Eur J Cardiothorac Surg 1999;16:S84-S85
© 1999 Elsevier Science NL
Minimally aortic valve surgery avoiding sternotomy
Federico Benetti*,
Jose Luis Rizzardi,
Claudio Concetti,
Mariana Bergese,
Alejandro Zappetti
Benetti Foundation, Entre Ríos 134, Rosario, Santa Fe, Argentina
* Corresponding author. ME de Alvear, 2323 2C122 Capital Federal, Buenos Aires, Argentina. Tel.: +54-1-210-800; fax: +54-1-210-800 (Email: fbenetti{at}infovia.com.ar).
 |
Abstract
|
|---|
Objectives: Minimally invasive valve surgery, although still in its pioneer era, can open new horizons in cardiac surgery. Following that trend we started aortic valve surgery through a right anterior minithoracotomy using a novel approach under 3-D video-assistance in most of the cases. Methods: Aortic valve replacement avoiding sternotomy through a right thoracotomy was performed in seven patients (14% were female, average age: 58 years) There were five aortic stenoses and two aortic insufficiencies. In four patients we employed central aortic and right atrium cannulation and in three, femoral artery returns. Antegrade cardioplegia was used in all patients. Results: The operative mortality was 0%, four patients received a mechanical aortic valve, two patients received a biological valve, and in one patient a decalcification of the valve was performed. The mean pump time was 110' (70–146), the mean cross-clamp time was 72' (52–95), the mean hospital stay was 7.7 days (4–11 days). One patient died 7 months after the operation of pulmonary insufficiency, the rest of the patients are alive and improved the clinical situation. Conclusions: This access produces an operative view adequate to safely perform aortic valve surgery. Therefore, removal of ribs or cartilage fragments is not necessary, which results in a less traumatic and less painful approach. Within this is a potential good approach for patients with sternal problems (radiation), redo in certain situations (example previous coronary surgery with LIMA open to LAD). Young patients are potential candidates for future coronary surgery as well as patients with long thoracic cavity and deep aortic plane.
Key Words: Minimally aortic valve surgery • Aortic valve surgery via minithoracotomy • Video-assisted aortic valve surgery • VISTA series 8000
|
1. Introduction
|
|---|
We performed for the first time the thoracoscopy to dissect the mammary artery and perform the coronary anastomosis through a small anterior incision in the beating heart [1]. Then, a big movement started all over the world with a different contribution called minimally invasive cardiac surgery [2–9]. For us, the definition of minimally invasive cardiac or cardiovascular surgery: is a method of treatment of the cardiac or cardiovascular disease. To achieve the best long-term results, in terms of surviving and quality of life for the patients. With less trauma and faster recovery of the treatment at the lower economic impact to the society as possible. In order to attempt this definition, we started using different approaches in mitral and aortic valve surgery avoiding median sternotomy under video-assistance, using 3D in most of the experience [10,11].
|
2. Materials and methods
|
|---|
From August 1996 to August 1998, seven patients were operated through a right anterior minimally thoracotomy (14% were female), the average age was 58 years (42–81), five were aortic stenosis and two aortic insufficiency. Three were in Class IV, two in Class III and two in Class II of the New York Heart Association Classification. Four patients were opened in the third right anterior intercostal space (ICS) and three in the second right anterior ICS. In four patients we used central cannulation (ascending aorta and right atrium), in three patients the femoral artery was cannulated for arterial return and the right atrium for venous return.
In all patients antegrade cardioplegia was used; in two patients crystalloid cold cardioplegia and in five patients cold blood cardioplegia. The left ventricles were vented, in two patients from the left atrium, in three patients through the main pulmonary artery and in two patients directly through the aortic valve.
