Eur J Cardiothorac Surg 1999;16:S80-S83
© 1999 Elsevier Science NL
Minimally invasive aortic valve replacement (AVR) compared to standard AVR
Jianshi Liu*,
Alexandros Sidiropoulos,
Wolfgang Konertz
Department of Cardiovascular Surgery, Charite, Humboldt-University, 10098 Berlin, Germany
* Corresponding author. Tel.: +49-30-2802-2606/8280; fax: +49-30-2802-5426
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Abstract
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Objectives: Minimally invasive cardiac surgery has been developed to offer patients the benefits of open heart operations with decreased pain and limited skin incision. A limited superior median sternotomy has been shown to provide a good exposure for aortic valve replacement (AVR) and good results. In this study we report the results of minimally invasive AVR compared to standard sternotomy AVR performed in the same period. Methods: From May 1996 to January 1998, 86 patients received isolated aortic valve replacement by the limited superior median sternotomy(group 1). As a control group (group 2), 78 patients were enrolled who underwent isolated aortic valve replacements by standard sternotomy in the same period. Results: Median ischemic time and median bypass time between the two groups showed no significant difference (P>0.05). Median entire operation time in group 1 was obviously shorter than that in group 2 (P<0.01). Median postoperative drainage was 229 ml in group 1, 369 ml in group 2. The difference between the two groups (P<0.05) was significant. Median postoperative respiratory support time was 7.43 h in group 1, 11.26 h in group 2, with significant difference (P<0.05). Median duration of hospital stay were 6.2 days in group 1, 9.4 days in group 2, with significant difference (P<0.01). Reoperations for bleeding were two in group 1, four in group 2, superficial wound infection and sternum disruption occurred once in group 1 and four times in group 2. There were two hospital deaths respectively in the two groups (not procedure related). Conclusions: The limited superior median sternotomy provides good exposure to the left ventricular outflow tract, aortic valve, ascending aorta, and even to the mitral valve through the roof of the left atrium. Therefore it seems to be suitable for all kinds of aortic valve operations. Besides less pain, shorter skin incision, shorter respiratory support time and lower blood loss, it has more advantages as opening and closure of the sternum is faster; decreasing infection and disruption of the sternum, and finally decreasing the time required for hospitalization and recovery.
Key Words: Minimally invasive surgery • Valve replacement • Partial sternotomy
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1. Introduction
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The advent of minimally invasive surgery has produced remarkable influence on cardiac surgery. Minimally invasive cardiac valve surgery is gaining acceptance. Recently, some new procedures have been reported. From May 1996, a limited superior median sternotomy was used in our institution that simplifies the technique and reduces surgical trauma [1].
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2. Materials and methods
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From May 1996 to January 1998, 86 patients received isolated aortic valve replacements by the limited superior median sternotomy (group 1). As a control group (group 2), 78 patients were enrolled who underwent isolated aortic valve replacements by standard sternotomy in the same period. Patient's demographics and diagnoses in the two groups are given in Table 1
. All patients were free from other concomitant cardiac or noncardiac disease; no additional surgery had to be performed. The mechanical valves used were St. Jude Medical® and Carbomedics®, and the stentless bioprostheses include the Baxter PRIMA® valve, the TORONTO SPV® and the Medtronic FREESTYLE®. The different valve sizes are given in Table 2
, and the different implantation techniques of stentless bioprostheses in Fig. 1.
The surgical procedure has been previously described [1]. A midline skin incision from the first to the third intercostal space about 5–7 cm in length and a partial median sternotomy from jugular notch to the fourth right intercostal space are performed. After excision of the retrosternal fat, the pericardium is incised and hanged on the incision of the skin, exposing the ascending aorta and right atrium. The aortic cannulation is performed at the ascending aorta, and the right atrial cannula is inserted at the right auricle as usual. Cardiopulmonary bypass and cardioplegia are applied by the usual technique. After opening the aorta, three traction sutures at the tip of each commissure are placed and suspended from the drapes under tension, elevating the valve for better exposure (Fig. 2). If it is necessary, a vent can be inserted into pulmonary artery, right superior pulmonary vein or left atrium through the left atrial roof. When the patient is weaned from cardiopulmonary bypass, left pleura is opened and one drainage tube is placed through the fourth intercostal space. The sternotomy is closed with one metal band (B-220 Sterna-Band) and two heavy absorbable sutures.
