EJCTS Click here to go to Edwards website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Eur J Cardiothorac Surg 2008;33:537-541. doi:10.1016/j.ejcts.2007.12.037
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Minoru Tabata
Ramanan Umakanthan
Lawrence H. Cohn
Prem S. Shekar
Frederick Y. Chen
Gregory S. Couper
Sary F. Aranki
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tabata, M.
Right arrow Articles by Aranki, S. F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tabata, M.
Right arrow Articles by Aranki, S. F.
Related Collections
Right arrow Minimally invasive surgery
Right arrow Valve disease

Early and late outcomes of 1000 minimally invasive aortic valve operations

Minoru Tabata, Ramanan Umakanthan, Lawrence H. Cohn*, Ralph Morton Bolman, III, Prem S. Shekar, Frederick Y. Chen, Gregory S. Couper, Sary F. Aranki

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

Received 10 September 2007; received in revised form 12 December 2007; accepted 19 December 2007.

* Corresponding author. Tel.: +1 617 732 7678; fax: +1 617 732 6559. (Email: lcohn{at}partners.org).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Objective: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. Methods: From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. Results: Median patient age was 68 years (range: 24–95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (≥80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. Conclusions: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.

Key Words: Minimally invasive cardiac surgery • Aortic valve • Elderly


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Minimally invasive aortic valve surgery (MIAVS) was introduced in 1996 [1,2] and has been gaining acceptance for the last decade. Many studies have shown that it can be done safely with mortality and morbidity similar to conventional full sternotomy aortic valve surgery [3–15]. Several studies have also shown that the minimal access approach contributes to better surgical outcomes compared to a full sternotomy [3–5,14–16] although it is still controversial. We began minimal access approaches for aortic valve surgery in July 1996 and have demonstrated excellent early outcomes [2,3]. Herein, we report early and late outcomes of our 11-year experience of MIAVS


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 Appendix A
 References
 
2.1 Patient data
We conducted a retrospective review of 1005 patients who underwent MIAVS between July 1996 and December 2006 at Brigham and Women's Hospital. We included aortic valve replacement, aortic valve repair and aortic root replacement that were performed through an upper hemisternotomy or parasternal approach. Ascending aortic replacement, valve-preserving aortic root replacement patients were excluded from this series. All preoperative data, in-hospital outcomes and post-discharge outcomes were collected from the medical records and the Brigham and Women's Hospital Cardiac Surgery Database according to The Society of Thoracic Surgeons (STS) National Adult Cardiac Database version 2.52 definitions. Hybrid procedure was defined as MIAVS following the same day percutaneous coronary interventions [17]. Late survival data were collected from National Social Security Number Database. Operative variables, blood transfusion requirement, operative morbidity and mortality, length of hospital stays and discharge destinations were analyzed in all patients and the subgroup of elderly patients (≥80 years). Predicted mortality was calculated based on the STS risk algorithm version 2004.2 for patients who underwent isolated aortic valve replacement with the stented bioprosthetic valve or mechanical valve. Analysis of the STS National Adult Cardiac Database was provided by the STS and Duke Clinical Research Institute. This study was approved by the institutional review board of Brigham and Women's Hospital (protocol number: #2005p000324).

2.2 Surgical procedure
We used a parasternal approach in 34 cases in 1996. Otherwise, we used an upper hemisternotomy to the 3rd or 4th intercostal space (Fig. 1 ) as a standard approach for aortic valve operations. Cardiopulmonary bypass (CPB) is established by direct ascending aortic cannulation and percutaneous femoral venous or direct right atrial cannulation using constant venous-side suction. In reoperative surgery, CPB is established via femoral or axillary arterial cannulation and femoral venous cannulation before sternotomy. Aortic cross-clamp is applied through the incision. Antegrade cardioplegia is delivered through the ascending aorta and coronary orifices after aortotomy. Retrograde cardioplegia, especially in patients with significant aortic insufficiency, is delivered through a coronary sinus cannula placed via the right atrial appendage using transesophageal echocardiography (TEE) guidance, and a left ventricular vent is placed through aortic valve or right superior pulmonary vein. In the setting of a patent left internal mammary artery (LIMA) graft, patients are cooled to 20–25 °C and potassium is occasionally administered through CPB circuit in addition to antegrade and retrograde cardioplegia. When collateral flow from the LIMA graft to coronary ostia obscures the operative field, CPB flow is turned down temporarily to 500–1500 ml/min. Our detailed strategy of MIAVR in patients with previous cardiac surgery has been published [18,19].


