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Ann Thorac Surg 1997;64:120-123
© 1997 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Single Access for Minimally Invasive Aortic Valve Replacement

Carmine Minale, MD, Hans J. Reifschneider, MD, Edgar Schmitz, MD, Frank P. Uckmann, MD

Department of Cardiothoracic and Vascular Surgery, Witten-Herdecke University in Wuppertal, Klinikum Wuppertal, Wuppertal, Germany

Accepted for publication January 15, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 Reference
 
Background. The method of replacing the aortic valve via a minithoracotomy has been reported in the recent literature. Although this strategy has clear advantages, further refinements of the process make the procedure even less invasive.

Methods. Aortic valve replacement was performed in 27 patients via a right parasternal minithoracotomy without rib resection. Cardiopulmonary bypass was connected through the same access site. Standard surgical technique and equipment were employed.

Results. There were no intraoperative complications. All patients survived and could be discharged home within 1 week, except 1. Cardiopulmonary bypass time, aortic cross-clamp time, and total operating time averaged 114 ± 26, 76 ± 19, and 190 ± 40 minutes, respectively. Three patients could be extubated in the operative theater, the others in the intensive care unit at an average of 10 ± 7 hours postoperatively. Chest drainage lost averaged 430 ± 380 mL.

Conclusions. The advantages of this method include further reduction of surgical trauma, early mobilization, and rehabilitation of the patient. Surgical technical improvements include avoidance of groin cannulation, simpler equipment, safe venting of the left ventricle, and preservation of chest wall integrity.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 Reference
 
In consequence of the growing challenge from interventional methods, minimally invasive techniques are also becoming more and more demanding in cardiac surgery.

Recently an approach has been proposed to replace the aortic valve via a minithoracotomy [1]. This strategy has clear advantages. However, there are a few technical steps that could be simplified to make the procedure even less invasive, namely, the avoidance of cannulation of both groins for cardiopulmonary bypass and the need for a supplementary centrifugal pump for active venous drainage. Moreover, an effective left ventricular vent, especially in case of aortic valve failure, along with maintenance of the anatomic integrity of the chest wall would also be desirable.

In the present article we report on our approach to these problems along with early results in our series of patients.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 Reference
 
From October 8, 1996, through January 7, 1996, a series of 27 consecutive patients with a severe aortic valve disease underwent aortic valve replacement with a St Jude Medical (St. Paul, MN) prosthesis via a minithoracotomy (Table 1Go).


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  		Table 1. . Preoperative Clinical Data
 
Patients were given total endovenous anesthesia and were ventilated via a left double-lumen endotracheal tube. A skin incision 8 cm long was made along the right sternal border (Fig 1Go). In female patients, a curved incision was made for cosmetic reasons (Fig 2Go). The pectoral muscle was divided vertically along its insertions to the ribs, close to the sternal border, and undermined up to the mammilla. The thorax was opened via the third intercostal space. The internal mammary artery was double-ligated and severed. The third and fourth costal cartilages were cut close to the sternum and retracted on top of the adjacent ribs by means of a self-retaining retractor. The pericardium was opened longitudinally and suspended with stay sutures. The ascending aorta was pulled down with a vessel band inserted between the aorta and pulmonary artery.



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  		Fig 1. . Picture taken of a male patient just before discharge. The length of the incision is about 8 cm.

 


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  		Fig 2. . Picture taken of a female patient at the end of the operation. The laterally curved shape of the incision allowed the wound to disappear within a normal neckline.

 
A 24F flexible aortic arch cannula (Sarns, 3M Health Care, Ann Arbor, MI) was then inserted through a pursestring suture on the anterior aortic wall, close to the origin of the common trunk. A standard 36-50F or 32-40F double-step cannula (Stöckert Instruments, Münich, Germany) was inserted through a pursestring suture around the right atrial appendage. With partial cardiopulmonary bypass, the aorta was pulled forward so that a 16F vent cannula (Stöckert Instruments) could be inserted into the left ventricle via a pursestring suture on the roof of the left atrium (Fig 3Go).



