HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lars G. Svensson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Articles by Kimmel, W. A. Search for Related Content PubMed PubMed Citation Articles by Svensson, L. G. Articles by Kimmel, W. A. Related Collections Minimally invasive surgery

Eur J Cardiothorac Surg 2001;19:30-33
© 2001 Elsevier Science NL

Minimal access aortic surgery including re-operations

Center for Aortic Surgery, Lahey Clinic, Burlington, MA, USA

Received 21 August 2000; received in revised form 8 October 2000; accepted 17 October 2000.

Corresponding author. Tel.: +1-781-744-8672; fax: 781-744-5641
e-mail: lars.g.svensson{at}lahey.org

	Abstract

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

 
Objective: Safety and benefits of minimal access ascending aorta and aortic arch surgery, including for re-operations has not been reported. Methods: Fifty-four patients undergoing minimal access operations were evaluated. Of the 54 patients, valve replacements were performed in 76% (41 patients) (including composite valve grafts), and re-operations in 33% (18 patients). Composite valve grafts were used in 28% (15 patients) patients, and elephant trunk type procedures in 6% (three patients). Results: The survival rate was 96% (52 patients), stroke 3.7% (two patients), and neurocognitive deficit 1.8% (one patient). The circulatory arrest time was 20 min (SD 17), aortic crossclamp time 91 min (SD 45) and cardiopulmonary bypass time 132 min (SD 59). Intraoperative homologous blood transfusion was a mean of 1.3 units (SD 2.3). ICU and postoperative stay were 1.8 days (SD 1.9) and 6.7 days (SD 3.7), respectively. No patient died after re-operation, although one patient had a stroke. Conclusions: Minimal access aortic surgery does not appear to carry a greater risk and, although more demanding technically, is associated with a reasonable ICU and hospital stay. For re-operations, we particularly recommend the technique.

Key Words: Minimal access • Minimally invasive • Aorta • Surgery • Cardiopulmonary bypass

	1. Introduction

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

 
Minimally invasive techniques for coronary artery, aortic, and mitral valve operations have evolved rapidly and become part of the surgeons armamentarium [1–10]. Based on a previous study that we performed, there may be some benefit to minimal access techniques as far as the length of stay and discomfort after surgery, in particular for re-operations [4,10]. We wished to evaluate our results with minimal access techniques in patients undergoing aortic surgery for aneurysms or dissection.

1.1. Materials and methods
Fifty-four patients underwent minimal access operations. The mean age was 60.8 years (SD±16.9 years). Valve replacements were performed in 76% (41 patients) (including composite valve grafts) and 33% underwent re-operations (18 patients). Composite valve grafts were used in 28% (15 patients). Thirty-six patients had ascending aorta repairs and 18 had ascending aorta and arch repairs, including elephant trunk type procedures in three patients. Variables and additional procedures are shown in Tables 1 and 2.

Kinetic vacuum assistance for venous drainage was not used except for re-operations when the venous cannula was passed up into the right atrium via the right femoral vein using a Seldinger technique and transesophageal echocardiography guidance. For re-operations, the right atrium and the right ventricle were not dissected free. A carbon dioxide line was also sutured to the upper extent of the incision to allow for flooding of the incision with 10 l/min of carbon dioxide gas to reduce the risk of air embolization [11]. The patients were then placed on cardiopulmonary bypass and cooled to 25°C except for re-operative patients who were cooled to 22°C. Patients requiring circulatory arrest were cooled to below 20°C and EEG silence at 2 µV sensitivity. No clamps were placed on the arch arteries. For patients who did not need circulatory arrest, the ascending aorta was pulled inferiorly by the anterior fatty rind and then a regular angled clamp placed immediately distal to the innominate artery, with the inferior part of the arch being clamped. The operative procedure was performed by the previously described techniques. To improve exposure of the aortic valve, a malleable retractor was used to retract the two-stage venous cannula inferiorly and to the right to expose the aortic root. In patients who were undergoing retrograde brain perfusion, a right-angle cannula was placed in the superior vena cava and looped with umbilical tape, rather than the usual method of placing it through the right auricle and then into the superior vena cava. For patients undergoing antegrade brain perfusion, the right subclavian artery was used for antegrade arterial inflow with occlusion of the innominate artery and the common carotid artery by balloon catheters. The left common carotid artery was also perfused with an arterial line. For both these cannulas, the pressure was monitored to ensure that perfusion pressures were adequate. For debubbling, after completion of the procedure but before completing the final anastomosis, and prior to unclamping, the ventricle was vigorously compressed using the pump sucker with the anaesthesiologist ventilating the lungs. With the patient in a Trendelenburg position, the aorta was then unclamped and an ascending aorta vent turned on. The patients were only removed from cardiopulmonary bypass when no further bubbles were seen on transesophageal echo or escaping from the ascending aorta vent side branch.