Figure 1
View larger version (98K):
[in this window]
[in a new window]

  		Fig. 1. Upper hemisternotomy approach.

 
The aortic valve procedure is performed in a standard fashion. After the aortic valve procedure is completed, the venous suction is discontinued temporarily and air is evacuated from the heart using TEE guidance. Temporary pacing wires and chest tubes are placed. In reoperative cases, a pulmonary artery catheter with pacing ports is used since it is difficult to expose the ventricular wall for temporary pacing wire insertion.

2.3 Statistical analysis
We calculate our standardized mortality ratio by dividing the number of observed deaths by the number of expected deaths. A standardized mortality ratio and 95% confidence intervals smaller than 1.0 indicate that our result is better than expected. We assessed trends in CPB time and incidence of reoperation for bleeding over time (1996–1999 vs 2000–2003 vs 2004–2006) using Spearman correlation coefficient and Mantel-Haenszel trend test, respectively. Continuous variables are expressed as median. A p-value was considered statistically significant when it was less than 0.05. Statistical analysis was performed with SPSS version 11.5 (SPSS, Inc., Chicago, IL).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 Appendix A
 References
 
3.1 Patient characteristics
The median age was 68 years (range: 24–95 years); 179 patients (18%) were 80 years or older. Other patient characteristics are shown in Table 1 .


View this table:
[in this window]
[in a new window]

  		Table 1 Preoperative characteristics of all the patients
 
3.2 Operative procedures
The operative procedures are shown in Table 2 . All 10 patients who underwent concomitant coronary artery bypass grafting had a single graft to the proximal right coronary artery. All mitral valve procedures were performed through the aortic root after removal of aortic valve. The median CPB and aortic cross-clamp times were 100 and 70 min, respectively. Nineteen patients (1.9%) had deep hypothermic circulatory arrest. No significant paravalvular leak requiring additional repair was found with an intraoperative TEE in this cohort.


View this table:
[in this window]
[in a new window]

  		Table 2 Operative procedure of 1005 MIAVS
 
3.3 Operative outcomes
Early operative outcomes are shown in Table 3 . Operative mortality rate was 1.9%. In the subgroup of patients undergoing isolated AVR with the stented bioprosthetic valve or mechanical valve (n = 820), operative mortality rate was 2.1% whereas predicted mortality rate was 4.2%. A standardized mortality ratio (95% confidence interval) was 0.50 (0.38–0.62), which indicates that the mortality is significantly lower than expected. Actuarial survival was 91% at 5 years and 88% at 10 years.


View this table:
[in this window]
[in a new window]

  		Table 3 Operative outcomes
 
3.4 Operative outcomes of the elderly
Among 179 patients of 80 years or older, operative mortality rate was 1.7%. In the subgroup of patients undergoing isolated AVR with the stented bioprosthetic valve or mechanical valve (n = 160) it was 1.9% whereas predicted mortality was 7.5%. A standardized mortality ratio (95% confidence interval) was 0.25 (0.11–0.40), which indicates that our mortality is significantly lower than expected. The STS National Adult Cardiac Database has 16,904 elderly (≥80 years) patients data undergoing isolated AVR between January 1997 and June 2006, and the operative mortality rate in that series was 6.7%. Actuarial survival at 5 years was 84%.

3.5 Trends
There was a significant decreasing trend in CPB time over time (Fig. 2A). The incidences of bleeding also had a significant decreasing trend (Fig. 2B).


