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Ann Thorac Surg 1998;65:1100-1104
© 1998 The Society of Thoracic Surgeons
a Department of Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
Address reprint requests to Dr Gundry, Division of Cardiothoracic Surgery, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
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Methods. Beginning in January 1996, we began approaching most infant and pediatric open heart procedures through an upper sternal split incision using a 1- to 3-inch skin opening and then extended this technique using a 2.5- to 3.5-inch incision for adult aortic and mitral valve replacement.
Results. A total of 82 patients, 57 infants and children and 25 adults, have been operated on using this approach (age range, newborn to 81 years). Operations accomplished through ministernotomy have included aortic valvotomy, arterial switch, tetralogy of Fallot, atrial or ventricular septal defect closure, aortic valve replacement, mitral valve replacement and repair, redo aortic or mitral valve replacement, double valve replacement, aortic root replacement, and complex arch reconstruction. In adults, the sternum was divided and then a T incision was made at the second, third, or fourth intercostal space. The mitral valve was reached through the roof of the left atrium. In children, a lower sternal split was used for atrial septal defect repairs. All cannulas were introduced through the ministernotomy incision, eliminating femoral cannulation. No new instruments, retractors, or ports were used. Mediastinal drainage was accomplished through a Blake drain connected to Heimlich-valved grenade suction. All but 2 patients were extubated immediately. Hospital stay was from 1 to 20 days (median 2 days). Patient and family acceptance is very high.
Conclusions. On the basis of this initial experience, we attempt all congenital cardiac and isolated adult valve operations through ministernotomy.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Beginning in January 1996, we elected to approach pediatric heart operations through a partial division of the sternum, ie, only a portion of the sternum was divided in the midline. Owing to the flexibility of children’s tissues, the partially divided sternum was stretched open with a retractor. Initially, these operations proceeded through an upper sternal split, but with time, we determined that atrial septal defects and some ventricular septal defects were more easily approached by division of the lower sternum. In March 1996, emboldened by our pediatric experience, we began performing aortic and mitral valve operations in adults through an upper sternal division. Our rationale for this approach was simple: both the aortic and mitral valves are midline structures and both lie in a plane that can be best viewed obliquely from above the right shoulder. Furthermore, upper sternal division brings the surgeon directly down to the aorta and right atrial appendage for facile cannulation. Unlike in children, in adults the inflexible sternum had a reverse T incision made at the second, third, or fourth intercostal space in addition to dividing it in the midline. Although many terms can be used to describe these sternal divisions, such as hemisternotomy, partial sternotomy, limited sternotomy, and so forth, we have chosen to coin the term "ministernotomy" to describe this form of access to the heart and great vessels. In this report, we describe the technique of ministernotomy and its application in 82 patients treated at Loma Linda University Medical Center.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Adults approached through ministernotomy ranged in age from 22 to 81 years (mean, 65 years). Operations included aortic valve replacement (n = 10), redo aortic valve replacement (n = 3), aortic root replacement (n = 1), aortic valve repair (n = 2), aortic valve replacement and myectomy (n = 1), complex aortic arch reconstruction (n = 1), mitral valve replacement (n = 2), redo mitral valve replacement (n = 3), mitral valve repair (n = 1), aortic valve replacement and mitral valve repair (n = 1), and repair of atrial septal defect (n = 1).
Congenital heart operations
The vast majority of congenital heart operations involving the base of the heart and great vessels can be approached through an upper ministernotomy. Depending on the age of the child, a 1.5- to 3-inch (3- to 7-cm) skin incision is placed over the mid to upper sternum (Fig 1). After exposing the sternum, a sternal saw is used from the top down to divide the sternum along half of its length. In cases in which an outflow tract or transannular patch is going to be used, three fourths of the sternum is divided. A pediatric Finochetti retractor is placed and the sternal edges separated. The thymus is divided or removed and the pericardium opened. The pericardial edges are sewn to the skin edges to further deliver the heart into the field.
