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Ann Thorac Surg 1996;61:1781-1786
© 1996 The Society of Thoracic Surgeons
Division of Thoracic and Cardiovascular Surgery, Division of Cardiology, and Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China
Accepted for publication February 10, 1996.
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Abstract |
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Methods. We report 2 patients who received emergency operations for thrombosis of a mitral prosthesis (patient 1, a 68-year-old man) and acute mitral regurgitation due to rupture of anterior chordae (patient 2, a 75-year-old woman). They both had severe congestive heart failure. Cardiogenic shock was noted in patient 2. The mitral valve was approached through a right anterior minithoracotomy with the aid of an endoscope by means of projected images on the video monitor under femorofemoral cardiopulmonary bypass. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The left atrium was entered posterior to the interatrial groove. Thrombectomy and mitral valve repair were performed successfully.
Results. The duration of extracorporeal circulation was 204 and 147 minutes, respectively. Both patients recovered from the operation rapidly with uneventful postoperative courses.
Conclusions. Our preliminary results suggest that video-assisted endoscopic cardiac surgery is technically feasible and could be performed in the milieu of open heart surgery.
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Introduction |
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Despite the wide application of video-assisted techniques in thoracic surgery [1–3], the majority of cardiac surgeons hardly have any experience with these techniques. The application of this technique offers safety, minimal discomfort, quick functional recovery, excellent cosmetic healing, and savings in cost [3]. Video-assisted endoscopic techniques have been used in surgical correction of coronary or congenital cardiac lesions that did not need extracorporeal circulation [4–6]. Animal experiments with canine hearts using video-assisted endoscopic techniques have been performed since the beginning of 1995 in our laboratory. We report our preliminary experience of video-assisted cardiac surgery (VACS) in 2 patients (Table 1
) with class IV congestive heart failure due to thrombosis of mechanical mitral prosthesis or acute severe mitral regurgitation, respectively.
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) revealed increased echodensity over the prosthetic valve, indicating thrombus in the prosthetic valve. A floating linear density was found over the left atrial wall near the mitral prosthesis. The mitral area was estimated to be 2.05 cm.2 Some echodense shadows presumed to be thrombi were found at the left atrial roof, and mild aortic regurgitation was also found. Emergency operation for thrombectomy of the mitral prosthesis was performed 96 months after his first cardiac operation [7]. Video-assisted techniques using an endoscope were applied through a right anterior minithoracotomy to avoid time-consuming, possibly dangerous, median resternotomy and extensive mediastinal dissection. Written consent was obtained from the family members before the operation.
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A 2-cm incision was made over the third intercostal space at the anterior axillary line, followed by entry of the chest through a stab incision (Fig 2). An 11-mm nondisposable trocar was inserted, through which the endoscope (Stryker Endoscopy, San Jose, CA) was inserted. A right anterior minithoracotomy (10 cm in length) (see Fig 2) through the fourth intercostal space was made as the ``manipulation incision'' for introduction of conventional surgical instruments into the chest and the left atrium [8]. A small rib retractor was used to facilitate insertion of instruments through this incision. An incision was created on the pericardium anterior to the phrenic nerve. The pericardium was carefully dissected away from the right atrium, and the previous suture line of left atriotomy was identified posterior to the interatrial groove. Other parts of the heart and aorta were not dissected out. Systemic hypothermia (22°C) began at this time. A stab incision 4 cm in length was made along the previous atriotomy suture line after the ventricle fibrillated and the left atrium was entered. The aorta was not cross-clamped. The heart was perfused continuously, although fibrillated.
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At termination of the thrombectomy the disc mechanism was found to be free of any mechanical impairment and the disc had free motion. After the left atrium and left ventricle were meticulously cleansed, they were filled with blood by slowing down the femoral venous drainage and ventilating the lungs. The air was carefully evacuated by rotating the operating table in all directions. The atriotomy was then closed with 4-0 Prolene (Ethicon, Ltd, UK) running suture, after which no obvious air bubble was noted by transesophageal echocardiographic examination. The patient was kept in a head-down position. Cardioversion was easily performed by putting the cardioverter (CodeMaster; Hewlett-Packard Company, McMinnville, OR) pads on the right upper and left lower anterior chest wall. Extracorporeal circulation was terminated after rewarming of the patient. The bypass time was 204 minutes. Intraoperative transesophageal echocardiographic examination showed smooth opening of the disc of the mitral prosthesis with a mitral area of 2.73 cm2 (Fig 1B
). There was no thrombosis noted. The pericardium was not closed. Dobutamine and sodium nitroprusside were infused in small doses to stabilize the hemodynamics. A pacemaker was not used. Two stab incisions were made in the seventh intercostal space in the anterior and posterior axillary line for insertion of the drainage tubes (see Fig 2). Hemostasis and closure of the incision were easily achieved.