After completion of the operation, usually two chest tubes were left in position, one in the mediastinum and one in the right chest. In addition to the usual horizontal stainless steel wires for re-approximating the midline sternal incision, one vertical and one angled stainless steel wire was used to repair the inferior transverse incision into the third or fourth intercostal space.

	2. Results

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

 
The survival rate was 96% (52 patients) and the incidence of stroke 3.7% (two patients). Neurocognitive deficits, either by extensive neurocognitive testing as part of a study on circulatory arrest or by a patient complaint of loss of memory or mental acuity, was 1.8% (one patient). The circulatory arrest time was 20 min±SD 17 min. The aortic crossclamp times was 91 min ±SD 45 min and cardiopulmonary bypass time 132 min±SD 59 min. Assessment of the intraoperative transfusion of homologous blood transfusion revealed the average number of units used was 1.3±SD 2.3. Postoperatively, examination of the intensive care unit stay showed that the patients stayed a mean of 1.8 days postoperatively (±SD 1.9 days) and similarly, for the total postoperative stay in hospital 6.7 days (±3.7 days). In the 18 patients undergoing re-operations, there were no deaths after surgery, although one patient suffered a stroke. The patient who suffered a stroke was a Marfan syndrome patient with extensive dissection of the carotid arteries who had previously had an aortic root replacement. This patient underwent a right subclavian artery cannulation and insertion of an elephant trunk procedure with innominate artery bypass. She postoperatively, suffered a mild middle cerebral artery stroke (that affected her speech) but she has since nearly completely recovered. At the time of surgery, it was recognized that the two lumens in the left common carotid artery would be difficult to perfuse adequately. She subsequently underwent a successful second-stage elephant trunk procedure without any problems. The other stroke occurred 10 days after surgery and was related to a thrombus in the left atrium following the use of intraoperative aprotinin. The patient subsequently died of multiple organ failure. The other death occurred after initial discharge from a ventricular tachycardia. There was one patient who suffered a postoperative myocardial infarct. No patient required conversion to a complete sternotomy. Postoperative complications are shown in Table 3.

	3. Discussion

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

Since the left side of the heart and the lower part of the right ventricle is not exposed during this re-operative technique this is particularly advantageous for re-operations since adhesions over the right ventricle and the left side of the heart do not need to be divided with the concurrent risk of myocardial injury. The technique was also particularly useful for patients who have had previous coronary artery bypass surgery (including with a patent left internal mammary artery) since these vessels do not have to be exposed and are safely away from the sternal incision. For patients with patent internal mammary arteries, myocardial protection is not a problem, since the patients are cooled to 22°C and combined antegrade and retrograde cardioplegia is given. This has not resulted in any myocardial dysfunction from ischemia in this series of patients.

Our experience with this series of patients has shown that even complex aortic arch operations can be done through a minimal access approach. Included in this series of patients were those who underwent innominate artery bypasses, elephant trunk procedures, and one patient who had a combined minimal access mediastinal approach and also a thoracoabdominal incision to replace the entire thoracic aorta and the upper abdominal aorta to the renal arteries. Furthermore, using the minimal access approach does not appear to have affected the circulatory arrest periods and thus would not expect to result in a higher neurologic injury. We believe however, it is essential to run carbon dioxide into the wound and vary carefully and thoroughly de-air the patient before coming off cardiopulmonary bypass surgery to reduce the risk of any air embolization after these complex repairs. While the ‘j’ incision has become the now preferred approach for re-operations, this approach for primary ascending aorta and aortic arch repairs will need to be better defined. Byrne and colleagues [3] have also reported their success with a minimal access approach inverted ‘T’ incision for aortic valve replacements and also have advocated this approach for re-operative valve operations based on their experience.

In summary, the technique for minimal access cardiac surgery will continue to evolve with the smaller incisions being tailored to the procedure that is required. For re-operative ascending aorta and aortic arch operations, we have found the minimal access ‘j’ incision to be particularly valuable.

