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Ann Thorac Surg 1998;65:275
© 1998 The Society of Thoracic Surgeons

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How to Do It

Minimally Invasive Aortic Valve Replacement via Partial Sternotomy

Department of Cardiac Surgery, The Prince Charles Hospital, Brisbane, Australia

Accepted for publication August 29, 1997.

Dr Tam, Department of Cardiac Surgery, The Prince Charles Hospital, Rode Rd, Chermside, Brisbane, Australia, 4032 (e-mail: tamr@health.qld.gov.au).

	Abstract

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A technique for aortic valve replacement is described in which the aortic valve is exposed through a partial sternotomy without transecting ("T’ing" off) the sternum. Aortic valve replacement can be performed with standard aortic and right atrial cannulation.

	Introduction

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Cosgrove and Sabik [1] described a technique of minimally invasive aortic valve operation through a right parasternal incision. Others have performed aortic valve operations via an upper sternotomy with an inferior T to horizontally transect the sternum. Konertz and colleagues [2] have described a superior paramedian sternotomy. The above approaches to aortic valve replacement have the disadvantages of disrupting the sternum and may injure the internal thoracic arteries. We approach the aortic valve using a partial sternotomy without transecting the sternum. Aortic valve replacement can be performed using standard equipment. This offers a stable sternum, with no risk of injury to the internal thoracic arteries, and has the potential benefit of shorter postoperative recovery with reduced surgical trauma.

	Technique

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The patient is prepared in standard fashion. External defibrillator pads are placed anteriorly and posteriorly on the left lateral chest wall. An incision is made from 2 cm below the sternal notch to the fourth intercostal space. The upper half of the sternum is split to the fourth intercostal space. One or two Tuffier retractors are inserted to expose the superior mediastinum. The pericardium is opened and sutured to the wound with strong traction to help expose the aorta and right atrial appendage (Fig 1). These are cannulated. Partial cardiopulmonary bypass is established. The collapsed right atrium allows easy insertion of the retrograde coronary sinus cannula. Its position is confirmed by pressure trace and a rise in pressure when heparinized normal saline solution is injected. Further confirmation of its position may be made by the use of transesophageal ehocardiography. After the venous cannula is secured and tied with a heavy ligature, the end of the ligature is passed through a stab wound in the right fifth intercostal space. Traction is applied to the tie, which will draw the right atrial appendage and the venous cannula to the right and inferiorly. The venous and coronary sinus cannulas are tucked under the retractor. This provides excellent exposure of the aortic root without the need for a separate incision for the venous cannula. Full cardiopulmonary bypass is established. The aorta is encircled with a tape and cross-clamped. Antegrade and retrograde cardioplegia is administered.

View larger version (134K): [in this window] [in a new window]   View of exposure before cannulation. The fourth intercostal space is below the inferior end of the incision. The xiphoid is not seen below the inferior margin of the photograph. (A = aorta; P = pulmonary artery; R = right atrial appendage; S = level of sternal notch.)

	Comment

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We have found that aortic valve replacement can be safely performed with partial sternotomy without transection of the distal end. Other minimally invasive approaches require greater exposure and result in a potentially unstable sternum. Our technique does not require exposure of the right superior pulmonary vein for venting of the left ventricle. We observed that venting this would require a wider exposure. If the left atrial appendage is not easily accessible, venting may be safely performed through the aortic vent. With the routine use of intraoperative transesophageal echocardiography to monitor deairing, we have found that the removal of air through the aortic vent is complete. To expose only the ascending aorta and right atrial appendage, excessive retraction is not required. Despite this the sternum may partially fracture; however, the periostium is always intact to maintain its stability. Cardiopulmonary bypass can be established without femoral cannulation. No special equipment is required, and antegrade and retrograde cardioplegia can be delivered.

Twelve patients have had operation for aortic valve disease using the above technique. They range from 35 to 84 years of age (mean age, 60.2 ± 16.8 years). No patients required conversion to full sternotomy. Aortic cross-clamp times (53 ± 10 minutes) and bypass times (68 ± 11 minutes) were satisfactory. Retrograde cardioplegia was not used in our first 3 patients and was routinely used later in our experience. There were four partial fractures in the sternum when the partial sternotomy was off midline; however, the intact periostium maintained its stability. The patients had minimal wound discomfort postoperatively, and the wounds (Fig 2) healed satisfactorily. Follow-up echocardiography showed normal valvular function in all patients. There were no embolic complications. In 1 patient with calcification of the membranous septum, complete heart block developed and necessitated permanent pacemaker insertion. One patient presented with a late pericardial effusion 4 weeks postoperatively, which required percutaneous drainage, despite having a normal echocardiogram before discharge.

View larger version (140K): [in this window] [in a new window]   Postoperative photograph demonstrating the incision.

	References

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1. Cosgrove DM, III, Sabik JF Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
2. Konertz W, Waldenberger F, Schmautzler M, Ritter J, Liau J Minimal access valve surgery through superior partial sternotomy: a preliminary study. J Heart Valve Dis 1996;5:638-640.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert K. W. Tam Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tam, R. K. W. Articles by Almeida, A. A. Search for Related Content PubMed PubMed Citation Articles by Tam, R. K. W. Articles by Almeida, A. A.