The postoperative course was uneventful, with no organ failure. Warfarin was prescribed for anticoagulation. The patient was followed up regularly for 3 months in the outpatient clinic in New York Heart Association functional class I. Echocardiography showed adequate mitral prosthetic function with good left ventricular function.
Patient 2
A 75-year-old woman was admitted on September 1995 with severe orthopnea and dyspnea on exertion that had developed in the past week. There had been no history of fever or chest discomfort recently. A holosystolic murmur was audible at the apex. A chest roentgenogram revealed acute pulmonary edema, and an echocardiogram showed severe mitral regurgitation with flail anterior leaflet due to rupture of chordae tendineae (Fig 1C). Cardiogenic shock developed 2 days after admission despite the use of dobutamine and sodium nitroprusside; therefore an emergency operation was arranged in an attempt to repair the mitral valve [9]. Written consent was obtained from the family members before the operation.
The video-assisted techniques used on this patient were basically the same as those in patient 1. Systemic hypothermia (20°C) began immediately after the start of femorofemoral extracorporeal circulation (Fig 3A). With the guide of an endoscope, which was inserted through a thoracotomy created in the third intercostal space in the anterior axillary line (Fig 3B), the pericardium was incised anterior to the right phrenic nerve and the left atrium was entered posterior to the interatrial groove after the ventricle fibrillated. The heart was protected with continuous coronary perfusion and hypothermic fibrillation. The entire left atrial cavity was carefully explored by endoscope and no thrombus was found. Rupture of the central primary chordae tendineae of the anterior leaflet of the mitral valve had occurred (Fig 3C), so the mitral valve was repaired with (1) plication of the anterior leaflet by hand-suturing the two chordae next to the ruptured one together and (2) annuloplasty with conventional instruments inserted through the manipulation incision under the guidance of the endoscope (Fig 3D). Mitral valve competence was evaluated by the left ventricular extension method, which showed good competence. After deairing of the left ventricle and atrium, the left atriotomy was closed and decannulation and closure were then performed. The bypass time was 147 minutes. Transesophageal echocardiographic examination showed a good coaptation of the leaflets (Fig 1D). The mitral valve area was estimated to be 2.80 cm2.
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Comment |
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Thrombotic obstruction is a rare but often fatal complication of cardiac mechanical valve prostheses. This type of complication occurs more frequently in tilting-disc valves than in other kinds of prostheses [7]. Surgical treatment of disc valve thrombosis includes thrombectomy or replacement of the prosthetic valve [7, 10, 11]. Our previous experience showed that thrombectomy is an easy, fast, and safe procedure, especially for those critically ill patients [7]. Thrombectomy was successfully performed in our first patient, who recovered rapidly.
Surgical treatment of mitral regurgitation has been the subject of numerous reports. By using valve repair, the well-recognized complications of valve replacement-bioprosthetic degeneration, prosthetic valve infection, transvalvular gradients, paravalvular leak, hemolysis, and thromboembolic events-are avoided [9, 12]. Our second patient suffered from severe mitral regurgitation with cardiogenic shock due to rupture of the chordae of the anterior leaflet of the mitral valve. Mitral valve repair, which was successfully accomplished, should be the best procedure for this older patient.
Since the first reports by Dr Ralph Lewis and his associates [1] in 1991, video-assisted techniques have been useful for surgical treatment of many intrathoracic diseases [2–6]. The problems of application and manipulation of this technique in cardiac operations are (1) the method of cardiopulmonary bypass, (2) the technique of myocardial protection, (3) the development of new instruments to be used through small trocar channels for cardiac procedures, (4) the possibility of air embolization, and (5) difficulty in hemostasis.