The 3-D camera system (Vista series 8000) was inserted into the upper part of the retractor before going on cardiopulmonary bypass. It was adjusted, so that the surgeon could look either direct through the chest incision or indirect through the headsets into the operative field during the different steps of the procedure without the necessity to move his head. Aortotomy was performed and the valve was inspected and decalcified, if necessary. As stitches for valve implantation were put at the left side of the valve ring, the mitral valve apparatus or even the cavity of the left ventricle could be appreciated. After prosthesis implantation the camera was taken out and CPB cannulas were removed. Hemostasis was performed and the wound was closed in layers.
|
3. Results
|
|---|
The operative mortality was 0%; four patients received a mechanical prosthesis, two patients a biological valve and on one patient decalcification of the valve was performed. The mean pump time was 110' (70–146), the mean cross-clamp time was 72' (52–95), and the mean hospital stay was 7.7 days (4–11). One patient died 7 months after the operation due to pulmonary insufficiency, the rest of the patients are alive and improved the clinical situation. Five of them were found to be in class I-II and one in class I-III of the New York Heart Association 24 months postoperatively.
|
4. Discussion
|
|---|
This access produces an operative view adequate to safe aortic valve surgery. Removal of ribs or cartilage fragments is not necessary, which results in a less traumatic and less painful approach. we think this is a potential good approach for patients with sternal problems (radiation), redo in certain situations (previous coronary surgery with LIMA open to LAD), young patient potential candidates for future coronary surgery and in patients with long thoracic cavity and deep aortic plane.
The use of 3D Vista Series 8000 in this series was very useful to put the stitches in the left side of the aortic annulus for decalcification of the aortic valve, for exploring inside the left ventricle and cleaning the rest of the debris and calcium, or even to visualize the mitral valve apparatus.
Minimally invasive valve surgery, although still in its pioneering era, can open new horizons for cardiac surgery. In fact, along with the widespread and well-defined application of video-assisted thoracic surgery minimally invasive coronary and valvular procedures are the reenergizing forefront of the future evolution of cardiac surgery, and could offer concrete benefits to patients with cardiac disease.
|
Footnotes
|
|---|
Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3– 5, 1998.
|
References
|
|---|
- Benetti F, Ballester C, Barnía A, et al. Uso de la toracospoía en cirugía coronaria para disecciónde la arteria mamaria interna. Prensa Méd Argentina 1994;81:877-879.
- Benetti F, Ballester C. Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. J Cardiovasc Surg 1995;36:159-161.[Medline]
- Benetti F, Ballester C, Sani G, Boonstra P, Grandjean J. Video assisted coronary bypass surgery. J Cardiovasc Surg 1995;10:620-625.
- Subramanian VA, Sani G, Benetti FJ, Calafiore AM. Minimally invasive coronary bypass surgery: a multi-center report of preliminary clinical experience. Circulation 1995 (Nov)..
- Carpentier A, Loulmet D, et al. First open heart operation (mitral valvuloplasty) under video-surgery through a minithoracotomy. C.R. Academie Sci, Paris 1996;319:219-230.
- Chitwood WR, Elbeery JR, Chapman WH, et al. Video-assisted minimally invasive mitral valve surgery: the ‘micro-mitral' operation. J Thorac Cardiovasc Surg 1997;113(2):413-414.[Free Full Text]
- Cosgrove 3rd DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62(2):596-597.[Abstract/Free Full Text]
- Lin PJ, Chang CH, Chu JJ, et al. Video-assisted coronary artery bypass grafting during hypothermic fibrillatory arrest. Ann Thorac Surg 1997;63:1113-1117.[Abstract/Free Full Text]
- Lin PJ, Chang CH, Chu JJ, et al. Video-assisted mitral valve operation. Ann Thorac Surg 1996;61(6):1781-1786Discussion 1786–1787.[Abstract/Free Full Text]
- Benetti FJ, Mariani MA, Rizzardi JL, Benetti I. Minimally invasive aortic valve replacement. J Thorac Cardiovasc Surg 1997;113(4):806-807.[Free Full Text]
- Benetti FJ, Rizzardi JL, Pire L, Polanco A. Mitral valve replacement under video assistance through a minithoracotomy. Ann Thorac Surg 1997;63(4):1150-1152.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
D. L. Ngaage, M. E. Cowen, S. Griffin, L. Guvendik, and A. R. Cale
The impact of symptom severity on cardiac reoperative risk: early referral and reoperation is warranted
Eur. J. Cardiothorac. Surg.,
October 1, 2007;
32(4):
623 - 628.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Farhat, S. Aubert, P. Rosamel, and O. Jegaden
Inferior T Hemisternotomy After Previous Bypass Grafting With the In Situ RITA in Front of the Aorta
Ann. Thorac. Surg.,
October 1, 2005;
80(4):
1532 - 1533.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
1. Introduction