Figure 2
View larger version (9K):
[in this window]
[in a new window]

  		Fig. 2. Trend in cardiopulmonary bypass time (p < 0.001) and incidence of reoperation for bleeding (p < 0.001). Error bars show 95% confidence intervals.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
Appendix A
 References
 
Our series of MIAVS have shown that aortic valve operations can be safely performed through a limited direct access. Observed mortality rates were significantly lower than expected ones. This excellence was more remarkable in the subgroup of the elderly patients who are more vulnerable to surgical invasiveness than younger patients.

It is controversial that a minimal direct access approach significantly reduces surgical invasiveness compared to a full sternotomy approach. The previously published studies have shown that minimal access approaches have shorter length of stay [3–5,15,16], more home discharge [3–5,15], less incisional pain [6,20], shorter duration of ventilation [4–6], less blood loss [4–6,11,16] and less blood transfusion [5], compared to a full sternotomy. In an early paper, blind calls to patients 3 months postoperatively revealed significantly earlier recovery and return to work in the minimally invasive aortic valve group [2]. On the other hand, several studies have reported no particular benefit other than cosmesis [7–10,13]. However, these potential benefits are biologically rational. Avoiding full sternotomy should contribute to better postoperative stability of the sternum and less incisional pain. Better-preserved stability of the sternum may prevent deep infection and help patient's respiratory function and mobility in the immediate postoperative period. Our low incidences of deep sternal wound infection and pneumonia support this assumption. A smaller area of exposed sternal bone marrow and periosteum may minimize bleeding from there. In reoperative surgery, this approach minimizes mediastinal dissection and secondary organ injury and bleeding. The other advantage of these minimal access approaches is that we can use most of the standard aortic valve surgery techniques and instruments.

On the other hand, limited exposure of the heart is a potential disadvantage of MIAVS Several studies have shown longer operation time compared to a full sternotomy. In our series, however, poor exposure of the aortic valve was very rare and cardiopulmonary bypass time had a significant decreasing trend that indicates a technical learning curve. Limited exposure makes it difficult to assess the volume load of the ventricles. Intraoperative TEE is essential for monitoring distension of the ventricle as well as air removal and assessment of the cardiac valves. Placement of retrograde cardioplegia and pacing wires can be difficult. A retrograde cardioplegia cannula is placed using TEE guidance. However, since we experienced coronary sinus injury in two patients, we recommend that should there be any difficulty in placing a retrograde cardioplegia cannula, the placement should be aborted or deferred until after an elective conversion to a full sternotomy [21]. Ventricular pacing wires are placed on the anterior right ventricular wall. This manipulation should be performed with the empty heart on cardiopulmonary bypass to avoid injury of the right ventricle [21]. The incidence of postoperative bleeding requiring reexploration was 2.5%. The most common bleeding source in those patients was the right internal mammary artery or vein that is stretched with a partial hemisternotomy. Careful confirmation of hemostasis in these sites is essential. The incidence of reoperation for bleeding had a significant decreasing trend over time.

Conversion to full sternotomy was required in 28 patients (2.7%, 28/1033) during the same period. We described detailed reasons and results of converted cases in a previous publication [21].

A limitation of this study is its observational nature without comparative control. Comparative study would be difficult because minimal access approaches are routine standards in our institution. We did not assess patient satisfaction, postoperative quality of life or cost-effectiveness, which are important outcome measures that need to be further investigated.

In conclusion, minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are especially well-tolerated in the elderly. These procedures should be performed in well-experienced institutions since there is a significant learning curve for operation time and the incidence of complications.


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

Dr M. Jahangiri (London, UK): This paper is timely, particularly during a period that we are learning about percutaneous valve replacements. The authors have presented excellent results for minimal access AVR, achieving an overall mortality of 2% in all their patients compared to 4% in the literature and various databases, and less than 2% in the over 80s compared to 7 to 12%.

We have been performing minimal access AVR at St. George's Hospital in London using the authors’ technique with some modification. Minimal access approaches have many advantages, most of which have been shown by the authors. Our experience concurs with theirs, particularly that patients with preoperative pulmonary dysfunction do better with minimal access surgery.