Cardiopulmonary bypass has been executed through cannulation of the peripheral arteries and veins, such as femoral artery and vein [13, 14], with excellent results. In our patients, simple femorofemoral bypass via the right femoral artery and vein could establish satisfactory cardiopulmonary bypass with adequate perfusion of all vital organs, including the brain. There was no organ failure postoperatively. Patients regained consciousness promptly after the operation.
Infusion of cardioplegic solution, crystalloid or blood, antegradely via the aortic root or retrogradely through the coronary sinus, with the aortic cross-clamped, was the gold standard of myocardial protection in most cardiac operations. However, continuous perfusion of the heart without cross-clamping of the ascending aorta can still offer adequate myocardial protection [15, 16]. With continuous coronary perfusion under hypothermic fibrillation, there was no low cardiac output postoperatively, indicating adequate myocardial protection.
Video-assisted operations in thoracic or abdominal diseases have been accompanied by the extensive application of expensive disposable endoscopic instruments. The delay in development of these instruments for endoscopic cardiac surgery had certainly postponed the advancement of these surgical skills. Our experience in video-assisted thoracic operations [3, 8] indicates that routine use of conventional nondisposable instruments can achieve a truly cost-effective and minimally invasive video-assisted procedure. In the operations for our patients, the creation of a manipulation incision made use of conventional instruments, dissection, grasping, suturing, removal of thrombi, and control of the hemorrhage much easier and faster. We did not use any disposable endoscopic instruments in these operations.
Air embolization occasionally causes trouble after a smooth cardiac operation. Adequate evacuation of the intracavitary air by filling the heart with blood or saline solution before closure of the cardiotomy is the rule [17]. We rotated the operating table in all directions while deairing and filled the left atrium and ventricle carefully with blood. The patients were kept in a head-down position. There were no obvious air bubbles in the heart noted by transesophageal echocardiographic examination [18, 19] before the heart started beating. Both our patients woke up from the anesthesia promptly after arriving at the intensive care unit. There was no evidence of neurologic defect. However, larger series of patients will be required to demonstrate the incidence of neurologic complications of VACS.
Cardioversion was not a problem in our patients. Defibrillation could be easily performed by putting the pads on the surface of the chest wall (patient 1) or the heart (patient 2). Hemostasis was easily established through the extended manipulation incision. Conventional hand-suturing for all cardiotomies could be performed smoothly through the manipulation incision with the guidance of endoscope to reduce the chance of bleeding from the suture lines to a minimum. Any bleeder could be easily controlled by hand sutures or electric cautery. Small incisions without sternotomy, minimal mediastinal dissection, and no incision on the high-pressure system of the heart (such as aorta or left ventricle) were also helpful for hemostasis.
The major advantage of VACS is the avoidance of a sternotomy. It minimizes mediastinal trauma, and hence decreases the chance of major injuries to the cardiac chambers or great vessels, especially in cases of redo operations. The minimally invasive nature of VACS will reduce the incidence of postoperative mediastinitis and pulmonary insufficiency to a minimum. As in video-assisted thoracic surgery, the application of VACS might offer the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, and excellent cosmetic healing [3]. These advantages are particularly helpful in patients who are critically ill, as in our patients.
From our experience, video-assisted mitral valve operations can be carried out with femorofemoral cardiopulmonary bypass, continuous coronary perfusion with hypothermic fibrillation, and conventional instruments without much difficulty through the extended manipulation incision. Deairing and hemostasis were easily accomplished and were very similar to the techniques used in standard open heart operations. However, our experience is still limited. The bypass time and the length of the manipulation incision were rather long due to unfamiliarity of the VACS techniques. The number of patients and operations are too few to make conclusions. The incidence of neurologic complications and the benefit of shortened hospital stay, seen in other video-assisted procedures [3], of VACS remain to be demonstrated. Nevertheless, our preliminary experience using VACS techniques in mitral valve operations is encouraging. Patients recovered rapidly from the operations, indicating that the advantages of VACS can overcome the technical difficulties in the learning period. With more experience, the bypass time and the length of the manipulation incision will be shortened. These initial results demonstrate that VACS is technically feasible and can be effectively executed in a minimally invasive manner. We believe that video-assisted technologies could be applied in the milieu of open heart surgery. We anticipate a striking extended role for VACS in major cardiac procedures in the near future.
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