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3. Results
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There occurred two deaths in group 1, secondary to postoperative multiorgan failure and two in group 2, one respiratory failure, one multiorgan failure. There was no late death. Aortic clamping time and cardiopulmonary bypass time showed no statistical difference between the two groups. Median entire operation time in group 1 was obviously shorter than that in group 2 (Table 2). Postoperative blood loss showed significant difference between the two groups, the volume in group 1 was much lower than that in group 2. Postoperative respiratory support time and hospital stay in group 1 was obviously shorter than that in group 2. (Table 2). Postoperative complications including reoperation for bleeding, sternum infection and disruption, and respiratory insufficiency occurred less frequently in group 1 than in group 2.
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4. Discussion
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Minimally invasive surgery is rapidly becoming an integral part of cardiac surgery. The points of controversy are whether it can provide good exposure for surgeons and beneficial results for patients. The limited superior median sternotomy we introduced simplifies the procedure for surgeons. The small incision makes opening and closing of the sternum easier and faster. The surgical exposure or access to the aortic root it is similar or often better than that from the standard sternotomy. That is related to the fact that not the total anterior mediastinum is dissected, so that the heart remains in a relatively anterior position, and exposure can be enhanced by three traction sutures at tips of the commissures which elevate the valve. Aortic valve repairs and replacements with mechanical grafts or bioprostheses were carried out without difficulty [1].
Comparing with standard sternotomy, this approach did not increase the ischemic and cardiopulmonary bypass time and moreover it reduced entire operation time. The respiratory functions were preserved because only part of the sternum was split. The smaller incision described in this procedure has a number of potential advantages. Clearly, the smaller incision is cosmetically more acceptable to patients. Also patients reported decreased pain. A small wound reduces the potential for wound infection, blood loss and sternal disruption. Patients were extubated earlier and discharged from the hospital earlier.
Some of the novel approaches apply a parasternal access or a transverse sternotomy with removal of the cartilage of the ribs, sacrifice of the unilateral or bilateral intra-thoracic artery and cannulation of femoral vessels for cardiopulmonary bypass [2–6]. A thoracotomy has been found to cause increased pain and decreased pulmonary function postoperatively. Pleural adhesions may cause long term morbidity after a successful open heart operation. The damages of the intra-thoracic artery have a great influence upon sternotomy healing [7,8] and coronary artery bypass operation on the patient in the future. These are not matters with the limited superior median sternotomy.
The limited superior median sternotomy preserves all advantages of the median access. This approach provides access for the surgeon to perform a procedure from the whole ascending aorta to the mid-left ventricular cavity and even to mitral valve through the roof of the left atrium. Therefore it is suitable to all kinds of aortic valve operations. In contrast to the standard sternotomy, it has a number of advantages; such as less pain; shorter skin incision; shorter respiratory support time and lower blood loss, and it makes opening and closing of the sternum easier and faster; decreasing infection and disruption of the sternum, and finally shortening the time required for hospitalization and recovery.
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Footnotes
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Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3– 5, 1998.
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References
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- Bruce W, Lytle MD. Minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 1996;111(3):554-555.[Medline]
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- Gundry SR, Shattuck OH, Razzouk AJ. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65(4):1100-1104.[Abstract/Free Full Text]
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- Grossi EA, Esposito T, Harris LJ. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 1991;102:342-347.[Abstract]
- Zacharias A, Habib RH. Factors predisposing to median sternotomy complications. Deep vs. superficial infection. Chest 1996;110(5):1173-1178.
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Abstract
1. Introduction
