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Ann Thorac Surg 1997;63:1219-1220
© 1997 The Society of Thoracic Surgeons

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Correspondence

Minimally Invasive Mitral Operations

Cardiothoracic Surgery, Minneapolis Heart Institute, Minneapolis, Mn 55407

To the Editor:

We read with interest the article by Navia and Cosgrove entitled "Minimally Invasive Mitral Valve Operations" [1]. We agree with them that the smaller incision has many potential advantages. There is less trauma and less pain. The small incision reduces the risks of wound infection and blood loss. The patients recover more rapidly and are discharged from the hospital sooner, further reducing the hospital cost.

However, there are two disturbing areas with the technique that can be easily avoided. First is the groin incision and groin cannulation, and second is the sacrifice of the internal thoracic arteries. We do not believe that groin incision and femoral cannulation are less invasive, and they may be associated with femoral artery dissection, delayed wound healing, and groin infection. Those complications were the reasons that we moved away from this approach several years ago. We have learned during the past decade, much of the information coming from the Cleveland Clinic, the precious value of the internal thoracic arteries [2]. Sacrificing this, to us, is inappropriate. On a lesser note, parasternal thoracotomy could create a chronic unstable chest wall, particularly in a small, thin patient.

We have used a small skin incision (about 6 cm long) and a partial sternotomy for both aortic and mitral valve replacement [3]. Because both the aortic and mitral valves are located near the midline, it is not necessary to spread the sternum more than 6 or 7 cm. This eliminates pain from traction on the ribs and thoracic ligaments. Partial sternotomy is different from complete sternotomy, as it is faster healing, more stable, and less painful. Because partial sternotomy of the cardiac procedure appears to be no different than the partial sternotomy for thymectomy, and thymectomy patients go home and resume their activity in about half the time required after conventional heart operations [4], we believe that partial sternotomy for valve patients could resume their activity faster as well.

For the skin incision, the patient is placed in a supine position, and the skin incision is made from a spot about four finger breadths caudal to the sternal notch and ending at the area adjacent to the fifth intercostal space. The skin incision at the cephalad end is undermined enough to reach the sternal notch. The skin is stretched with a surgical lap packed tightly in the subcutaneous space. At the caudal end, the dissection is carried more laterally and caudally to expose the fifth sternocostal angle.

The sternotomy begins using the Kelly clamp, creating a small entry for the saw at the desired costosternal angle and medial to the internal thoracic vessels. The Hall sternum saw (Hall Surgical, Division of Zimmer, Carpinteria, CA) is used to initiate the "hockey stick" sternotomy and carried as far as possible cephaladly up the limit from the skin incision. At this point, if one wants to keep the benefits of a small skin incision, a Striker oscillating saw (Hall Surgical) can be used to go underneath the skin to complete the sternotomy. Adding on more length of skin incision at this end does not add any benefit to the exposure.

With Cooley's retractor in place, the opening is about 6 x 6 cm, which gives enough room for aortic and right atrial cannulation, using the same cannulas and the same cannulation technique as with the full sternotomy approach. The pursestring suture can be applied in the usual site at the arch of the aorta near the take-off of the innominate artery and atrial cannulation via the right atrial appendage. The same aortic cross-clamp has been used, but a newly designed clamp could improve the exposure. With this approach, the retrograde cardioplegia cannula can be placed in the usual fashion [5], but requires the coronary pressure waveform to confirm the position because finger-guiding the tip of the cannula into the coronary sinus is no longer feasible. The left ventricular vent was also feasible through the right superior pulmonary vein (Fig 1).

View larger version (130K): [in this window] [in a new window]   Fig 1. . The 6 x 7-cm skin opening with Cooley's retractor and pericardial retraction stitches in place. The aortic cannula is behind at the cross-clamp and not visualized in the drawing. A two-stage right atrial cannula, right superior pulmonary vein vent catheter, and transatrial retrograde cardioplegia catheter fit into this small opening. The mitral valve is exposed through the dome of the left atrium, and three or four pairs of pledget stitches are placed on the left and right side of the atriaotomy, giving good exposure of the mitral valve without any retractor. (AO = aorta; MV = mitral valve; RT. SUP. PULM. VEIN = right superior pulmonary vein; SVC = superior vena cava.)

For aortic valve replacement, a transverse aortotomy is made about 1 cm distal to the take-off of the right coronary artery. Three or four retraction sutures placed on the adventitia near the aortic opening help to minimize the number of instruments inside the opening and increase exposure of the valve.

We have used this technique in 17 patients, and exposure is good. The short-term outcomes are satisfactory and long-term follow-up is under way.

References

1. Navia JL, Cosgrove DM III. Minimally invasive mitral valve operation. Ann Thorac Surg 1996;62:1542–4.[Abstract/Free Full Text]
2. Loop FD. Internal-thoracic-artery grafts. Biologically better coronary arteries [Editorial]. N Engl J Med 1996;334:263–5.[Medline]
3. Arom KV, Emery RW, Nicoloff DM. Mini-sternotomy for cardiac surgery. In: Emery RW, Arom KV, Fonger J, Robinson MC, Subramanian VA, eds. Minimally invasive coronary bypass surgery: the Minneapolis Symposium. Philadelphia: Hanley and Belfus (in press).
4. Blumberg D, Port JL, Weksler B, et al. Thymoma: a multivariate analysis of factors predicting survival. Ann Thorac Surg 1995;60:908–14.[Abstract/Free Full Text]
5. Arom KV, Emery RW. Retrograde cardioplegia: detail for coronary sinus cannulation technique. Ann Thorac Surg 1992;53:714–5.[Abstract/Free Full Text]

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