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Eur J Cardiothorac Surg 2000;17:710-713
© 2000 Elsevier Science NL

Limited right anterolateral thoracotomy for mitral valve surgery

Nasser Institute Hospital, 1351 Korneish El-Nile, Cairo, Egypt

Corresponding author. Tel.: +20-2-432-8768; fax: +20-2-432-8763
e-mail: mfiky{at}misrnet.com.eg

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

 
Objective: There has been great enthusiasm in recent years to perform mitral valve surgery through small multiple incisions with the use of the Port Access technique. The procedure is costly, involves a relatively long training curve and leaves the patient with multiple scars in the chest and groin. We used a mini-thoracotomy technique for mitral valve patients and compared our results with the conventional technique. Methods: We randomized 100 consecutive patients presenting to our practice for mitral valve surgery between two groups. The first group (test group) consisted of 50 patients in which mitral valve surgery was performed via mini-right anterolateral thoracotomy approach. The control group (50 patients) underwent classical mitral valve surgery through median sternotomy. Standard aortic and bicaval cannulation with antegrade blood cardioplegia was adopted in both groups. Results: There was no statistical difference between the two groups preoperatively regarding their age, pathology, LV function and male/female ratio. Most of the patients had valve replacement except four in the test group and three in the control group. The incision in the test group was 12–15 cm long in the right submammary groove. Direct aortic cannulation, clamping and cardioplegia administration was achieved in all patients easily. The mean bypass time was slightly longer in the test group (64±12 min) when compared with the test group (59±11 min). The cross-clamp time was lower in the test group (27±8 min) when compared with the control group (31±9 min). There was no hospital mortality in both groups and there was one morbidity in the form of sternal infection in the control group. The mean hospital stay was similar for both groups (7±2 days). Conclusion: The cosmetic appearance in the test group was excellent and the patients’ wounds were scarcely apparent in the female patients. The study demonstrates the efficacy and safety of this older technique, with excellent cosmetic results and no additional cost or risk to the patients.

Key Words: Mitral valve replacement • Mitral valve repair • Minimal invasion

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

 
Right thoracotomy for mitral valve surgery is not a new technique [1,2]. However, the routine approach for the mitral valve in most centers became through use of a median sternotomy incision. It remained a preference in our center to perform the mitral valve surgery utilizing a right thoracotomy, whenever possible, especially for female patients. With the increasing interest in minimally invasive surgery in recent years, we initiated a study to compare the access to the mitral valve through a mini-right thoracotomy incision as opposed to the median sternotomy incision. We aimed to compare the difficulties, limitations, clinical results and cosmetic results of the mini-thoracotomy technique with the standard sternotomy approach. We also aimed to compare the results of the thoracotomy using the innovative Port Access technique [3] to decide whether our Institution should start performing mitral valve surgery using such a technique.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

 
2.1. Material
We included 100 consecutive mitral valve patients presenting to our Institution who were willing to participate in the study on the basis of an informed consent. The exclusion criteria for the study were: (1) previous cardiac surgery, (2) associated coronary artery disease, (3) associated aortic valve disease needing intervention, and (4) failure to give informed consent. The first exclusion criterion is not a contraindication of the right thoracotomy approach; it was, however, decided to exclude previous surgery in order to harmonize the two groups and to fulfill the cosmetic goal of the study.

2.2. Methods
Once the patient entered the operating theater, she/he was randomized to either group by drawing an envelope to decide the approach. The same general anesthetic techniques with routine arterial and venous monitoring were utilized for both groups. For the test group, the patient was positioned on his/her back with a 30° elevation of the right shoulder using a sandbag under the right scapula. The right arm was adequately padded and suspended over the head (attached to the anesthetic screen). The patient was draped in the usual fashion with exposure of the sternum, right chest up to the posterior axillary line and right groin. A 10–12-cm incision was created in the right submammary fold starting 3–5 cm from the lateral border of the sternum. The breast tissues were gently mobilized and the right chest cavity was entered through the fourth intercostal space. A chest retractor was placed and opened gradually so as not to break any ribs. The right lung was compressed with a wet lap to expose the pericardial sac. The right lobe of the thymus gland was dissected and resected totally, taking good care not to injure the phrenic nerve. The pericardial sac was entered through an incision 2–3 cm anterior and parallel to the phrenic nerve extending from the diaphragm to the aortic reflection. The pericardium was then fixed to the wound edge using heavy silk sutures. Heparin was then administrated at a dose 3 mg/kg body weight to achieve an activated clotting time longer than 400 s. Aortic and bicaval cannulation was then performed in the usual manner and cardiopulmonary bypass instituted. After cooling to 32°C, the aorta was cross-clamped using a long curved aortic clamp (to keep it out of the surgeon's field), and aortic root blood cardioplegia was delivered at a dose of 15–20 ml/kg body weight. The left atrium was opened through an incision posterior and parallel to the interatrial groove giving access to the mitral valve. The mitral valve lesion was then dealt with by either replacement or repair. The left atriotomy was closed by a single layer of 3/0 polypropylene suture and de-airing was performed through the suture line before removing the aortic cross-clamp. Following rewarming to 37°C, the heart was allowed to take over the circulation. Decannulation was then performed and the suture line secured before giving the protamine. This was followed by complete closure of the pericardium by interrupted sutures, leaving a small drain. The chest was then closed in layers leaving a separate thoracic drain. Intercostal block was routinely performed using Marcaine to reduce postoperative pain.