	References

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

 

1. Gundry S.R., Shattuckm O., H ., Razzouk A.J., del Rio M.J., Sardari F.F., Bailey L.L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Throac Surg 1998;65:1100-1104.
2. Cosgrove D.M., III, Sabik J. Minimally invasive approach to aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
3. Byrne J.G., Aranki S.F., Couper G.S., Adams D.H., Allred E.N., Cohn L.H. Re-operative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy. J Thorac Cardiovasc Surg 1999;118:991-997.[Abstract/Free Full Text]
4. Svensson L.G. Minimal-access ‘J’ or ‘j’ sternotomy for valvular, aortic and coronary operations or re-operations. Ann Thorac Surg 1997;64:1501-1503.[Abstract/Free Full Text]
5. Tam R.K., Garlick R.B., Almeida A.A. Minimally invasive redo aortic valve replacement. J Thorac Cardiovasc Surg 1997;114:682-683.[Free Full Text]
6. Cohn L.H., Adams D.H., Couper G.S., Bichell D.P., Rosborough D.M., Sears S.P., Aranki S.F. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing cost of cardiac valve replacement and repair. Ann Surg 1997;26:421-428.
7. Cohn L.H. Parasternal approach for minimally invasive aortic valve surgery. Operat Tech Card Thorac Surg 1998;3:54-61.
8. Von Segesser L.K., Westaby S., Pomar J., Loisance D., Groscurth P., Turnia M. Less invasive aortic valve surgery: rationale and technique. Eur J Cardio thorac Surg 1999;15:781-785.[Abstract/Free Full Text]
9. Navia J.L., Cosgrove D.M., III Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:152-154.
10. Svensson L.G., D'Agostino R.S. Minimal-access aortic valvular operations, including ‘J/j’ incision. Ann Thorac Surg 1998;66:431-435.[Abstract/Free Full Text]
11. Nadolny E.M., Svensson L.G. Carbon dioxide field flooding techniques for open heart surgery: monitoring and minimizing potential adverse effects. Perfusion 2000;15:151-153.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Tabata, Z. Khalpey, S. F. Aranki, G. S. Couper, L. H. Cohn, and P. S. Shekar Minimal Access Surgery of Ascending and Proximal Arch of the Aorta: A 9-Year Experience Ann. Thorac. Surg., July 1, 2007; 84(1): 67 - 72. [Abstract] [Full Text] [PDF]

				F. A. Atik, J. L. Navia, L. G. Svensson, P. R. Vega, J. Feng, M. E. Brizzio, A. M. Gillinov, B. G. Pettersson, E. H. Blackstone, and B. W. Lytle Surgical treatment of pseudoaneurysm of the thoracic aorta. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 379 - 385. [Abstract] [Full Text] [PDF]

				L. G. Svensson, E. H. Blackstone, J. Rajeswaran, J. F. Sabik III, B. W. Lytle, G. Gonzalez-Stawinski, P. Varvitsiotis, M. K. Banbury, P. M. McCarthy, G. B. Pettersson, et al. Does the Arterial Cannulation Site for Circulatory Arrest Influence Stroke Risk? Ann. Thorac. Surg., October 1, 2004; 78(4): 1274 - 1284. [Abstract] [Full Text] [PDF]

				J.-M. De Smet, B. Rondelet, J.-L. Jansens, M. Antoine, D. De Canniere, and J.-L. Le Clerc Assessment Based on EuroSCORE of Ministernotomy for Aortic Valve Replacement Asian Cardiovasc Thorac Ann, March 1, 2004; 12(1): 53 - 57. [Abstract] [Full Text] [PDF]

				R. Sharony, E. A. Grossi, P. C. Saunders, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, P. Ursomanno, F. G. Baumann, A. C. Galloway, and S. B. Colvin Minimally Invasive Aortic Valve Surgery in the Elderly: A Case-Control Study Circulation, September 9, 2003; 108(90101): II-43 - 47. [Abstract] [Full Text] [PDF]

				N. Motoyoshi, K. Oda, Y. Tsuru, and K. Tabayashi Ascending aortic replacement through right thoracotomy Eur. J. Cardiothorac. Surg., January 1, 2002; 21(1): 97 - 99. [Abstract] [Full Text] [PDF]

				V. Zamvar, S. Webster, and B. Falase Neurocognitive impairment after minimally invasive aortic valve replacement Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 889 - 889. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lars G. Svensson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Articles by Kimmel, W. A. Search for Related Content PubMed PubMed Citation Articles by Svensson, L. G. Articles by Kimmel, W. A. Related Collections Minimally invasive surgery