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For operations involving the atrial septum and some ventricular septal defects, an alternative approach uses a lower sternal split with the incision centered over the lower sternum. The sternum is divided up to the fifth, fourth, third, or second intercostal space depending on orientation of the heart in the chest and the exposure desired. Cannulation of the ascending aorta is accomplished by downward traction on the aorta. Dual venous cannulas are introduced through pursestring sutures in the right atrium. Once on bypass, decompression of the heart allows easy access to the superior and inferior venae cavae for snare placement. Aortic clamping is accomplished by a right-angle cross-clamp placed backwards, ie, with the handle facing caudad. Antegrade or retrograde cardioplegia can be delivered as desired. Removal of air is again accomplished with a needle hole in the ascending aorta.
A 10F or 19F Blake drain (Johnson and Johnson, Cincinnati, OH) is wrapped around the heart within the pericardium and brought out through an intercostal space (upper ministernotomy) or in the epigastrium (lower ministernotomy). This drain is connected to a grenade suction with an integral Heimlich valve, ensuring unidirectional flow, as well as preventing aspiration of air into the chest.
Sternal closure is accomplished in a standard fashion using interrupted wires or running polypropylene suture. Extubation is usually accomplished in the operating room. Drains are usually left open to air on the first postoperative morning and then removed.
Adult cardiac operations
An upper sternal ministernotomy is used for all work on the aortic and mitral valves, as well as the ascending aorta. Groins and upper legs are prepared for all valve operations. A single-lumen endotracheal tube is used. Unlike a child’s sternum, the adult sternum is inflexible; as such, the sternum must be divided not only in the midline but also by making a T incision into an intercostal space. This sternal incision merely cuts the sternum; the surrounding tissues including the internal mammary arteries are left undisturbed.
The level of sternal division needed to provide access to the base of the heart varies greatly with physique, degree of emphysema, and whether the heart lies transversely or longitudinally within the chest. Early in our experience, we divided the sternum routinely into the third intercostal space. Recently we have used transesophageal echocardiography to locate the annulus of the aortic valve and to mark this on the skin by measuring with a tape measure from the edge of the manubrium to the corresponding depth of the echo probe. This technique is extremely accurate in determining the proper interspace for sternal division. In general, a third or fourth interspace T incision will suffice; however, with severe emphysema or when aortic root replacement is planned, a fifth interspace T incision has proved useful. Moreover, as a learning technique, a fourth interspace ministernotomy provides generous access to the cardiac structures and inspires surgical confidence. As familiarity with the technique increases, a third or second intercostal space ministernotomy can be increasingly employed. In general, a 7-cm (3-inch) 3 skin incision is used but in actual practice it varies from 6 cm (2
inches) to 9 cm (4 inches). Early in our experience, we used a standard sternal saw to accomplish the vertical sternal division, then made the T incision with a neuro drill. More recently, we have done all sternal division using a redo oscillating saw with a narrow blade. After the sternum is divided, a small Finochetti retractor is placed and the upper sternal edges spread. Thymic tissue is divided with electrocautery and the pericardium opened. Traction on the lower sternal edge allows further opening of the pericardium. Once opened the pericardial edges are sewn to the skin, delivering the cardiac structures further into the incision (Fig 2).
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For mitral valve access, an additional 24F venous cannula is placed into the superior vena cava through a direct pursestring suture (Fig 3). Once on bypass, venting of the left heart can be accomplished by a number of equally satisfying approaches. After the lungs are deflated and the heart emptied, the superior pulmonary vein is easily cannulated in a traditional manner, a vent can be placed through the dome of the left atrium, or a vent can be dropped through the aortic or mitral valves. Finally, direct venting of the pulmonary artery can be used.
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Mitral or aortic valve repair or replacement proceeds in a normal fashion. Sutures may be tied directly. Once the valvular procedure is finished, atrial or aortic closure proceeds in the routine fashion. Maneuvers to remove air are greatly aided by transesophageal echocardiography, locating potential pockets of air. Gentle shaking of the heart is usually all that is required to remove air from the atrium or ventricle; however, forceps handles can reach all areas of the heart, even through a limited incision, to jiggle the heart.
