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Ann Thorac Surg 1998;65:1538-1539
© 1998 The Society of Thoracic Surgeons
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Discussion |
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 Top Discussion |
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Our results basically agree with Dr Cosgrove’s that the advantages of this approach are not in a dramatic reduction in the patient’s length of stay in the hospital, but what we have found has been a more rapid trajectory in the rate of recovery in the 1 to 3 weeks after the operation. So my first question would be to ask Dr Cosgrove about the relative recovery of these patients versus those with median sternotomy.
The other question I have has to do with arrhythmias. Because this particular approach to the mitral valve is not typical for most of us and has been associated in the past with sinus node dysfunction and bradycardias, I wonder whether the rate of arrhythmias is at all increased, whether pacing is required, and whether this is a long-term problem.
Second, the incidence of stroke in the mitral group, which comprised 2 patients, or 4%, seemed somewhat elevated, and I wonder if these are at all a result of deairing, because those who have not done minimally invasive procedures have been concerned about the ability to deair the heart with this approach.
Next, the durability of the procedure was not described, as this report does not give us long-term follow-up. I wonder if any of these patients have required reoperation at any time.
Finally, the patients presented here are a group of patients with relatively good risk, and some surgeons have touted the benefits of minimally invasive operations as allowing even higher risk patients to go through the operations with less morbidity. I wonder at this point, having seen the feasibility of this approach, whether patients with renal insufficiency or respiratory dysfunction now are done with the minimally invasive approach and can safely go through these operations less traumatically.
DR LARS G. SVENSSON (Burlington, MA): I also rise to congratulate Dr Cosgrove on an excellent study and also for introducing these novel and innovative techniques. He has also introduced the important principle of tailoring the minimal access incision for the operative site that requires operation. For some patients in whom we have needed a bit more exposure (for example, composite valve grafts, reoperations, and where the hemiarch has needed to be fixed), we have used a J incision, starting either in the first intercostal space or the sternal notch, and then coming down to the third or fourth intercostal space on the right side. We have found this to be a useful incision that has not required ligation of the mammary artery.
What we have noticed in some of our patients is that when the pericardium is tented up the right-sided pressures increase and left ventricular dysfunction occurs. Furthermore, when one comes off pump, the anesthesiologists are very keen to start giving a whole lot of inotropic agents. We have taken the course of releasing the sutures and allowing some time for the heart to recover, and with that the problem has resolved. I was wondering if you could comment on what you think the reasons are for this. Is this a left ventricular filling dysfunction or a type of cardiac tamponade, and how do you manage it?
Finally, we have looked at our patients, because of this, with some concern about left ventricular protection and have noticed that on transesophageal echocardiography, measurement of creatine kinase-MB levels, and electrocardiographic studies, there is no evidence of left ventricular dysfunction or injury. We think this is a temporary problem, and I was wondering if you could comment on this. Congratulations once again on a fine study.
DR RICARDO J. MORENO-CABRAL (San Diego, CA): I rise to congratulate Dr Cosgrove for his outstanding results and to suggest an alternative approach that may be more appealing to surgeons familiar with the midline sternotomy and also to some female patients.
About 3 years ago, we used a T-shaped lower sternotomy for coronary bypass grafting in a patient with a permanent tracheostomy. This incision extended from the side of the xiphoid to the second or third intercostal space without cutting the manubrium.
We have now used this incision in about 20 patients, not only for mitral and aortic valve replacement or repair, but also for repair of septal defects and for coronary bypass grafting including the internal mammary. Exposure is enhanced by placing an internal mammary retractor. By lifting the manubrium, it is easier to cannulate the ascending aorta directly. We have had some difficulty obtaining satisfactory exposure in patients with a barrel chest, but in general this incision has provided satisfactory exposure and easy access for myocardial protection and deairing. In your experience, have you encountered difficulty with exposure in patients with a barrel chest when you used the transverse or parasternal incision, and how have you managed these patients?
DR COSGROVE: Our entire experience in 1966 was 236 procedures, of which 116 were on mitral valves, 94 were on aortic valves, and the remainder were on various combinations of valves, coronary arteries, atrial septal defects, ascending aortas, tricuspid valves, and others. The operative mortality rate was 0.9%.
Conversion to sternotomy was required in 6 patients. Patients who have pectus excavatum present the greatest problem. Very often the heart lies completely in the left chest and it is very difficult to approach the mitral valve through this incision. Pectus excavatum and reoperations are our current contraindications.
Recovery in patients undergoing minimally invasive procedures was significantly more rapid. The hospital length of stay was shortened, as was the rapidity with which these patients returned to full activity. No long-term follow-up is available in these patients, although 2 of the 236 patients required reoperation, 1 for mitral insufficiency and the other for an atrial septal defect.
The Guiraudon incision passes through the sinoatrial node artery in 100% of the cases. Transient nodal rhythm occurred in many of these patients, requiring atrial pacing for approximately 24 hours. There were no increased incidences of pacemaker requirements or nodal rhythm. This is confirmed by three reports in the literature that show exactly the same result.
A study performed by our cardiologists comparing patients with this incision with patients with other incisions shows a lower incidence of atrial fibrillation in the postoperative period. The reasons for this are not clear.
Doctor Svensson raises an interesting point regarding the compression of the right ventricle and low cardiac output afterwards. It is important that one release the traction sutures on the pericardium, as one can compress the heart against the posterior sternum by tension on those.
Finally, I would like to add that these smaller incisions are not the final word. We have learned that cardiac surgeons have tremendous imaginations and that they will learn to make an incision that is appropriate for the operation. With this, we will find a more rapid recovery for our patients and fewer complications associated with the perioperative period.
This article has been cited by other articles:
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  R. Sharony, E. A. Grossi, P. C. Saunders, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, P. Ursomanno, F. G. Baumann, A. C. Galloway, and S. B. Colvin Minimally Invasive Aortic Valve Surgery in the Elderly: A Case-Control Study Circulation, September 9, 2003; 108(90101): II-43 - 47. [Abstract] [Full Text] [PDF]
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