On the other hand, limited access AVR has some drawbacks, as you pointed out. Increased cross-clamp and bypass times which decrease with experience. Another problem can be placement of the ventricular pace wires. These are best placed in the right ventricular free wall during bypass. De-airing can be a problem. Use of transesophageal echo is mandatory for de-airing and monitoring ventricular distension. It should be left in place until completion of the operation to also monitor blood collection in the posterior part of the pericardium. Placement of the internal defibrillators can also be difficult. External defibrillators should be placed properly from the start. Pediatric defibrillators can be helpful. In fact, we had to convert a case because earlier in our experience we couldn’t defibrillate and we learned that the external defibrillators were misplaced. Attention to hemostasis is required, particularly in the T part of the incision where the right internal mammary artery and vein can be stretched. I have four questions for you.

We have been avoiding cannulation of the femoral vein as we believe that peripheral cannulation has its inherent morbidity and to some extent can defeat the objectives of minimal access surgery. Do you have any experience with a three-stage venous cannula placed through the superior vena cava?

My next question is retrograde cardioplegia via the coronary sinus. We have found this cumbersome, and we have essentially avoided this.

What degree of hypothermia do you use in all your patients, not necessarily your redo cases?

You have not commented on the incidence of paravalvular leak. I am certain this is zero or near zero. However, it would be helpful to know this, particularly if you have to compare minimal access aortic valve surgery with the evolving percutaneous valve replacement.

Dr Tabata: First of all, I agree with all your comments. Sometimes minimal access increases cardiopulmonary bypass time, but we found a significant learning curve and we do not see any difference in operation time between minimal access and conventional approaches now. The ventricular pacing wire is difficult to place and we always put it on bypass. TEE is essential for monitoring ventricular distension and de-airing as well as valve assessment, and appropriate positioning of an external defibrillator is very important. And for your questions, the first question you asked is if we have experience placing a three-stage cannula through the SVC. I don’t think we do, but we sometimes put the three-stage cannula through the right atrial appendage as we do in a regular full sternotomy access, and then even if we do so, we still can obtain good exposure of the aortic valve.

And in terms of a retrograde cannula, I totally agree, it is sometimes very difficult to place and sometimes it is very dangerous. Actually we had two cases who had a coronary sinus injury from a retrograde cannula placement, and we had to convert those cases to a full sternotomy. So if we feel uncomfortable, we feel any resistance, we have a very low threshold to abort retrograde cardioplegia cannula placement.

And in terms of the temperature, we use 32 to 34 °C in the primary operation. In reoperative cases with a patent LIMA, we use 20 to 25 °C. In such cases, we do not clamp the LIMA, so we cool down to obtain cardiac asystole.

And in terms of paravalvular leak, to the best of my knowledge we had only one significant paravalvular leak in which we needed to convert to a full sternotomy to redo the procedure. This is very rare. And I would say the minimal access approach provides excellent exposure in most cases, and then all of us, including residents, are comfortable to complete aortic valve replacement with this exposure. So I don’t think this approach causes a higher incidence of paravalvular leak or any other problems of valve replacement.

And lastly in terms of transcatheter valve placement, I think it is an excellent option for high-risk patients, but it is still a minimal indication. So I think we choose an appropriate technique for each case.

Dr M. Emara (Cairo, Egypt): What is the incidence of your postoperative pericardial effusion, because we have a vast experience in this procedure and we noticed it has a difference between the conventional and the minimal exposure, and where do you put your pericardial drainage tubes?

Dr Tabata: It is a very important question. But we never experienced a higher incidence of pericardial effusion compared to a full sternotomy because we always put a Blake drain tube in the posterior pericardial space. If we advance a Blake tube through the anterior pulmonary artery and then left atrial appendage, we can reach the posterior pericardial space. It works very well.

Dr C. Mestres (Barcelona, Spain): Only 37% of your patients were discharged home? Only 37% of patients?

Dr Tabata: Yes, in the elderly subgroup.

Dr Mestres: What were the others?

Dr Tabata: They went to the rehabilitation center.

