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Fig. 1. Picture taken of a male patient just before discharge. The length of the incision is about 8 cm.
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With partial cardiopulmonary bypass, the aorta was pulled forward so that a 16-Fr. vent cannula (Stockert) could be inserted into the left ventricle via a purse-string suture on the roof of the left atrium (Fig. 2
). For safety, cardiopulmonary bypass was conducted under moderate general hypothermia. The left lung was statically overinflated and the right lung partially collapsed during the phase of valve replacement. The aorta was cross-clamped and opened above the sino-tubular junction. Cold potassium-rich blood cardioplegia was administered either directly into both coronary ostia with two rigid cannulas (DLP, Grand Rapids, MN) in valve incompetence, or into the aortic root in stenosis. A temporary epicardial pacemaker wire was inserted on the front of right ventricle at this time. The aortic valve was resected in all cases and replaced with a mechanical double-leaflet prosthesis by a simple interrupted 2/0 Ethibond (Ethicon GmbH, Norderstedt, Germany) suture technique. Prostheses models and sizes are reported in Table 3
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Fig. 2. Picture taken from surgeon's position. Cannulation of the heart for cardiopulmonary bypass is through the mini-thoracotomy access. AA, ascending aorta; 1, aortic cannula; 2, left ventricle vent; 3, double step right atrial cannula.
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In addition, subaortic myectomy, single and double CABG were, respectively, performed in seven, four, and one patients. In these latter cases, bypasses to the left anterior descending artery and to a circumflex marginal branch were done via an additional left mini-thoracotomy. The aortic wall was closed with two continuous layers of 4/0 Prolene (Ethicon). The left ventricle was deaired both through the cavity vent and through a continuously aspirating needle on the aortic roof. Before removing the aortic clamp, a warm-shot of blood-cardioplegia was given into the aortic root. With the exception of the first six patients, all others were given 100 mg xylocaine directly into the aortic root just after removing the aortic clamp. When needed, the heart was defibrillated by means of disposable paddles placed on the patient's back prior to operation. After rewarming on cardiopulmonary bypass, left vents were removed and the patient weaned off bypass. The heart was decannulated, and a 2nd single temporary pacemaker wire was inserted on the right atrium. Two chest tubes, 24 and a 32 Fr., were inserted into the pericardial and chest cavity, respectively. The pericardium was closed with interrupted sutures, rib cartilages were reduced in their original position and stabilized with Vicryl (Ethicon) sutures. The 3rd intercostal muscle was reattached to the corresponding cartilage with interrupted Vicryl sutures. The 3rd and 4th intercostal nerves were infiltrated with a long-lasting local anesthetic. After the first five cases, a Redon drainage was put regularly between ribs and pectoral muscle in all other patients. The wound was closed in layers.
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3. Results
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There were no intraoperative complications requiring conversion in either extended thoracotomy or median sternotomy. The routinely use of 100 mg xylocaine directly into the aortic root just after declamping in the last 46 cases was followed by a rapid decrease of defibrillation rate of the heart. Only seven of them (15%) did not resume spontaneously a normal cardiac rhythm. Cardiopulmonary bypass time, aortic cross-clamp time and total operation time averaged 118±32 (45–204), 70±21 (30–121), 180±45 (120–285) min, respectively.
Thirteen patients needed slight inotropic support with epinephrine during the first hours after the operation. Four patients could be weaned off the respirator and extubated directly in the operating theater. All others were extubated on the intensive care unit at an average of 12±6 (0–24) h postoperatively, and mobilized on the next day.
Two patients had to be ventilated for 115 and 470 h, respectively. One out of four patients with a severe chronic obstructive lung disease (COLD) had to be reintubated and supported with a ventilator for several days. The data of these latter three cases are not included in the average intubation time.
One patient with a very thin aortic wall sustained a severe hemorrhage from the aortic cannulation site during an hypertensive crisis, just after extubation. He had to be re-entered immediately via a median sternotomy.
