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Ann Thorac Surg 1998;66:431-435
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Minimal-access aortic and valvular operations, including the "J/j" incision

^a Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts, USA

Accepted for publication March 11, 1998.

Address reprint requests to Dr Svensson, Department of Thoracic and Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. We compared five current minimal-access approaches, namely, parasternal incision, transverse sternotomy, manubrial inverted "T" incision, incomplete mediastinotomy, and our "J/j" incision, to operations in matched patients, including aortic operations.

Methods. In a case-control study of 74 patients, 37 individuals consecutively underwent minimal-access operations (aortic valve, 18, including one mitral valve operation; composite valve graft, six, including one arch and one transaortic mitral valve operation for a patient with Marfan’s syndrome; ascending aorta operation, two; root repair/reconstruction, three; mitral valve repair/replacement, seven, including one maze operation; and atrioseptal defect repair, one). The patients were matched by sex, age, surgeon, and operation with 37 control patients who had standard incisions. Patients having the "J/j" incision (n = 25) had sternotomies from the first right intercostal space, or sternal notch, to the third to fifth right intercostal space.

Results. Minimal-access patients had a shorter postoperative hospital stay than standard incision patients (6.2 versus 8.2 days; p = 0.0055), and required similar volumes of blood (0.86 versus 1.03 units; p = 0.7243), postoperative morphine dosages (28 mg versus 40 mg, p = 0.0643), and oral narcotics (8.1 versus 10.0 doses; p = 0.3562). "J/j" incision patients, however, required less morphine (20.6 mg versus 40.9 mg; p = 0.0028), but not fewer doses of oral narcotics (7.5 versus 9.9 doses; p = 0.2640) and had the shortest postoperative stay (5.1 versus 8.1 days; p < 0.0001). No stroke or clinically noted neurocognitive deficit developed. One minimal-access patient (1/37, 2.7%) with severe preoperative pulmonary morbidity died of adult respiratory distress syndrome. Sternal nonunion developed in 1 patient with an inverted "T" manubrial incision. In a further seven patients, the "J/j" incision was used without a problem, for a total of 32 patients. This compared with a consecutive series of 125 aortic valve replacement operations without a death and 181 patients undergoing ascending arch operations with two 30-day hospital deaths (1.1%) and two strokes (1.1%).

Conclusion. Minimal-access incisions are associated with shorter hospital stays. For the "J/j" incision, even if used for more extensive double-valve, ascending aortic arch, or composite valve operations, postoperative pain appears to be less and patients are discharged even earlier.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Minimal-access aortic valve and mitral valve procedures are increasingly being performed, although with different incisional approaches [1–5]. Cosgrove and colleagues [2–4] have advocated a transsternal or parasternal incision for aortic valve replacements and a parasternal incision for mitral valve procedures. Other incisions that have been described include an inverted "T" incision into the manubrium, incomplete median sternotomy, and our recent report of the "J" or "j" incision [1–5]. We, therefore, sought to compare our experience and the resultant outcomes with these incisions with the classic standard median sternotomy incision. We realized that only a prospectively randomized study could fully evaluate the benefits of minimal-access incisions, although such a study would be fraught with the problems of blinding surgeons and evaluators to the patients’ randomized assignments.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
On January 3, 1997, one of us (L.G.S.) had the opportunity to observe Dr Cosgrove at the Cleveland Clinic Foundation using his parasternal approach, and we commenced using this approach. Subsequently, on January 7, 1997, we needed greater exposure of the ascending aorta for a patient with Marfan’s syndrome who required both a composite valve graft and a transaortic annulus mitral valve replacement, and decided to make a sternal incision from the sternal notch down to the third right intercostal space (Figs 1, 2). We called this a "j" incision to differentiate it from a partial sternotomy, because with the "j" incision the intercostal space is entered. We also found that an aortic valve, a mitral valve, or an atrial septal defect could also be approached through a sternal incision from the right first intercostal space down to the fourth or fifth intercostal space. This we called the "J" incision. We described these "J/j" incisions at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons in San Diego in February 1997 in the commentary on Dr Cosgrove and colleagues’ presentation, and also in the commentary on the paper by Kouchoukos’ group [6], and we subsequently published a full description of the technique [5]. We continue to believe that the parasternal approach is superior to the "J/j" incision for right atrial tumor removal in conjunction with renal or adrenal carcinoma removal when tumor extends into the inferior vena cava and right atrium [7]. We routinely use right subclavian arterial perfusion for these operations.