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  		Fig 3. . Picture taken from the anesthesiologist's position of cannulation of the heart for cardiopulmonary bypass through the minithoracotomy access. (Ao =aortic arch cannula; LV= left ventricular vent; RA = double-step right atrial cannula.)

 
For safety, cardiopulmonary bypass was conducted under moderate general hypothermia. The left lung was statically overinflated and the right lung partially collapsed during the phase of valve replacement. The aorta was cross-clamped and opened above the sinotubular junction. Cold potassium-rich blood cardioplegia was administered either directly into both coronary ostia with two rigid cannulas (DLP Inc, Grand Rapids, MI) in valve incompetence, or into the aortic root in stenosis. A temporary epicardial pacemaker wire was placed on the front of the right ventricle at this time. The aortic valve was resected in all cases and replaced with a St. Jude mechanical prosthesis by a simple interrupted 2-0 Ethibond (Ethicon GmbH, Norderstedt, Germany) suture technique (Fig 4Go). Distribution of the prosthesis sizes was as follows: 19 mm, 2; 21 mm, 4; 23 mm, 8; 25 mm, 7; and 27 mm, 6. The aortic wall was closed with two continuous layers of 4-0 Prolene (Ethicon). In addition, subaortic myectomy, single coronary artery bypass grafting, and double coronary artery bypass grafting were respectively performed in 2 patients, 2 patients, and 1 patient. In this latter case, left internal mammary artery bypass to the left anterior descending artery and venous coronary artery bypass grafting to a circumflex marginal branch were done via an additional left minithoracotomy. The left ventricle was deaired both through the cavity vent and through a continuously aspirating needle on the aortic roof (Fig 5Go).



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  		Fig 4. . Picture taken from the anesthesiologist's position. The aortic valve prosthesis is ready to be inserted into the aortic root through the minithoracotomy access with the simple interrupted suture technique. The cardiopulmonary bypass cannulas are visible through the same access site.

 


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  		Fig 5. . Picture taken from the anesthesiologist's position. The aortic root has been closed, and the cross-clamp has been removed. Air will be removed from the left heart cavities through the left ventricular vent (LV) and aortic roof needle (AN).

 
Before the aortic clamp was removed, a warm shot of blood cardioplegia was given into the aortic root. The last 21 patients were given 100 mg of xylocaine directly into the aortic root just after removal of the aortic clamp. When needed, the heart was defibrillated by means of disposable paddles placed on the patient's back before the operation. After rewarming on cardiopulmonary bypass, left vents were removed and the patient was weaned off bypass. The heart was decannulated, and a second single temporary pacemaker wire was inserted on the right atrium. Two chest tubes, 24F and a 32F, were inserted into the pericardial and chest cavity, respectively. The pericardium was closed with interrupted sutures, and rib cartilages were reduced in their original position and stabilized with Vicryl (Ethicon) sutures (Fig 6Go). The third intercostal muscle was reattached to the corresponding cartilage with interrupted Vicryl sutures. The third and fourth intercostal nerves were infiltrated with a long-lasting local anesthetic. After the first five cases, a Redon drainage catheter was put regularly between ribs and pectoral muscle in all other patients. The wound was closed in layers.



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  		Fig 6. . Picture taken from the anesthesiologist's position. The third and fourth cartilages have been replaced in their original position. The arrows indicate the third (3) and the fourth (4) cartilages.

 

   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 Reference
 
There were no intraoperative complications requiring conversion in either extended thoracotomy or median sternotomy. We had some difficulties in defibrillating the first few patients; many electric shocks were needed for each one. After introduction to our protocol of 100 mg xylocaine directly into the aortic root just after declamping, only 1 of 21 patients had to be defibrillated. The cardiac rhythm of all others resumed spontaneously. Cardiopulmonary bypass time, aortic cross-clamp time, and total operation time are listed in Table 2Go.