Myocardial protection has been accomplished primarily by retrograde continuous warm blood cardioplegia, but we have also used cold, intermittent blood antegrade or retrograde cardioplegia without difficulty. As replacement of a dislodged retrograde catheter may prove more difficult in a tiny incision, arrangements to change to antegrade or direct coronary osteal cannulation is advisable when using only retrograde cardioplegia through a ministernotomy. In this series, no patient required inotropic support to be weaned from bypass. Defibrillation has rarely been needed, but a pair of pediatric paddles fit easily within the incision. Pacing is not routine but atrial or ventricular wires can be placed and brought out through an interspace. Placement of ventricular wires on the right ventricle should be done on bypass with the heart decompressed. In this series, no pacing wires were used or needed.
After completion of the procedure and removal of cannulas, a 19F Blake drain is placed around the heart within the pericardium, brought out lateral to the internal mammary artery in an intercostal space, and connected to a Heimlich valve grenade suction device. The upper and lower sternal edges are wired together with separate wires and then the two upper edges are reclosed with wires. A subcuticular suture is used for skin closure. Extubation is anticipated within the operating room or shortly thereafter.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Once bypass was underway, no patient required conversion to full sternotomy. In 2 of 24 patients (8%), cannulation of the coronary sinus could not be accomplished and antegrade cardioplegia was used.
Twenty of 24 adult patients (80%) and 54 of 57 pediatric patients (95%) were extubated immediately or within 2 hours of operation. Two patients with severe, new-onset mitral or aortic regurgitation required overnight ventilation. Only central venous pressure monitoring was used. No reoperations were required for bleeding.
Hospital stay ranged from 1 to 20 days (median 3 days). In general, children were discharged home on postoperative day one or two. Adults were generally discharged home on postoperative day two or three, although 2 adults (including one redo aortic valve replacement) went home on the first postoperative day. Warfarin is administered immediately postoperatively, and the appropriate international normalized ratio obtained by daily blood samples as an outpatient for patients with prostheses. There were no readmissions among adults and no wound complications. Two children required readmission for postpericardiotomy syndrome. There were no deaths.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Unfortunately, minimally invasive procedures to cardiac surgeons frequently imply limited access or limited control, both anathemas to heart surgeons accustomed to being ready to directly control almost any untoward situation. Additionally, many minimally invasive cardiac operations propose using incisions that are foreign to many practicing surgeons, and involve cannulation of structures, such as the femoral artery or vein, that, although routinely used in cardiac surgery’s infancy, are now rarely used, owing to the known sequelae [2] associated with their use. Finally, although laparoscopic techniques will undoubtedly be increasingly applied to cardiac surgery, a transitional step using common techniques performed through smaller "holes" seems logical, allowing the cardiac surgeon to operate facilely within a comfort zone based on years of practice and training [3, 4].
It is with these concepts in mind that we propose and use ministernotomy to access the heart in congenital heart and adult valvular and aortic operations. In our early experience with retrograde cardioplegia and redo operations, we determined that bypass could be initiated and cardioplegia delivered with only the ascending aorta and a small portion of the right atrium freed from adhesions [1]. With more experience, it became clear that there was no reason to dissect out the entire heart in redo aortic or mitral valve operations, when all the surgeon was operating on was the valve. If exposure of the entire heart is not needed in redos, why then would it be needed in supposedly simpler first-time operations?
The ascending aorta and right atrial appendage are essentially upper midline structures. Hence, the two structures necessary to institute bypass are within easy reach after only upper sternal division. These structures are also within the reach of paramedian or transverse sternal incisions, but one or both internal mammary arteries will be sacrificed by this approach. Additionally, neither of the latter approaches approximate the intrinsic exposure of the base of the heart with which cardiac surgeons are familiar. This is not to imply that other incisions away from the midline are not without merit. The history of cardiac surgery suggests that there are multiple excellent methods of accessing the heart.
Facile minimally invasive heart surgery should allow a practicing surgeon to continue to use familiar tools and approaches for cardiac operations. In general, the more a surgeon has to change, usually the less facile (at least initially) he or she becomes. Ministernotomy allows the use of standard retractors, standard cannulas, standard myocardial protection techniques, and standard surgical techniques, as well as the introduction of fingers to tie knots and large instruments to remove or cut calcified valves. The only difference between traditional exposure and ministernotomy is that ministernotomy permits the surgeon access only to that portion of the heart of interest, rather than "seeing" the entire cardiac structure. However, unlike other "mini" approaches, should the surgeon want or need to have immediate access to the entire heart, simple completion of sternal division provides full cardiac exposure.