Dr Mestres: You have nursing homes that are able to handle ventilators?

Dr Tabata: Yes.

Dr Mestres: That is a very good advantage.


   Footnotes
 
{star} Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

  1. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
  2. Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF. Minimally invasive cardiac valve surgery improves patient satisfaction whole reducing costs of cardiac valve replacement and repair. Ann Surg 1997;226:421-428.[CrossRef][Medline]
  3. Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations. Early and late results. Ann Surg 2004;240:529-534.[Medline]
  4. Liu J, Sidiropoulos A, Konertz W. Minimally invasive aortic valve replacement (AVR) compared to standard AVR. Eur J Cardiothorac Surg 1999;16(Suppl. 2):S80-S83.[Abstract/Free Full Text]
  5. Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg 2002;73:460-466.[Abstract/Free Full Text]
  6. Mächler HE, 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]
  7. Szwerc MF, Benckart DH, Wiechmann RJ, Savage EB, Szydlowski GW, Magovern Jr. GJ, Magovern JA. Partial versus full sternotomy for aortic valve replacement. Ann Thorac Surg 1999;68:2209-2214.[Abstract/Free Full Text]
  8. Aris A, Cámara ML, Montiel J, Delgado LJ, Galán J, Litvan H. Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study. Ann Thorac Surg 1999;67:1583-1588.[Abstract/Free Full Text]
  9. Christiansen S, Stypmann J, Tjan TD, Wichter T, Van Aken H, Scheld HH, Hammel D. Minimally-invasive versus conventional aortic valve replacement – perioperative course and mid-term results. Eur J Cardiothorac Surg 1999;16:647-652.[Abstract/Free Full Text]
  10. Detter C, Deuse T, Boehm DH, Reichenspurner H, Reichart B. Midterm results and quality of life after minimally invasive vs. conventional aortic valve replacement. Thorac Cardiovasc Surg 2002;50:337-341.[CrossRef][Medline]
  11. Dogan S, Dzemali O, Wimmer-Greinecker G, Derra P, Doss M, Khan MF, Aybek T, Kleine P, Moritz A. Minimally invasive versus conventional aortic valve replacement: a prospective randomized trial. J Heart Valve Dis 2003;12:76-80.[Medline]
  12. Corbi P, Rahmati M, Donal E, Lanquetot H, Jayle C, Menu P, Allal J. Prospective comparison of minimally invasive and standard technique for aortic valve replacement: initial experience in the first hundred patients. J Card Surg 2003;18:133-139.[CrossRef][Medline]
  13. Stamou SC, Kapetanakis EI, Lowery R, Jablonski KA, Frankel TL, Corso PJ. Allogeneic blood transfusion requirements after minimally invasive versus conventional aortic valve replacement: a risk-adjusted analysis. Ann Thorac Surg 2003;76:1101-1106.[Abstract/Free Full Text]
  14. Sharony R, Gross EA, Saunders PC, Schwartz CF, Ribakove GH, Culliford AT, Ursomanno P, Baumann FG, Galloway AC, Colvin SB. Minimally invasive aortic valve surgery in the elderly: a case-control study. Circulation 2003;108(Suppl. 1):II43-II47.[Medline]
  15. Sharony R, Grossi EA, Saunders PC, Galloway AC, Applebaum R, Ribakove GH, Culliford AT, Kanchuger M, Kronzon I, Colvin SB. Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement. J Heart Valve Dis 2004;13:887-893.[Medline]
  16. Bakir I, Casselman FP, Wellens F, Jeanmart H, De Geest R, Degrieck I, Van Praet F, Vermeulen Y, Vanermen H. Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients. Ann Thorac Surg 2006;81:1599-1604.[Abstract/Free Full Text]
  17. Brinster DR, Byrne M, Rogers CD, Baim DS, Simon DI, Couper GS, Cohn LH. Effectiveness of same day percutaneous coronary intervention followed by minimally invasive aortic valve replacement for aortic stenosis and moderate coronary disease (‘hybrid approach’). Am J Cardiol 2006;98:1501-1503.[CrossRef][Medline]