View larger version (141K): [in this window] [in a new window]   Fig 1. Skin incision with underlying bone structures. (© 1997 Lahey Hitchcock Clinic; reprinted with permission.)

View larger version (143K): [in this window] [in a new window]   Fig 2. Sternal "J/j" incisions. The "j" incision (solid line) begins at the sternal notch and the "J" incision ( broken line) at the first intercostal space. (© 1997 Lahey Hitchcock Clinic; reprinted with permission.)

The operative procedures performed during the period ending August 1997 included aortic valve replacement in 18 patients, including double-valve replacement in 1 patient for mitral valve disease. Among the 18 patients having aortic valve replacements, 6 underwent composite valve graft operations, including 1 patient with hemiaortic arch replacement using hypothermic arrest and retrograde brain perfusion. One additional patient also had a transaortic annulus replacement of the mitral valve in conjunction with composite valve graft insertion. Two patients had ascending aorta repairs alone and three had aortic root reconstructions, including native aortic valve reimplantations and repair of ruptured coronary sinus aneurysm in 1 patient. Seven patients underwent mitral valve replacement or repair, including a maze procedure in 1 patient. Atrioseptal defect repair was performed in 1 patient. Nine patients had previously undergone a cardiac operation before the minimal-access operation.

The operative incisions have been described previously [1–5]. The operative approaches were as follows: "J/j" incision, 25; incomplete median sternotomy, 5; parasternal, 4; transverse sternotomy 2; and inverted "T" 1. The parasternal and transverse sternotomy incisions were done using the technique described by Cosgrove and colleagues [2–4]. For the "J/j" incisions, the technique has been reported previously by us (Figs 1, 2) [5]. Briefly, a "J" incision was made from the right first intercostal space into the midline of the sternum and then down to the right fourth or fifth intercostal space. For the "j" approach, the incision was made from the sternal notch down to the right third or fourth intercostal space. The latter incision allowed better exposure of the ascending aorta and proximal aortic arch when needed. For patients undergoing reoperations, an oscillating saw was used for dividing the sternum and, more recently, the oscillating saw has been found to be preferable for primary sternal "J/j" incisions. No attempt was made to divide the right internal mammary artery and in no patient was this necessary.

In 6 of the patients, the femoral artery was used for arterial infusion and in 1 patient the right subclavian artery was used. For the remaining patients, arterial infusion was through the ascending aorta or proximal aortic arch. For venous drainage, the femoral vein was used in 10 patients and in the remaining patients the cannula was inserted into the inferior vena cava through the right atrium. In those patients undergoing mitral valve repair or replacement, a right-angled cannula was inserted into the superior vena cava and the femoral vein cannulated for inferior vena caval drainage. In 1 patient, because of the inability to pass a femoral venous cannula into the inferior vena cava for mitral valve repair, the cannula was switched to the atrium. We now routinely cannulate the right atrium rather then the femoral vein for mitral procedures. A straight cannula is inserted into the superior aspect of the right atrium just inferior to the junction with the superior vena cava and then threaded into the inferior vena cava. A transverse sternotomy for an aortic valve operation in 1 patient had to be converted to a "T" incision to obtain adequate exposure of the aortic valve and right atrium. In 1 patient undergoing reoperative mitral valve repair through a parasternal incision, the approach had to be changed to the standard median sternotomy because of bleeding posterior to the inferior vena cava.

Data were collected prospectively for the minimal access patients and careful note made of any complications or difficulties with the operations. In addition, the patient’s requirement for intravenous morphine and oral narcotic pain medication, in the form of oxycodone or propoxyphene, was also noted. In the matched standard incision patients, the hospital charts were reviewed to obtain the patient’s requirement for morphine and oral pain medications.

