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Eur J Cardiothorac Surg 2000;18:282-286
© 2000 Elsevier Science NL

Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery

John G. Byrne1,1, Alexandros N. Karavas, David H. Adams, Lishan Aklog, Sary F. Aranki, Gregory S. Couper, Robert J. Rizzo, Lawrence H. Cohn

Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA

Received 22 March 2000; received in revised form 13 June 2000; accepted 28 June 2000.

Corresponding author. Tel.: +1-617-732-7678; fax: +1-617-732-6559
e-mail: jgbyrne{at}partners.org


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Objective: We developed techniques for ‘inverted T’ partial upper re-sternotomy for aortic valve replacement (AVR) or re-replacement (AVreR) after previous cardiac surgery. We previously reported on decreased blood loss, transfusion requirements and total operative duration when compared to conventional full re-sternotomy. This report updates our series, one of the few to document a substantial benefit from a ‘minimally-invasive’ approach, refines a number of technical aspects of this new approach and reports follow-up. Methods: Between November 1996 and December 1999, we performed 34 AVRs or AVreRs after previous cardiac surgery by use of an ‘inverted T’ partial upper re-sternotomy. There were 25 (74%) men. Median ejection fraction was 54%, range 15–80%. Median age was 72, range 38–93. All were New York Heart Association functional class (NYHA) functional class II or III. Twenty-one (62%) had previous coronary artery bypass grafts (CABG) while 14 (41%) had previous valve surgery. Follow-up was 100% complete for a total of 593 patient months (median 19 months). Results: Twenty-three (66%) underwent AVR of the native aortic valve while 11 (33%) underwent AVreR of a prosthetic aortic valve. There were no intraoperative or valve-related complications, and no conversion to full re-sternotomy was necessary. There were two (5.9%) operative deaths from an arrhythmia on postoperative day 4 and a large stroke during surgery, respectively. Twenty-four (75%) patients were free of major complications. There was no need for reoperation for bleeding and patients required a median of two units of packed red blood cells. Complications included new atrial fibrillation (n=3, 9%), pacemaker implantation (n=3, 9%) and deep sternal wound infection (n=2, 6%). Median lengths of stay in the intensive care unit (ICU) and in the hospital were 1 and 7 days, respectively. There was one (3%) late deep sternal wound infection and 2/32 (6%) late deaths due to congestive heart failure at 22 months and myocardial infarction at 23 months, respectively. Conclusions: Partial upper re-sternotomy presents a safe and effective alternative approach to AVR and AVreR after previous cardiac surgery, and is associated with low morbidity and mortality.

Key Words: Minimally-invasive • Reoperation • Aortic valve replacement


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Aortic valve replacement (AVR) or re-replacement (AVreR) may be particularly challenging in the setting of patent coronary artery bypass grafts (CABGs) and particularly in the setting of a patent left internal mammary artery to left anterior descending coronary artery graft (LIMA-LAD) [1]. Injury to the LIMA-LAD is a major complication, which is not infrequently fatal [2].

We have previously reported a series of 20 patients, in whom partial upper re-sternotomy was compared to conventional full re-sternotomy for AVR and AVreR after previous cardiac surgery. The smaller incision was associated with decreased bleeding, transfusions and total operative duration [3]. This is among only a few reports to-date to document a substantial benefit from a ‘minimal-invasive’ approach, perhaps because reoperative surgery is a more rigorous ‘model’, compared to primary surgery, and differences between groups become apparent only with a more severe model (or much larger numbers). Indeed reoperative surgery may be where the true benefit of ‘minimally-invasive’ approaches resides.

Now, with 34 patients, we have refined a number of technical aspects of this new approach for AVR and AVreR and are able to report follow-up.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
Over a 38-month period between November 1996 and December 1999, 34 patients underwent partial upper re-sternotomy for isolated native AVR or prosthetic AVreR after previous cardiac surgery. No additional procedures, such as CABG, were performed on any patient, with the exception of replacement of the aortic root in three patients. Table 1 summarizes the preoperative patient characteristics.


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  		Table 1. Preoperative patient characteristicsa

 
2.1. Surgical technique
The surgical approach is shown in Fig. 1 . In all patients, peripheral cannulation sites were exposed and dissected prior to partial upper re-sternotomy. An external defibrillator (R2 Stat Padz, Zoll, Inc, Burlington, MA) was placed on the patient prior to draping for subsequent defibrillation, as necessary. A transesophageal echo (TEE) probe was placed in every patient. An ‘inverted T’ [4,5] partial upper re-sternotomy was carried out to the 3rd or 4th intercostal space depending on the estimated position of the aortic valve as documented by TEE. The oscillating saw was used to divide the anterior sternal table while the straight Mayo scissors, under direct visualization, was used to divide the posterior sternal table. The chest wall incision was then extended laterally into the intercostal spaces on both sides. In the setting of a patent LIMA-LAD graft, or other anterior CABG grafts, patients were placed on cardiopulmonary bypass (CPB) prior to partial re-sternotomy. Mediastinal dissection was limited to the ascending aorta for clamping and aortotomy, and the right atrium (RA) only if the RA was cannulated. Although intra-thoracic cannulation was preferred, we frequently used peripheral cannulation even without indications for CPB prior to partial re-sternotomy. This was primarily to avoid clutter in the chest. In patients in whom retrograde cardioplegia was used – and this became standard later in the series – it was delivered via a Heartport® trans-jugular coronary sinus catheter (Heartport®, Redwood City, CA). Vacuum assistance of venous drainage was used in the majority of cases and all recent cases. On CPB, all patients were systemically cooled to 20–25°C. Patients with patent LIMA-LAD grafts were routinely cooled to 20°C. If collateral flow from the patent LIMA-LAD graft flowed out of the left main ostium on CPB and obscured the operative field, pump flows were turned down temporarily to 500 or 100 ml/min, as needed for visualization. Venting was accomplished by placing a pediatric vent through the aortic annulus. The aortic valve operation was then performed based on patient indications by using standard techniques. While completing closure of the aortotomy, intra-cardiac air was removed by insufflating the lungs and decreasing the flows on CPB. Following removal of the clamp and establishment of a rhythm, insufflating the lungs and decreasing the flows on CPB while maintaining a vent in the ascending aorta and the patients in Trendelenberg position further removed air. The patients were also tilted to both sides to aid in the removal of air as documented by TEE. The ascending aortic vent was maintained open until the patient was separated from CPB. Temporary epicardial pacing wires were placed on the anterior surface of the right ventricle before the aortic cross-clamp was removed with the heart completely decompressed. Two 32Fr right-angled sub-mammary chest tubes were placed through the right pleural space, one angled medially into the mediastinum and one angled posterior into the pleural space. Decannulation and closure was then routine.



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  		Fig. 1. The previous sternotomy incision is exposed to the 3rd or 4th intercostal space, depending on the position of the aortic valve as documented by transesophageal echocardiography. The incision on the chest wall is extended laterally into the intercostal spaces on both sides for increased exposure. After dissection of the ascending aorta, paying particular attention to the position of CABG grafts and their proximal anastomoses, cannulation is carried out. In this figure, the ascending aorta and innominate vein are cannulated. Frequently however, other cannulation sites are required due to space limitations in the chest (see text). The ascending aorta is cross-clamped and aortic valve replacement or re-replacement is conducted in the standard fashion.

 
2.2. Patient follow-up
Patients were followed after surgery with clinic visits, initially 4 weeks after surgery and then according to their complaints. Finally, before analyzing our database, we telephoned all our patients and a questionnaire was completed. Major complications and events were recorded.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
Arterial cannulation choices were femoral artery in 18/34 (53%), ascending aorta in 13/34 (38%), and axillary artery in 3/34 (9%). Venous cannulation choices were femoral vein in 23/34 (68%), innominate vein in 6/34 (18%), right atrium in 3/34 (9%) or a combination in 2/34 (6%). Aprotinin was used in 30/34 (88%) of patients. Cardioplegia was given antegrade only in 14/34 (41%), retrograde only in 1/34 (3%) or a combination of both antegrade and retrograde in 19/34 (56%).

Twenty-three of 34 patients (66%) underwent native AVR (typically after CABG) while 11/34 (33%) underwent prosthetic AVreR. The pathologic status of the native AVRs were calcific degeneration in 20/23 (87%), endocarditis in 2/23 (9%) and congenitally bicuspid in 1/23 (4%). The pathologic status of the prosthetic AVreRs were structural degeneration in 6/11 (55%), non-structural degeneration or periprosthetic leak in 5/11 (45%).

Valve choices were St Jude Medical® (Minneapolis, MN) in 14/34 (41%), Carpentier–Edwards® Pericardial (Edwards Lifesciences, Irvine, CA) in 13/34 (38%), Hancock® porcine (Medtronic, Minneapolis, MN) in 3/34 (9%), Homograft in 3/34 (9%) and Freestyle (Medtronic, Minneapolis, MN) in 1/34 (3%). Median cardiopulmonary bypass and aortic cross-clamp duration were 125 (range 90–300) min and 78 (range 45–229) min, respectively.