  18. Byrne JG, Karavas AN, Adams DH, Aklog L, Aranki SF, Couper GS, Rizzo RJ, Cohn LH. Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery. Eur J Cardiothorac Surg 2000;18:282-286.[Abstract/Free Full Text]
  19. Byrne JG, Karavas AN, Filsoufi F, Mihaljevic T, Aklog L, Adams DH, Cohn LH, Aranki SF. Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts. Ann Thorac Surg 2002;73:779-784.[Abstract/Free Full Text]
  20. Candaele S, Herijgers P, Demeyere R, Flameng W, Evers G. Chest pain after partial upper versus complete sternotomy for aortic valve surgery. Acta Cardiol 2003;58:17-21.[CrossRef][Medline]
  21. Tabata M, Umakanthan R, Khalpey Z, Couper GS, Aranki SF, Cohn LH, Shekar PS. Full sternotomy conversion following minimal access cardiac surgery: reasons and rationales during a 9.5 year experience. J Thorac Cardiovasc Surg 2007;134:165-169.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
A. Zierer, G. Wimmer-Greinecker, S. Martens, A. Moritz, and M. Doss
Is transapical aortic valve implantation really less invasive than minimally invasive aortic valve replacement?
J. Thorac. Cardiovasc. Surg., November 1, 2009; 138(5): 1067 - 1072.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
S. Perrotta and S. Lentini
Ministernotomy approach for surgery of the aortic root and ascending aorta
Interactive CardioVascular and Thoracic Surgery, November 1, 2009; 9(5): 849 - 858.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
D. Wendt, S. Stuhle, H. Wendt, M. Thielmann, B. Kipfmuller, F. Hauck, B. Vogel, and H. Jakob
Cutting precision in a novel aortic valve resection tool. Research in progress
Interactive CardioVascular and Thoracic Surgery, October 1, 2009; 9(4): 672 - 676.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
U. F.W. Franke, M. Albert, C. Rustenbach, and H. Baumbach
Minimally invasive Ross procedure through partial upper sternotomy
Interactive CardioVascular and Thoracic Surgery, September 1, 2009; 9(3): 545 - 546.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
S. Salizzoni, P. Bajona, K. J. Zehr, W. D. Anderson, S. Vandenberghe, and G. Speziali
Transapical off-pump removal of the native aortic valve: a proof-of-concept animal study.
J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 468 - 473.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
S. Bleiziffer, H. Ruge, D. Mazzitelli, C. Schreiber, A. Hutter, J.-C. Laborde, R. Bauernschmitt, and R. Lange
Results of percutaneous and transapical transcatheter aortic valve implantation performed by a surgical team
Eur. J. Cardiothorac. Surg., April 1, 2009; 35(4): 615 - 621.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
E. Balaras, K.S. Cha, B. P. Griffith, and J. S. Gammie
Treatment of aortic stenosis with aortic valve bypass (apicoaortic conduit) surgery: an assessment using computational modeling.
J. Thorac. Cardiovasc. Surg., March 1, 2009; 137(3): 680 - 687.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. Tabata, Z. Khalpey, P. S. Shekar, and L. H. Cohn
Reoperative minimal access aortic valve surgery: minimal mediastinal dissection and minimal injury risk.
J. Thorac. Cardiovasc. Surg., December 1, 2008; 136(6): 1564 - 1568.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll Cardiol IntvHome page
J. G. Byrne, M. Leacche, D. E. Vaughan, and D. X. Zhao
Hybrid Cardiovascular Procedures
J. Am. Coll. Cardiol. Intv., October 1, 2008; 1(5): 459 - 468.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Minoru Tabata
Ramanan Umakanthan
Lawrence H. Cohn
Prem S. Shekar
Frederick Y. Chen
Gregory S. Couper
Sary F. Aranki
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tabata, M.
Right arrow Articles by Aranki, S. F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tabata, M.
Right arrow Articles by Aranki, S. F.
Related Collections
Right arrow Minimally invasive surgery
Right arrow Valve disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS