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Ann Thorac Surg 1996;62:596-597
© 1996 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
Accepted for publication April 19, 1996.
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Introduction |
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Technique |
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A right parasternal incision is made, extending from the lower edge of the second costal cartilage to the superior edge of the fifth costal cartilage (Fig 1
). The pectoralis major muscle is divided, exposing the second, third, and fourth intercostal spaces and the third and fourth costal cartilages (Fig 2). The third and fourth costal cartilages are totally excised. The right internal thoracic artery is ligated just below the second costal cartilage and just above the fifth costal cartilage. Intercostal muscles and pleura are incised lateral to the edge of the sternum, entering the right pleural cavity. The pericardium is incised, exposing the ascending aorta and right atrium, and a tangential incision is made in the aorta, exiting into the noncoronary sinus (Fig 3).
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After cardiopulmonary bypass is established, the aorta is encircled with umbilical tape and the aorta cross-clamped with a right-angled clamp. A suture is then placed just above each commissure and clamped to the surrounding drape under tension. This elevates the aortic root into the operative field. When isolated aortic stenosis is present, cardioplegia is administered into the ascending aorta; in the presence of aortic insufficiency, cardioplegia is given directly into the coronary ostia after the aortotomy is performed (Fig 4). The aortic valve is either repaired or replaced. A suction catheter is placed into the left ventricle through the aortic annulus as needed. At the completion of the repair or replacement, the aortotomy is closed, and air is removed from the heart through the aortic incision with the assistance of the transesophageal echocardiography probe. Atrial and ventricular pacing wires are placed, and the cross-clamp is removed (Fig 5).
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From January to April 1996, this approach was employed in 25 patients with isolated aortic valve disease. Repairs of the aortic valve were carried out in 6 patients. Nineteen patients had valve replacement: 10, Carpentier-Edwards pericardial valves; 8, aortic homografts; and 1, St. Jude valve. There were no deaths, reoperations for bleeding, strokes, or wound infections.
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The smaller incision described in this procedure has a number of potential advantages. Clearly, the smaller incision is cosmetically more acceptable to patients. The decreased pain reported by patients may, in fact, be related to the absence of retraction and stress placed on the ribs with a median sternotomy. A small wound reduces the potential for wound infection and blood loss from the incision. Patients have been extubated earlier and discharged from the hospital earlier. Reoperation through a median sternotomy should be less difficult because the pericardium below the sternum remains intact, protecting the heart during reentry.
This approach provides access for the surgeon to perform a procedure from the mid-ascending aorta to the mid-left ventricular cavity. Additional procedures in this area through limited incisions may be possible.
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R. K.W Tam and A. A Almeida Minimally invasive aortic valve replacement via hemi-sternotomy: a preliminary report Eur. J. Cardiothorac. Surg., October 1, 1998; 14(suppl_1): S134 - S137. [Abstract] [Full Text] [PDF]
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M. Massetti, G. Babatasi, A. Lotti, S. Bhoyroo, O. Le Page, and A. Khayat Less-invasive heart surgery: the preservation of median approach Eur. J. Cardiothorac. Surg., October 1, 1998; 14(suppl_1): S138 - S142. [Abstract] [Full Text] [PDF]
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M. Massetti, G. Babatasi, A. Lotti, S. Bhoyroo, O. Le Page, and A. Khayat Less invasive cardiac operations through a median sternotomy: 100 consecutive cases Ann. Thorac. Surg., September 1, 1998; 66(3): 1050 - 1054. [Abstract] [Full Text] [PDF]
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D. A. Cooley Minimally invasive valve surgery versus the conventional approach Ann. Thorac. Surg., September 1, 1998; 66(3): 1101 - 1105. [Abstract] [Full Text] [PDF]
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E. Weinschelbaum, P. Stutzbach, A. Machain, R. Favaloro, V. Caramutti, A. Bertolotti, and H. Fraguas Valve operations through a minimally invasive approach Ann. Thorac. Surg., September 1, 1998; 66(3): 1106 - 1109. [Abstract] [Full Text] [PDF]
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L. G. Svensson and R. S. D'Agostino "J" incision minimal-access valve operations Ann. Thorac. Surg., September 1, 1998; 66(3): 1110 - 1112. [Abstract] [Full Text] [PDF]