The role that small incisions play in patient well-being and comfort should not be underestimated, nor should the elimination of chest tubes be questioned as a worthy goal. Surveys at our institution consistently demonstrate that chest tubes and their removal are a leading cause of patient discomfort (alternating with endotracheal intubation as the number one and two complaints). The 10F and 19F Blake drains have improved patient mobility and comfort substantially and their removal is painless, with, to date, no untoward effects.
We have yet to correlate patient discomfort with the degree of sternal division. This has encouraged us to use a small skin incision and a somewhat larger sternal incision to accomplish aortic root replacement, tetralogy of Fallot repair with transannular patching, and arterial switch procedures. The small skin incisions have been uniformly praised by parents and patients, and to date there have been no wound complications nor sternal healing problems.
Finally, a comment about costs. In the era of efficiency, the operating room has become a focal point for cost containment. Minimally invasive cardiac operations must, of necessity, neither prolong the operation nor increase costs over traditional cardiac surgical procedures. We have found no detriment in this regard with ministernotomy, because no deviation from traditional methods is required except for smaller skin and bone incisions.
In conclusion, on the basis of application to 82 children and adults, ministernotomy allows facile minimally invasive cardiac surgery. Ministernotomy uses standard instruments, cannulas, approaches to cardiac structures, and myocardial protection techniques, but does not fully divide the sternum, allowing for a small skin incision. Chest tube and water seal drainage is abandoned in favor of grenade type suction, further improving patient comfort and mobility. Combined with immediate or rapid extubation, hospital stays of 1 to 3 days may be anticipated and realized for most cardiac operations.
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I. A. Nicholson, D. P. Bichell, E. A. Bacha, and P. J. del Nido Minimal sternotomy approach for congenital heart operations Ann. Thorac. Surg., February 1, 2001; 71(2): 469 - 472. [Abstract] [Full Text] [PDF]
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 C. Hagl, U. Stock, A. Haverich, and G. Steinhoff Evaluation of Different Minimally Invasive Techniques in Pediatric Cardiac Surgery : Is a Full Sternotomy Always a Necessity? Chest, February 1, 2001; 119(2): 622 - 627. [Abstract] [Full Text] [PDF]
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L. Sun, J. Zheng, Q. Chang, Y. Tang, J. Feng, X. Sun, and X. Zhu Aortic root replacement by ministernotomy: technique and potential benefit Ann. Thorac. Surg., December 1, 2000; 70(6): 1958 - 1961. [Abstract] [Full Text] [PDF]
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P. A. Berdat, T. Chatterjee, J.-P. Pfammatter, S. Windecker, B. Meier, and T. Carrel Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale J. Thorac. Cardiovasc. Surg., December 1, 2000; 120(6): 1034 - 1039. [Abstract] [Full Text] [PDF]
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J. G. Grandjean, M. Lucchi, and M. A. Mariani Reversed-T upper mini-sternotomy for extended thymectomy in myasthenic patients Ann. Thorac. Surg., October 1, 2000; 70(4): 1423 - 1424. [Abstract] [Full Text] [PDF]
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S. Taguchi, T. Niibori, and K. Moro Use of three-dimensional computed tomography images in deciding the approach for ministernotomy operations Ann. Thorac. Surg., September 1, 2000; 70(3): 1090 - 1093. [Abstract] [Full Text] [PDF]
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J. G. Byrne, A. N. Karavas, D. H. Adams, L. Aklog, S. F. Aranki, G. S. Couper, R. J. Rizzo, and L. H. Cohn Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery Eur J Cardiothorac Surg, September 1, 2000; 18(3): 282 - 286. [Abstract] [Full Text] [PDF]
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D. P. Bichell, T. Geva, E. A. Bacha, J. E. Mayer, R. A. Jonas, and P. J. del Nido Minimal access approach for the repair of atrial septal defect: the initial 135 patients Ann. Thorac. Surg., July 1, 2000; 70(1): 115 - 118. [Abstract] [Full Text] [PDF]
