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Eur J Cardiothorac Surg 1998;14:S143-S147
© 1998 Elsevier Science NL

Mitral valve operation via Port Access versus median sternotomy 1

Donald D Glower*, Kevin P Landolfo, Fiona Clements, Norbert P Debruijn, Mark Stafford-Smith, Peter K Smith, Francis Duhaylongsod

Departments of Surgery and Anesthesia, Duke University Medical Center, Durham, NC 27710, USA

* Corresponding author. Box 3851, Duke University Medical Dented, Durham, NC 27710, USA. Tel.: +1 919 6815789; fax: +1 919 6818912; e-mail: glowe001@mc.duke.edu


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: The advantages and disadvantages of minimally invasive Port Access mitral valve operation have not been defined relative to standard median sternotomy. A study was therefore designed to delineate differences in outcome from mitral operation via Port Access versus sternotomy in comparable patients. Methods: The records of 41 consecutive patients undergoing isolated mitral valve replacement (n=14) or repair (n=27) were examined. All operations were performed using cardioplegic arrest through either median sternotomy (n=20) or a small right anterolateral thoracotomy using an endoaortic clamp and catheter system (Heartport, Redwood City, CA) to arrest and decompress the heart (Port Access, n=21). Results: Both groups were well matched for age, mitral pathology, ejection fraction, and comorbidity, except that Port Access patients were less likely to be female. Three patients had undergone previous cardiac operations. Surgical procedure time was longer for Port Access patients (384±80 vs. 263±41 min, P<0.05). Port Access provided significantly smaller incision length (8±2 vs. 26±2 cm, P<0.01) and similar or shorter hospital stay (6±4 vs. 7±3 days). Port Access provided excellent visualization of the mitral valve and subvalvular apparatus, generally better than sternotomy, to allow complex mitral valve repairs. The greatest advantage of Port Access mitral operation was that Port Access patients returned to normal activity more rapidly (4±2 vs. 9±1 weeks, P=0.01) than did patients undergoing standard median sternotomy. Conclusions: By avoiding a sternotomy, Port Access mitral valve operation provided a smaller incision and a dramatically more rapid return to normal activity than did median sternotomy. Port Access cardioplegic arrest with the Heartport system allowed visualization of the mitral valve superior to median sternotomy and has become the standard approach at this institution.

Key Words: Minimally invasive • Mitral repair • Mitral replacement • Endoaortic clamp


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Mitral valve operations have been performed through an anterior thoracotomy or median sternotomy since the early days of cardiopulmonary bypass [7]. With the introduction of minimally invasive coronary bypass procedures, interest has been rekindled in minimally invasive mitral operations. Several minimally invasive approaches to the mitral valve have been described, including parasternal incision [9]and right anterolateral thoracotomy [2, 6, 8]. Originally intended as a purely thoracoscopic procedure, Port Access cardiac operations were developed by Stevens et al. [11, 12]to combine thoracoscopy and a limited thoracotomy with specialized catheters to arrest the heart and provide cardiac decompression. The Port Access technique has only recently been applied to treat clinical mitral valve disease [6].

While minimally invasive mitral valve procedures have become the focus of intense interest, the advantages and disadvantages relative to median sternotomy approach have not been defined. The initial results of Port Access mitral valve operation were therefore compared to those from median sternotomy in comparable patients at a single institution.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Forty-one consecutive patients underwent isolated mitral valve operation using cardioplegic cardiac arrest. The first 20 patients underwent median sternotomy. After the Heartport (Redwood City, CA) catheters became available in September, 1996, the subsequent 21 patients underwent Port Access operation using the Heartport system [10–12]and a small right anterolateral thoracotomy [6]. All patients were operated by the same two surgeons using the same techniques of mitral valve replacement or repair. All patients received temporary right ventricular and right atrial pacing wires, except for three patients with Port Access and dense pericardial adhesions preventing ventricular wire placement.

Median sternotomy patients underwent anesthetic induction followed by a standard median sternotomy [3]. After cannulating the ascending aorta and the inferior and superior venae cavae, cardiopulmonary bypass was initiated at 26–28°C. The ascending aorta was clamped. and intermittent cold-blood cardioplegia was administered with an initial dose through the ascending aorta. Subsequent cardioplegia doses were given through a retrograde catheter placer into the coronary sinus via the right atrium. The left atrium was opened anterior to the right superior pulmonary vein. The mitral valve was repaired or replaced using standard techniques [4, 5], and the sternotomy was closed using stainless steel sternal wires [3].

Port Access patients underwent anesthetic induction and were intubated with a dual-lumen endotracheal tube. A transcranial Doppler flow meter was placed to follow symmetry of cerebral blood flow. Using transesophageal echocardiography and/or fluoroscope, a percutaneous endocoronary sinus catheter (Heartport, Redwood City, CA) was placed into the coronary sinus via the right internal jugular vein. A second percutaneous endopulmonary vent catheter was placed into the pulmonary artery via the right internal jugular vein using a balloon-tipped guide which was then withdrawn (Heartport) (Fig. 1 ). A small right anterolateral thoracotomy was then performed through the bed of the right fifth or fourth rib, from which a 6-cm segment was resected (Fig. 2 ). A soft tissue retractor was placed in the incision (Heartport) (Fig. 2). Through a 4-cm transverse incision, the right femoral artery was cannulated with a 21 Fr or 23 Fr arterial return cannula, and the right femoral vein was cannulated through a purse-string of 5–0 polypropylene using a 28 Fr venous-return cannula which was placed over a wire into the right atrium using transesophageal echocardiography and/or fluoroscope. Cardiopulmonary bypass was initiated at 26–28°C using a standard membrane oxygenator and roller pump with augmentation of venous return by an additional centrifugal pump head (Fig. 1). The heart was arrested with a single anterograde dose of cold-blood cardioplegia given through a balloon-tipped catheter (endoaortic clamp, Heartport) placed through the femoral arterial cannula into the distal ascending aorta using transesophageal echocardiography and/or fluoroscopy [11, 12]. Subsequent cardioplegia was given via the percutaneous coronary sinus catheter.


Figure 1
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  		Fig. 1. Patient preparation for Port Access mitral valve operation with a dual-lumen endotracheal tube, percutaneous placement of the endocoronary sinus catheter (A) and the endopulmonary vent catheter (B), cannulation of the right femoral artery (E) and vein (D), and placement of the endoaortic clamp (C) into the aortic arch. A 6-cm anterolateral thoracotomy was performed through the bed of the right fifth or fourth rib (H). Cardiopulmonary bypass was performed using a membrane oxygenator and pump (G) with augmentation of venous return by an additional centrifugal pump (F).

 

Figure 2
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  		Fig. 2. Surgical view of the right anterolateral thoracotomy, soft tissue retractor (A), left atrial retractors (B), thoracoscope for illumination and video assistance (C) and sump sucker in the left atrium (D).

 
The left atrium was opened as above, and the mitral valve was exposed using specially-designed atrial retractors passed through the anterior chest wall (Fig. 2). A standard video thoracoscope was passed through the chest wall anterior and lateral to the thoracotomy (Fig. 2) to provide illumination and assist visualization. Mitral valve repair or replacement was performed as above except that a knot thrower was used to secure annular sutures, and specially-designed long instruments (Heartport) were used to manipulate the valve and sutures. Cardiopulmonary bypass was discontinued the femoral vessels were repaired, and the thoracotomy was closed.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Median sternotomy and Port Access patients were well matched for age, sex, mitral pathology, ventricular function, and comorbidity except that Port Access patients were less likely to be female (Table 1 ). Three patients had undergone previous cardiac operations. Operations performed (Table 2 ) were mitral-valve replacement (n=14) with either mechanical (St. Jude Medical, n=12) or biological (Carpentier-Edwards standard porcine, n=2) prostheses or mitral-valve repair (n=27) using the techniques of Carpentier [5]. Incision length averaged 8±2 cm for Port Access patients and 26±2 cm for median sternotomy patients. Incision length was 6 cm for the last 11 Port Access patients.


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  		Table 1. Patient characteristics
 

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  		Table 2. Operations performed
 
Aortic clamp times, cardiopulmonary bypass times, surgical procedure times, and operating room times (including induction, line placement, and prep times) were longer with Port Access, although all times have fallen significantly with experience (Table 3 ). Mitral valve visualization was almost always better by Port Access with an excellent view of the subvalvular apparatus being provided.


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  		Table 3. Results
 
Hospital stay, blood use, and intubation time tended to be less for Port Access patients (Table 3). Chest tube drainage did not differ between Port Access and sternotomy patients (Table 3). The incidence of atrial fibrillation was similar for both groups (10/20 median sternotomy, 6/21 Port Access, P=0.16). Subjectively, postoperative pain was similar between the two groups, except that pain tended to resolve more quickly in Port Access patients, and Port Access patients had less difficulty coughing and getting out of bed than did sternotomy patients.