The quantitative data obtained in the two patient groups were compared using the Student’s t test.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Of the 37 patients undergoing minimal-access incisions, 36 survived; 1 patient (2.7%) died postoperatively of adult respiratory distress syndrome after aortic valve replacement. The latter patient had preoperative obesity, chronic obstructive pulmonary disease, pulmonary hypertension, pneumonia, and pulmonary edema, and was operated on urgently because of increasing respiratory failure. No patient developed a postoperative stroke or clinically manifest neurologic event. No postoperative superficial or deep wound infections developed, although sternal nonunion developed in 1 patient who underwent an inverted T incision; although this caused the patient discomfort, it has not required repair. The operative procedures were performed satisfactorily through the minimal-access incisions chosen in all patients except in the 2 patients noted previously. One patient was an elderly man with a particularly elongated ascending aorta in whom a transverse sternotomy did not give adequate exposure. The other patient, who required mitral valve repair, had previously had an operation on the mitral valve. No patient required reoperation for postoperative bleeding.

The mean aortic cross-clamp time in the minimal-access patients was 90.3 minutes (standard deviation [SD], 41.2 minutes) and in the standard incision patients it was 92 minutes (SD, 40.2 minutes; p = 0.8623). In the minimal access patients the mean cardiopulmonary bypass time was 128.8 minutes (SD, 47 minutes) versus 123 minutes (SD, 50.1 minutes; p = 0.6325) in the standard incision patients. The mean operative blood use in the minimal-access patients was 0.86 units (SD, 1.9 units) versus 1.03 units (SD, 2.0 units) for patients with the standard incision (p = 0.7243). However, 9 of the minimal-access patients underwent reoperations, compared with 2 in the standard incision control group.

The mean time to extubation was 0.55 days (SD, 0.40 days, minimum 0.1 day, maximum 1.5 days, excluding the patient who died of adult respiratory distress syndrome) for the minimal-access group. Data were not available for the standard incision control group. The postoperative day of discharge for patients who had the minimal-access incisions was 6.2 days (SD, 3.2 days) versus those with the standard incisions, 8.2 days (SD, 2.7 days; p = 0.0055). Because our anesthetic techniques may have influenced the postoperative length of stay, we compared standard incision patients operated on during 1993, 1994, and 1995 with those operated on during 1996. The respective postoperative lengths of stay were similar (8.3 days [SD, 2.6 days] versus 8.8 days [SD, 5.2 days; not significant]). Notwithstanding this insignificant difference in our standard-incision patients, we acknowledge that anesthetic modifications may have played a role in the earlier discharge of our minimal-access incision patients. However, we did not make a concerted effort to extubate minimal-access patients earlier.

The pain medication dosages with intravenous morphine for the minimal-access and standard sternotomy patients were 28 mg (SD, 31 mg) and 40.0 mg (SD, 23.9 mg; p = 0.0643), respectively. The oral pain medication dosages for the two groups were 8.11 doses (SD, 6.6 doses) and 10.0 doses (SD, 10.4 doses; p = 0.3562), respectively. The pain medication requirements were inversely proportional to the age of the patient (R²; p = 0.06; with morphine dose = 59.97 - 0.42 x age). When the "J/j" incision patients were compared with the other patients, there was no statistical significance in aortic cross-clamp time, operative blood use, or cardiopulmonary bypass time. For those patients who underwent "J/j" incisions (n = 25), however, the mean postoperative stay was 5.1 days (SD, 1.7 days) versus 8.1 days (SD, 3.1 days; p < 0.00011) for the other patients. Morphine requirements for the "J/j" incision patients were also significantly lower, 20.6 mg (SD, 13.75 mg), versus the other patients’ requirements of 40.9 mg (SD, 31 mg; p = 0.0028).

In comparison with the one death in patients undergoing minimal-access incisions, in 125 patients undergoing aortic valve replacement over the last 4 years, either electively or under urgent circumstances, the mortality rate has been zero. In comparison with 181 ascending and arch operations, there have been two inhospital 30-day postoperative deaths (1.1%) and two strokes (1.1%).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Increasing interest among both patients and surgeons for minimal-access cardiac procedures has stimulated the use of several different incisional approaches [1–5]. To date, there is little published literature comparing techniques or outcome for minimal-access valvular or aortic procedures. This study suggests that (1) results of standard versus minimal-access incisions are comparable in safety and neurologic outcome, (2) pain may be less with some incisions, and (3) minimal-access incisions may be associated with earlier discharge from the hospital and earlier return to work. These approaches, however, raise several issues.