Postoperative characteristics are summarized in Table 2. There were neither intraoperative deaths nor any valve related complications. There were 2/34 (5.9%) hospital deaths. One patient died due to a cardiac arrhythmia on postoperative day 4, while another patient suffered a large stroke and support was withdrawn. Twenty-four of 32 patients (75%) were free of complications during the hospital course. No conversion to full re-sternotomy was necessary, no injury of CABG grafts occurred and no patient required reoperation for bleeding.


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  		Table 2. Operative patient characteristicsa

 
Follow-up was 100% complete in the 32 survivors for a total of 593 patient months (median 19 months, range 2–39 months). Follow-up data are summarized in Table 3. There were two late deaths due to congestive heart failure at 22 months and myocardial infarction at 23 months, respectively.


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  		Table 3. Postoperative patient characteristics, complications and deathsa

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
‘Minimal-invasive’ cardiac valve procedures have gradually become more accepted as new technologies and instrumentation develop. Several approaches and techniques have already been proposed, but they are mainly focused on primary valve surgery [4–13]. Reoperative procedures are more challenging due to the diffuse mediastinal and pericardial adhesions but also pose an area where ‘minimally-invasive’ procedures may be of most benefit [3,14]. A large incision will increase surgeon's operative field, but is associated with a higher risk of injury of cardiac structures, CABG grafts and greater bleeding and transfusion requirements. A smaller incision, on the other hand, will reduce the area of pericardiolysis, thus limit these effects, and additionally reduce operative duration. The remaining intact lower sternum will preserve integrity of the caudal chest wall, enhancing sternal stability and promote earlier extubation [12], although the incidence of respiratory compromise may not be effected [15].

We have performed over 500 ‘minimally-invasive’ valve operations since 1996 [7]. With increasing experience, we attempted to refine our technique for AVR and AVreR after previous cardiac surgery as an alternative to the conventional full re-sternotomy approach [3]. We have refined certain technical details of the partial upper re-sternotomy approach (Table 4) and, by using these, have not had to convert any patient to a full re-sternotomy. Lateral chest X-ray or transesophageal echocardiography may be helpful in locating the level of the aortic valve and determining the proximity of the aorta to the posterior aspect of the sternum [5]. If necessary, additional information can be obtained with computed tomography (CT) scanning or magnetic resonance imaging (MRI). Also, extension of the sternal incision laterally on both sides through the intercostal spaces helps the reapproximation of the sternum and relieves tension caused by the retractor. In the setting of patent LIMA-LAD graft, we have routinely placed patients on CPB prior to re-sternotomy primarily to aid in rapid cooling should injury to this vital structure occur.


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  		Table 4. Late eventsa

 
Mediastinal and pericardial dissection is limited primarily to the aorta. The right atrium is dissected only for the purpose of cannulation. We believe this limited dissection is the principle reason for decreased bleeding and transfusion requirements [3]. The right ventricle, which is often attached to the sternum, does not need to be dissected, thus injuries are less likely. Also, injuries to and manipulation of patent but atherosclerotic vein grafts can be reduced (‘no-touch’ technique), owed to the less manipulation of the heart [16].

Arterial and venous cannulation sites varied considerably, and this represents the choice of the surgeon for sufficient intrathoracic space availability. Cannulation sites, that were used beside the standard ones, include the axillary artery, innominate vein and percutaneous femoral vein insertion [17,18]. The use of innominate vein or percutaneous femoral vein cannulae, as well as the use of the transjugular retrograde cardioplegia coronary sinus catheter have been extremely helpful in minimizing the dissection of the right atrium, which may be limited due to the small access.

Myocardial protection by routine use of systemic hypothermia and antegrade cardioplegia (CP) as well as retrograde CP delivered by the trans-jugular retrograde coronary sinus catheter has been extremely valuable. Since the patients are cooled systemically to 20°C, (Table 5) we believe that interruption of patent LIMA flow is not necessary for myocardial protection. If blood flows retrograde out of the left main ostium and obscures the operative field, flows were turned down temporarily. This has been our standard approach with reoperative aortic or mitral valve surgery [19] We believe that attempting to isolate the LIMA poses considerable more difficulty than allowing perfusion to the anterior myocardium with very cold oxygenated blood during the procedure. Although cardioplegia ‘washout’ from the patent LIMA-LAD graft may occur, we have not found this to be particularly problematic. If electrical activity is observed – unlikely at 20°C – additional retrograde CP can be given. We have also not placed a vent through the right superior pulmonary vein primarily to avoid the necessary dissection but also to avoid the air which is entrained. Rather, if visualization is poor, the flows are turned down temporarily and this is well tolerated at the cold temperature. Although the CPB duration are necessarily longer due to the need to re-warm, we believe the advantages of less blood loss, transfusions, and avoidance of LIMA-LAD dissection far outweigh the extra 15 min or so to re-warm.