Perioperative complications included right-leg ischemia requiring a fasciotomy in a Port Access patient undergoing a fourth-time re-do procedure with cannulation of the right femoral artery for 5 h. One Port Access patient required conversion to median sternotomy for injury of the superior vena cave during placement of the venous return cannula early in the experience. One median sternotomy patient with severe steroid dependent lung disease died on the sixth postoperative day, from pneumonia. One Port Access patient and one sternotomy patient suffered transient neurological deficits, and one sternotomy patient with preoperative endocarditis experienced femoral artery embolism.

The most clinically-evident difference between the two groups was that Port Access patients returned to work or normal activity much more quickly than did sternotomy patients (Table 3, P=0.01), especially in patients that worked or were active preoperatively.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Because minimally invasive mitral valve procedures are a recent phenomenon, few studies are available to document the results of these procedures. Navia and Cosgrove [9]reported the use of a 10-cm right parasternal incision, direct clamping of the aorta, and transeptal approach to the mitral valve, with cannulation of the femoral artery, femoral vein, and superior vena cave. No complications were observed in 25 patients. Lin et al [8]reported two patients undergoing a small right anterior thoracotomy with femoral vein to femoral artery bypass and ventricular fibrillation for mitral valve operation. Chitwood et al. [2]described a right anterolateral thoracotomy in two patients with cannulation of the femoral artery and vein, direct clamping of the aorta, and use of video assistance. One patient developed deep venous thrombosis. Falk [6]reported the University of Leipzig experience with the Port Access approach in 24 patients undergoing mitral operation. One patient developed aortic dissection.

The current study provides the first detailed information regarding the in-hospital and early course following minimally invasive or Port Access mitral valve operation. Most importantly, the current study is the first to directly compare results from minimally invasive mitral operations to operation through standard median sternotomy in comparable patients. Although the current series is small, the major advantages and disadvantages of Port Access minimally invasive mitral operation were clearly demonstrated.

The greatest benefit from Port Access mitral operation relative to median sternotomy was the faster return to normal activity with Port Access. This benefit may be especially important to the young, physically active patient, although even more elderly and sedentary patients can benefit from a shorter recovery period. This shorter recovery period probably resulted from the fact that a small thoracotomy involving a limited amount of musculoskeletal trauma healed more quickly than did the median sternotomy which required 6 weeks for bone stabilization. Although the number of patients in this series was small, thoracotomies have a lower incidence of wound infection than does sternotomy, and infections of thoracotomy incisions are less costly and less morbid than are infected sternotomies, which often require flap muscle closure.

An additional benefit from Port Access mitral operation was the cosmetic advantage of a 6-cm anterolateral thoracotomy versus a 26-cm median sternotomy. Pain was felt to be subjectively better and of shorter duration with Port Access than with sternotomy, as would be expected with a more rapidly-healing incision. Pain from the small thoracotomy incision also was less likely to impair early postoperative pulmonary toilet or transfer in and out of bed. Blood use, chest tube output, intubation time, hospital stay and the incidence of atrial arrhythmias tended to be similar or lower with Port Access, but these trends were not significant. Yet another advantage of the Port Access approach was that visualization of the mitral valve was generally better through Port Access than through median sternotomy. An anterolateral thoracotomy provided excellent visualization of the anterior mitral annulus (often difficult through sternotomy), and the view of the entire mitral annulus was sufficiently good that the quality of mitral repair may be better with Port Access relative to sternotomy. The view of the subvalvular apparatus for complex mitral repair procedures was also better through the anterolateral thoracotomy due to a more direct line of view.

While minimally invasive Port Access appeared to have advantages over median sternotomy, several disadvantages were also present. Port Access generally involved additional operating-room expenses for the endoaortic clamp, endocoronary sinus and endopulmonary vent catheters, expense for fluoroscopy and transesophageal echocardiography, and longer operating-room time. All of these expenses can be potentially minimized or eliminated with experience in many patients. Data regarding the cost of Port Access versus median sternotomy will require further study. Since the risk of aortic dissection is always low, no study has established whether minimally invasive approaches with cannulation of the femoral artery pose a greater risk of aortic dissection than does sternotomy with cannulation of the aorta. Careful preoperative and intraoperative screening for aorto–femoral vascular disease, at well as attention to detail in instrumenting the arterial system, are clearly important to minimize arterial complications from perfusing the femoral artery.