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S. M. Marianeschi, F. Seddio, D. B. McElhinney, L. Colagrande, R. F. Abella, T. de la Torre, M. Meli, F. S. Iorio, and C. F. Marcelletti Fast-track congenital heart operations: a less invasive technique and early extubation Ann. Thorac. Surg., March 1, 2000; 69(3): 872 - 876. [Abstract] [Full Text] [PDF]
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P. C. Laussen, D. P. Bichell, F. X. McGowan, D. Zurakowski, D. R. DeMaso, and P. J. del Nido Postoperative recovery in children after minimum versus full-length sternotomy Ann. Thorac. Surg., February 1, 2000; 69(2): 591 - 596. [Abstract] [Full Text] [PDF]
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V.R. Machiraju, C. A.B. Lima, M. H. Culig, R. D. Bennett, and N. S. Thakur Exposure of the mitral valve by transecting the ascending aorta during aortic and mitral valve replacement Ann. Thorac. Surg., February 1, 2000; 69(2): 646 - 647. [Abstract] [Full Text] [PDF]
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J. G. Byrne, S. F. Aranki, G. S. Couper, D. H. Adams, E. N. Allred, and L. H. Cohn REOPERATIVE AORTIC VALVE REPLACEMENT: PARTIAL UPPER HEMISTERNOTOMY VERSUS CONVENTIONAL FULL STERNOTOMY J. Thorac. Cardiovasc. Surg., December 1, 1999; 118(6): 991 - 997. [Abstract] [Full Text] [PDF]
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V. Rao, R. M. Freedom, and M. D. Black Minimally invasive surgery with cardioscopy for congenital heart defects Ann. Thorac. Surg., November 1, 1999; 68(5): 1742 - 1745. [Abstract] [Full Text] [PDF]
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M. Massetti, P. Nataf, G. Babatasi, and A. Khayat Cosmetic aspects in minimally invasive cardiac surgery Eur J Cardiothorac Surg, November 1, 1999; 16(Supplement_2): S73 - S75. [Abstract] [Full Text] [PDF]
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J. Liu, A. Sidiropoulos, and W. Konertz Minimally invasive aortic valve replacement (AVR) compared to standard AVR Eur J Cardiothorac Surg, November 1, 1999; 16(Supplement_2): S80 - S83. [Abstract] [Full Text] [PDF]
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K. V. Arom, R. W. Emery, V. R. Kshettry, and K. A. Dubois Evaluation of two new heart valve surgery techniques: partial sternotomy and port-access approaches Eur J Cardiothorac Surg, September 1, 1999; 16(Supplement_1): S99 - S102. [Abstract] [Full Text] [PDF]
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M. Massetti, G. Babatasi, S. Bhoyroo, O. Le Page, and A. Khayat A special adapted retractor for the mini-sternotomy approach Ann. Thorac. Surg., July 1, 1999; 68(1): 274 - 277. [Abstract] [Full Text] [PDF]
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J. M Toomasian Cardiopulmonary bypass for less invasive procedures Perfusion, July 1, 1999; 14(4): 279 - 286. [PDF]
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A. Aris, M. L. Camara, J. Montiel, L. J. Delgado, J. Galan, and H. Litvan Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study Ann. Thorac. Surg., June 1, 1999; 67(6): 1583 - 1587. [Abstract] [Full Text] [PDF]
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H. Y. Karagoz, K. Bayazit, B. Battaloglu, M. Kurtoglu, G. Ozerdem, B. Bakkaloglu, and B. Sonmez Minimally invasive mitral valve surgery: the subxiphoid approach Ann. Thorac. Surg., May 1, 1999; 67(5): 1328 - 1332. [Abstract] [Full Text] [PDF]
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A. Y. Zlotnick, M. S. Gilfeather, D. H. Adams, L. H. Cohn, and G. S. Couper Innominate vein cannulation for venous drainage in minimally invasive aortic valve replacement Ann. Thorac. Surg., March 1, 1999; 67(3): 864 - 865. [Abstract] [Full Text] [PDF]
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M. J. Reardon, L. D. Conklin, R. Philo, G. V. Letsou, H. J. Safi, and R. Espada The anatomical aspects of minimally invasive cardiac valve operations Ann. Thorac. Surg., January 1, 1999; 67(1): 266 - 268. [Abstract] [Full Text] [PDF]
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