The chest-drainage lost and blood substitution averaged 751±400 (230–1600) and 274±390 ml (0–1500) ml, respectively. Twenty-seven (56%) patients did not need any blood transfusion at all.
One patient suffered a transient ischemic attack (TIA) on the 5th postoperative day from which, however, he recovered completely.
There was no hospital death. Patients could be discharged home at an average of 10±3 (4–20) days, postoperatively. Although patient conditions would have allowed an earlier discharge from the hospital, for social reason, in Germany it is uncommon to discharge patients early. Almost all of them are admitted thereafter to specialized hospitals for a 3–4 weeks rehabilitation course.
One of the 1st patients in whom no Redon drain was put under the pectoral muscle had to be readmitted and drained for a superinfected seroma underneath the muscle.
A 2nd patient, who was initially operated on because of a florid non-specific aortitis, had a limited periprosthetic leak 2 months postoperatively. The leak was repaired via a median sternotomy. Also in this case the reoperation was easy to do, as the anterior mediastinum was in native condition and the heart fully covered with pericardium.
At the present time, all patients are alive.
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4. Comment
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Minimally invasive replacement of the aortic valve is suitable for the majority of patients with isolated aortic defects. Concomitant coronary revascularisation is also possible either through the same access or through an additional left mini-thoracotomy.
The technical improvements mentioned above make the approach even simpler and safer. Besides the minimal surgical trauma, the limitation of the wound to a small incision in the chest wall, without further incision of the groin, also provides a good cosmetic result. In women, the wound disappears within a normal neckline. Moreover, there is the advantage of avoiding the healing problems which are very often observed after operations in the groin, especially when patients are mobilized soon after.
Preservation of the anatomical integrity of the chest wall by avoiding rib resection is also advantageous, especially for slim patients. Flail chest is a possible complication in the case of rib resection. We used the same technique that we have employed routinely for decades for operations via thoracotomy accesses. Only the insertion of the ribs to the sternum is cut, whereas the cartilages are neither injured nor stripped.
Despite limited access size, the total duration of the operation and of the single technical steps were not substantially longer than with the conventional approach. However, the limited surgical trauma favored an early extubation and recovery. Rehabilitation of the patients was also favorably affected by the avoidance of the sternotomy. In case of reoperation, the sternal approach is advisable as this route is in native conditions. Heart injuries typically occurring in case of reoperations can be avoided.
In conclusion, single access for minimally invasive replacement of the aortic valve is an excellent option for most patients with aortic valve disease. Typical postoperative complications observed with the traditional approach, namely pains, sternal instability, pseudarthrosis, and overstretching of the sternum with resulting brachial plexus damage, are not expected to occur. It could be also postulated that mediastinal infections are avoided. Patients can be rehabilitated earlier without fear of developing serious problems of healing. Especially in women, cosmetic and psychological requirements are also met. Improvements of surgical techniques also include avoidance of groin cannulation, simpler equipment, and an easy access if reoperation is needed.
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Acknowledgments
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We wish to thank Prof. A. Pierangeli, University Hospital, Bologna, Italy, and Prof. O. Alfieri, Hospital S. Raffaele, Milano, Italy for the invitation to operate on two and one patients, respectively, whose data are part of the present paper, at their institutions. Moreover, we wish to thank the anesthesiologist Dr. Herbert Krauskopf for the quality of the pictures he took during the operations.
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Footnotes
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1 Presented at the World Congress on Minimally Invasive Cardiac Surgery, Paris, May 30–31, 1997. 
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References
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- Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operation. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
- Hearn CJ, Kraenzler EJ, Wallace LK, Starr NJ, Sabik JF, Cosgrove DM. Minimally invasive aortic valve surgery: anesthetic considerations. Anesth Analg 1996;83:1342-1344.[Medline]
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Abstract
1. Introduction