Simultaneous mitral and tricuspid operation has been easily accomplished. These patients were placed on cardiopulmonary bypass, as in mitral valve procedures, using a cannula in the right femoral artery and. venous cannula placed from the right femoral vein into the right atrium. Once cardiopulmonary bypass was established, a second angled venous cannula was inserted into the superior vena cave through a small port in the right third intercostal space and through a purse string in the caval–atrial junction. The right atrial venous return catheter was then withdrawn into the inferior vena cava, and full cardiopulmonary bypass was accomplished by placing tapes or caval clamps around the inferior and superior venae cavae. The endopulmonary vent was not used in tricuspid valve procedures and the coronary sinus was cannulated directly instead of using the endocoronary sinus catheter. The exposure of the tricuspid valve was excellent without other obtrusive hardware in the right atrium.

Patient selection for Port Access mitral operation was important. Relative contraindications included: presence of peripheral vascular disease, a prior right thoracotomy, presence of a patent mammary artery graft (precluding complete cardiac arrest), and the need for concomitant aortic valve or coronary operation. Presence of a previous median sternotomy can be a relative indication for the Port Access approach to avoid the difficulties and morbidity of repeat median sternotomy [1]. At this institution, 90% of isolated mitral and or tricuspid operations have been performed by Port Access in the last 9 months.

Port Access mitral valve operation provided the advantages of improved cosmetics, more rapid recovery, and better intraoperative visualization in most patients requiring isolated mitral valve operation. This approach should provide a valuable option to the surgeon and to the patient for isolated mitral valve operations.


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


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Braxton JH, Higgins RSD, Schwann TA, Sanchez JA, Dewar ML, Kopf GS, Hammond GL, Letsou GV, Elefteriades JA. Reoperative mitral valve surgery via right thoracotomy: decreased blood loss and improved hemodynamics. J Heart Valve Dis 1995;5:169-173.
  2. Chitwood Jr. WR, Elbeery JR, Chapman WH, Moran JM, Lust RL, Wooden WA, Deaton DH. Video-assisted minimally invasive mitral valve surgery: the `micro-mitral' operation. J Thorac Cardiovasc Surg 1997;113:413-414.[Free Full Text]
  3. Douglas JM Jr, Median sternotomy. In: Sabiston DC Jr, editor, Atlas of Cardiothoracic Surgery. Philadelphia: Saunders, 1995;40–44..
  4. Douglas JM Jr, Mitral valve replacement. In: Sabiston DC Jr, editor, Atlas of cardiothoracic surgery. Philadelphia: Saunders, 1995:389–397..
  5. Douglas JM Jr, Mitral valve repair. In: Sabiston DC Jr, editor, Atlas of cardiothoracic surgery. Philadelphia: Saunders, 1995:398–412..
  6. Falk V, Walther T, Diegeler A, Wendler R, Autschbach R, van Son JAM, Siegel LC, Pompili MF, Mohr FW. Echocardiographic monitoring of minimally invasive mitral valve surgery using an endoaortic clamp. J Heart Valve Dis 1996;5:630-637.[Medline]
  7. Lillehei CW, Gott VL, DeWall RA, Varco RL. The surgical treatment of stenotic or regurgitant lesions of the mitral and aortic valves by direct vision utilizing a pump-oxygenator. J Thorac Surg 1958;35:154-191.[Medline]
  8. Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Chu PH, Chiang CW, Yang MW, Shyr MH, Tan PPC. Video-assisted mitral valve operations. Ann Thorac Surg 1996;61:1781-1787.[Abstract/Free Full Text]
  9. Navia JL, Cosgrove III DM. Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
  10. Pompili MF, Stevens JH, Burdon TA, Siegel LC, Peters WS, Ribakovc GH, Reitz BA. Port Access mitral valve replacement in dogs. J Thorac Cardiovasc Surg 1996;112:1268-1274.[Abstract/Free Full Text]
  11. Stevens JH, Burdon TA, Siegel LC, Peters WS, Pompili MF, St. Goar FG, Berry GJ, Ribakove GH, Vierra MA, Mitchell RS, Toomasian JM, Reitz BE. Port Access coronary artery bypass with cardioplegic arrest: acute and chronic canine studies. Ann Thorac Surg 1996;62:435-440.[Abstract/Free Full Text]
  12. Stevens JH, Burdon TA, Peters WS, Siegel LC, Pompili MF, Vierra MA, St. Goar FG, Ribakove GH, Mitchell RS, Reitz BE. Port Access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]



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