As for the control group, the patient was placed supine, the approach was through the standard median sternotomy, but otherwise the operative technique was essentially the same.

The results were presented as mean±1 standard deviation from the mean. Statistical analysis was performed between the two groups using the Mann–Whitney test for parametric data and Fisher's exact test for nonparametric data. A significant difference was recorded if the P-value was less than or equal to 0.05. SPSS for Windows was used for statistical analysis.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

 
Fifty patients completed the study in each group (Table 1). The mean age was 22±10 years for the test group, 23±9 years for the control group; there was no significant statistical difference between the two groups (P=0.65). Most of our patients were females due to the prevalence of the disease and the male/female ratio was not statistically different between the two groups. Rheumatic etiology was the most common cause for valve pathology in both groups; however, few patients with congenital mitral valve pathology were encountered in both groups with no significant difference in the distribution between them. Mitral valve mixed lesions (stenosis and regurgitation) was the most frequently encountered pathology in both groups; however, mitral regurgitation represented 14% (seven patients) in the test group and 10% (five patients) in the control group. Also, isolated mitral stenosis was found in two patients in the test group and two patients in the control group. There was no significant difference between the two groups as regards the preoperative pathology. There was a significant difference between the two groups as regards the preoperative New York Heart Association classification (P=0.05) but not the preoperative left ventricular ejection fraction (P=0.06).

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

One of the disadvantages of the right mini-thoracotomy approach is that it needs a learning curve for the surgeon and team to be able to perform the procedure through a smaller incision, with the right chest retractor, the suitable aortic clamp and arterial and venous cannulae. They may have to start doing this procedure through a more formal incision then gradually reduce the length of the scar. The reason for longer bypass times in the test group is that the cannulation and decannulation of these patients is done in a graded manner to allow maximal safety. Another disadvantage is that the technique is less suitable for obese female patients with pendulous breast in view of avoiding excessive mobilization of the breast tissue. It is also less suitable for patients with previous cardiac surgery unless femoral arterial cannulation is employed [4,5].

The cosmetic end product of the right mini-thoracotomy technique was excellent, especially in young females. The wound was totally not apparent in these patients and more patients requested this approach, which made it difficult for us towards the end of the study to recruit patients.

We examined the literature to compare our approach with the newer and more elaborate technique of Port Access so to assess our need to introduce this technique to our Institution. Although the patient cohort is different in both groups, we were evaluating the need to introduce this novel technique to our Institution for mitral valve surgery. The length of the incision varied from 3.8 to 8.1 cm [3,6–10]. This was not much less than the incision made by our right mini-thoracotomy approach of 11.5±0.7 cm. In addition, in our approach there are no extra femoral or jugular wounds. As for the theater time, it varied between 196±53 [9] and 384±80 min [7] which is significantly longer than their median sternotomy times and definitely longer than the right mini-thoracotomy time (142±20 min). The hospital stay varied between 6±4 days [7], 5–6 days [3] to a mean of 13 days [9], which was not much different to our hospital stay of 7±2 days.

In addition, the Port Access technique is not suitable and totally contraindicated for patients with peripheral vascular disease [3]. This technique also introduced unknown complications for mitral valve procedures such as retrograde aortic dissection [9,11], endoclamp displacement [12] and retention of the pulmonary catheter [13].

The cost aspect of the Port Access system is an additional factor to consider when we thinking of introducing this system to our Institution. We had a quotation from one manufacturer for an additional cost of $4500 per patient. However, some reports indicated that the Port Access system lowers the cost of the procedure [14]. We have decided not to introduce the Port Access technique to our Institution for this subset of patients until it becomes more cost-effective and safer to use.

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

	Appendix A Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

 
Dr D. Wheatley (Glasgow, UK): I think that the most important thing is to show that these patients have a mean age of 22 years. These are severely calcific valves very often. It is the sort of practice that is common in the Middle East, the Far East and many other parts of the world, and the points you make have been very well made indeed. In view of the time we should not have a discussion now, but I think you will find that you have provoked a lot of questions and discussion, which will have to be done outside.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Conference discussion References

 

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