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L. G. Svensson and R. S. D'Agostino Minimal-access aortic and valvular operations, including the "J/j" incision Ann. Thorac. Surg., August 1, 1998; 66(2): 431 - 435. [Abstract] [Full Text] [PDF]
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D. M. Cosgrove III, J. F. Sabik, and J. L. Navia Minimally Invasive Valve Operations Ann. Thorac. Surg., June 1, 1998; 65(6): 1535 - 1538. [Abstract] [Full Text] [PDF]
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G. Watanabe, T. Misaki, K. Kotoh, A. Yamashita, and K. Ueyama Bilateral Thoracoscopic Minimally Invasive Direct Coronary Artery Bypass Grafting Using Internal Thoracic Arteries Ann. Thorac. Surg., June 1, 1998; 65(6): 1673 - 1675. [Abstract] [Full Text] [PDF]
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 B Bridgewater, R S Steyn, S Ray, and T Hooper Minimally invasive aortic valve replacement through a transverse sternotomy: a word of caution Heart, June 1, 1998; 79(6): 605 - 607. [Abstract] [Full Text]
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R. U. Nair and D. A.C. Sharpe Minimally Invasive Reversed Z Sternotomy for Aortic Valve Replacement Ann. Thorac. Surg., April 1, 1998; 65(4): 1165 - 1166. [Abstract] [Full Text] [PDF]
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C.-A Mestres, N. Cassinello, and M. Fuentes Minimally Invasive Valve Replacement: Surgical Disasters Might Also be Expected Asian Cardiovasc Thorac Ann, March 1, 1998; 6(1): 60 - 61. [Abstract] [Full Text] [PDF]
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P. J. Lin, C.-H. Chang, J.-J. Chu, H.-P. Liu, F.-C. Tsai, F.-C. Lin, C.-W. Chiang, and P. P. C. Tan Minimal Access Surgical Techniques in Coronary Artery Bypass Grafting for Triple-Vessel Disease Ann. Thorac. Surg., February 1, 1998; 65(2): 407 - 412. [Abstract] [Full Text] [PDF]
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H. Kasegawa, T. Shimokawa, Y. Matsushita, S. Kamata, T. Ida, and M. Kawase Right-Sided Partial Sternotomy for Minimally Invasive Valve Operation: "Open Door Method" Ann. Thorac. Surg., February 1, 1998; 65(2): 569 - 569. [Abstract] [Full Text] [PDF]
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D. B. Doty, G. B. DiRusso, and J. R. Doty Full-Spectrum Cardiac Surgery Through a Minimal Incision: Mini-Sternotomy (Lower Half) Technique Ann. Thorac. Surg., February 1, 1998; 65(2): 573 - 573. [Abstract] [Full Text] [PDF]
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P. J. Lin, C.-H. Chang, J.-J. Chu, H.-P. Liu, F.-C. Tsai, W.-J. Su, M.-W. Yang, and P. P. C. Tan Minimally Invasive Cardiac Surgical Techniques in the Closure of Ventricular Septal Defect: An Alternative Approach Ann. Thorac. Surg., January 1, 1998; 65(1): 165 - 169. [Abstract] [Full Text] [PDF]
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R. R. Lazzara and F. E. Kidwell BS Right Parasternal Incision: A Uniform Minimally Invasive Approach for Valve Operations Ann. Thorac. Surg., January 1, 1998; 65(1): 271 - 271. [Abstract] [Full Text] [PDF]
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R. K. W. Tam and A. A. Almeida Minimally Invasive Aortic Valve Replacement via Partial Sternotomy Ann. Thorac. Surg., January 1, 1998; 65(1): 275 - 275. [Abstract] [Full Text] [PDF]
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W. R. Chitwood Jr., C. L. Wixon, J. R. Elbeery, J. F. Moran, W. H. H. Chapman, and R. M. Lust VIDEO-ASSISTED MINIMALLY INVASIVE MITRAL VALVE SURGERY J. Thorac. Cardiovasc. Surg., November 1, 1997; 114(5): 773 - 782. [Abstract] [Full Text]
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R. K. W. Tam, R. B. Garlick, and A. A. Almeida MINIMALLY INVASIVE REDO AORTIC VALVE REPLACEMENT J. Thorac. Cardiovasc. Surg., October 1, 1997; 114(4): 682 - 683. [Full Text]
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M. B. Mitchell, J. M. Brown, and M. J. London Cardiac Entrapment During Minimally Invasive Aortic Valve Replacement Ann. Thorac. Surg., October 1, 1997; 64(4): 1171 - 1173. [Abstract] [Full Text]
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 B. A. Carabello and F. A. Crawford Valvular Heart Disease N. Engl. J. Med., July 3, 1997; 337(1): 32 - 41. [Full Text] [PDF]
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C. Minale, H. J. Reifschneider, E. Schmitz, and F. P. Uckmann Single Access for Minimally Invasive Aortic Valve Replacement Ann. Thorac. Surg., July 1, 1997; 64(1): 120 - 123. [Abstract] [Full Text]
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G. Watanabe, T. Misaki, K. Kotoh, Y. Abe, A. Yamashita, and K. Ueyama BILATERAL MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS GRAFTING WITH THE USE OF TWO ARTERIAL GRAFTS J. Thorac. Cardiovasc. Surg., May 1, 1997; 113(5): 949 - 951. [Full Text]
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F. J. Benetti, M. A. Mariani, J. L. Rizzardi, and I. Benetti MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT J. Thorac. Cardiovasc. Surg., April 1, 1997; 113(4): 806 - 807. [Full Text]
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