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  		Table 2. . Operative Data
 
Eight patients needed slight inotropic support with epinephrine during the first hours after the operation. Three patients could be weaned off the respirator and extubated directly in the operating theater. All others were extubated in the intensive care unit at an average of 10 ± 7 (standard deviation) hours (range, 3 to 24 hours) postoperatively and mobilized on the next day. One of 3 patients with severe chronic obstructive lung disease had to be reintubated and supported with a ventilator for several days. One patient suffered a transient ischemic attack on the fifth postoperative day from which, however, he recovered completely. The chest drainage lost during the first 24 hours averaged 430 ± 380 (standard deviation) mL (range, 230 to 1,600 mL). The need for blood transfusion was 235 ± 400 (standard deviation) mL (range, 0 to 1,500 mL); 17 patients (63%) had no blood transfusion at all.

All patients survived. Except 1, all could be discharged home within 1 week. One of the first patients in whom no Redon drain was put under the pectoral muscle had to be readmitted so that a superinfected seroma underneath the muscle could be drained.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 Reference
 
Minimally invasive replacement of the aortic valve is suitable for the majority of patients with isolated aortic defects. The technical improvements mentioned here make the approach even simpler and safer, particularly in patients with a severe dilatory hypertrophy of the left ventricle. In these cases, an appropriate vent of the left ventricle is important because acute overdistention of the heart is difficult to detect through this access site. Moreover, a vent allows a blood-free field both during and after the insertion of the valve prosthesis. Besides the minimal surgical trauma, the limitation of the wound to a small incision in the chest wall, without further incision of the groin, also provides a good cosmetic result. In women, the wound disappears within a normal neckline. Moreover, there is the advantage of avoiding the healing problems that are very often observed after operations in the groin, especially when patients are mobilized soon after. The use of a flexible aortic arch cannula facilitates good exposure of the aorta despite cannulation of its ascending portion. For patients with relatively small body surface areas, a 32-40F double-step cannula is adequate for atrial cannulation.

The use of a left double-lumen endotracheal tube is not strictly required. However, as a result of the selective overdistention of the left lung during the phase of extracorporeal circulation, the heart was pushed to the right side, allowing better exposure of the aorta and its root. Postoperatively, there was no lung complication specifically related to this procedure.

Preservation of the anatomic integrity of the chest wall by avoiding rib resection also looks good, especially for slim patients. We used the same technique that we have routinely used for decades for operations via thoracotomies. Only the insertion of the ribs to the sternum is cut, but the cartilages are neither injured nor stripped.

After the initial experience with a few cases, we modified our protocol in a few respects. Temporary pacemaker wires have to be implanted when the heart is not beating. Otherwise, performance of the protocol is difficult and can cause bleeding. Xylocaine should be given directly after removal of the aortic cross-clamp, and into the aortic root. With high myocardial concentration of this drug, the chances of terminating the ventricular fibrillation without electric shock are very high (20 of 21 cases). Routine use of a Redon drainage catheter under the pectoral muscle avoided further cases of seroma collection and infection.

In conclusion, single access for minimally invasive replacement of the aortic valve is an excellent option for most patients affected by isolated aortic valve disease. Typical postoperative complications observed with the traditional approach, namely, pains, sternal instability, and overstretching of the sternum with resulting brachial plexus damage, are not expected to occur. It could be also postulated that mediastinal infections are avoided. Patients can be rehabilitated earlier without fear of serious healing problems. Cosmetic and psychological considerations are also met, especially in women.


   Acknowledgments
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
Reference
 
We thank the anaesthesiologist, Dr Herbert Krauskopf, for the quality of the pictures he took during the operations.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 Reference
 
Address reprint requests to Prof Minale, Klinikum Wuppertal, Heusner Str 40, 42283 Wuppertal, Germany.


   Reference
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 Reference
 

  1. Cosgrove DM III, Sabik JF. Minimally invasive approach for aortic valve operation. Ann Thorac Surg 1996;62:596–7.



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This Article
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