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  		Table 5. Thirteen technical details for successful AVR or AVreR after previous cardiac surgery by use of partial upper re-sternotomy

 
In our experience with 34 patients, the incidence of complications was 25%, which is lower compared to full re-sternotomy of our previous study [3]. Hospital mortality was reasonably low (5.9%) and remained under the US 7.7% hospital mortality of reoperative AVR, according to the STS database for 1997 (http://www.ctsnet.org/graphics/sts/db/us98/gchart66.gif).

In conclusion, partial upper re-sternotomy approach for AVR and AVreR after previous cardiac surgery is a safe and effective alternative to full re-sternotomy and it is associated with low morbidity and mortality. We now consider it our standard approach for isolated elective reoperative AVR/AVreR.


   Footnotes
 
1 http://www.partners.org/bwh/home.html Back


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. Odell J., Mullany C., Schaff H., Orszulak T., Daly R. Aortic valve replacement after previous coronary artery bypass grafting. Ann Thorac Surg 1996;62:1424-1430.[Abstract/Free Full Text]
  2. Gillinov A., Casselman F., Lytle B., Blackstone E., Parsons E., Loop F., Cosgrove D. Injury to a patent left internal thoracic artery graft at coronary reoperation. Ann Thorac Surg 1999;67:382-386.[Abstract/Free Full Text]
  3. Byrne J., Aranki S., Couper G., Adams D., Allred E., Cohn L. Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy. J Thorac Cardiovasc Surg 1999;118:991-997.[Abstract/Free Full Text]
  4. Gundry S. Aortic valve replacement by mini-sternotomy. Oper Tech Cardio-thorac Surg 1998;3:47-53.
  5. Gundry S., Shattuck O., Razzouk A., Rio M.D., Sardari F., Bailey L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
  6. Aklog L., Couper G., Gobezie R., Sears S., Cohn L. Techniques and results of direct access minimally invasive mitral valve surgery: a paradigm for the future. J Thorac Cardiovasc Surg 1998;116:705-715.[Abstract/Free Full Text]
  7. Byrne J., Hsin M., Adams D., Aklog L., Aranki S., Couper G., Rizzo R., Cohn L. Minimally invasive direct access heart valve surgery. J Card Surg 2000 in press.
  8. Cohn L., Adams D., Couper G., Bichell D., Rosborough D., Sears S., Aranki S. Minimallly invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 1997;226:421-428.[Medline]
  9. Cohn L. Parasternal approach for minimally invasive aortic valve surgery. Oper Tech Cardio-thorac Surg 1998;3:54-61.
  10. Cosgrove D., Sabik J. Minimally invasive approach to aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
  11. Klokocovnik T. Aortic and mitral valve replacement through a minimally invasive approach. Tex Heart Inst J 1998;25:166-169.[Medline]
  12. Mächler H., Bergmann P., Anelli-Monti M., Dacar D., Rehak P., Knez I., Salaymeh L., Mahla E., Rigler B. Minimally invasive versus conventional aortic valve operations: a prospective study in 120 patients. Ann Thorac Surg 1999;67:1001-1005.[Abstract/Free Full Text]
  13. Svensson L. Minimal-Access ‘J’ or ‘j’ Sternotomy for valvular, aortic, and coronary operations or reoperations. Ann Thorac Surg 1997;64:1501-1503.[Abstract/Free Full Text]
  14. Tam R., Garlick R., Almeida A. Minimally invasive redo aortic valve replacement. J Thorac Cardiovasc Surg 1997;114:682-683.[Free Full Text]
  15. Aris A., Camara M.L., Casan P., Litvan H. Pulmonary function following aortic valve replacement: a comparison between ministernotomy and median sternotomy. J Heart Valve Dis 1999;8:605-608.[Medline]
  16. Cohn L. Myocardial protection for reoperative cardiac surgery in acquired heart disease. Semin Thorac Cardiovasc Surg 1993;5:162-167.[Medline]
  17. Bichell D., Balaguer J., Aranki S., Couper G., Adams D., Rizzo R., Collins J., Cohn L. Axilloaxillary cardiopulmonary bypass: a practical alternative to femorofemoral bypass. Ann Thorac Surg 1997;64:702-705.[Abstract/Free Full Text]
  18. Zlotnick A., Gilfeather M., Adams D., Cohn L., Couper G. Innominate vein cannulation for venous drainage in minimally invasive aortic valve surgery. Ann Thorac Surg 1999;67:864-865.[Abstract/Free Full Text]
  19. Byrne J., Aranki S., Adams D., Rizzo R., Couper G., Cohn L. Mitral valve surgery after previous CABG with functioning IMA grafts. Ann Thorac Surg 1999;68:2243-2247.[Abstract/Free Full Text]



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