The first area of concern is exposure and cannulation access obtained by the incisions. In our experience, the best minimal-access exposures for aortic valve and aortic procedures are the "J/j" incisions described by us [5]. Through the "J/j" incision, with the upper incision extending into the right first intercostal space, a simple aortic valve replacement or aortic root repair can be performed, including cannulation of the aorta, right atrium, and coronary sinus. Although initially our cross-clamp times were longer for simple aortic valve procedures using this incision, we have become more adept with the "J/j" incisions and in a further 7 patients undergoing aortic valve replacement, the aortic cross-clamp and cardiopulmonary bypass times were reduced to satisfactory respective mean times of 44 minutes (range, 39 to 51 minutes) and 61.4 minutes (range, 46 to 74 minutes). For composite valve grafts, ascending aorta, or aortic arch repairs, the "j" incision into the sternal notch is preferable because better exposure of the arch is required for cannulation or repair of the arch. We have even used this incision for arch repairs using our modification of the elephant trunk procedure [8], with the patient being discharged on the fifth postoperative day. For mitral valve, atrioseptal defect, and maze procedures, either the parasternal incision described by Cosgrove’s group [2–4, 7] or the "J/j" incisions described by us [5] give good exposure.

Although we initially cannulated the femoral vein for these procedures, more recently we have found that exposure is satisfactory by cannulating the right atrium (for the inferior vena cava) through the "J/j" incision. We place a right-angle cannula through a pursestring into the superior vena cava rostrally and place a pursestring suture superiorly on the right atrium immediately below the junction with the superior vena cava. A straight cannula is then inserted through the latter pursestring down into the inferior vena cava. By keeping this cannula laterally in the right atrium, it does not obstruct exposure and the femoral vein does not need to be cannulated.

Second, concern has been raised about the safety of minimal-access procedures. In this series, we had 1 patient die from adult respiratory distress syndrome after an aortic valve replacement, compared with no deaths in 125 aortic valve replacements and 2 deaths (1.1%) in 181 ascending/aortic arch repairs. We do not believe this patient’s death was caused by the technique. Nevertheless, meticulous attention to myocardial protection is important. Because left ventricular distention cannot be noted except for through an increase in pulmonary artery pressure from the back pressure into the pulmonary circulation, in patients with even slight aortic valve regurgitation we recommend retrograde cardioplegia administration and direct coronary ostial antegrade cardioplegia. In patients with left ventricular hypertrophy and aortic valve stenosis, transesophageal echocardiography is of value. We also place a transright ventricular temperature probe into the ventricular septum to ensure that the myocardium is cooled adequately by a combination of antegrade ostial and retrograde blood cardioplegia. We also avoid excessive tension on pericardial stay sutures to reduce compression of the heart, which can impede venous return and cause incompetence of the aortic valve after unclamping the aorta [5]. These sutures probably also produce left ventricular diastolic dysfunction within the confined space of the pericardium; if needed, tightening of the heart with epinephrine produces a smaller heart and reduces this problem. The patient can be rapidly weaned from the epinephrine after the procedure. We have been unable to show by electrocardiography, transesophageal echocardiography, or measurement of cardiac enzymes that this early initial dysfunction after unclamping the aorta is not more than a transient reversible phenomena.

In this consecutive series, we did not exclude any patients from minimal-access "J/j" procedures based on preoperative morbidity or associated problems. Indeed, since referring cardiologists have become aware of our approach, we have been increasingly faced with patients with severe chronic obstructive pulmonary disease and minimal forced expiratory volumes (forced expiratory volume in 1 second of 0.4 L to 0.6 L/s). The latter patients appear to have tolerated the procedure better than expected. We speculate that this is because the lower chest, with the "j" incision, and both upper and lower chest, with the "J" incision, are stable and not disrupted, so that patients have better postoperative pulmonary function, including the ability to cough better. This potential benefit will require more detailed evaluation.

Because of our concern for retained left ventricular air and subsequent postoperative stroke or neurocognitive deficits, we perform several procedures. A left ventricular vent placed through the right superior pulmonary vein is rarely used to reduce air accumulation in the left atrium. Instead, the pump suction tip is used to aspirate the left ventricle through the aortic annulus; this also serves the purpose of retracting the native valve. Before final closure of the aortotomy, the pump suction tip is used to compress the left ventricle from the outside to evacuate air from the left ventricle. The anesthesiologist also ventilates the lungs and once no further air is evacuated from the aortotomy, the anesthesiologist keeps the lungs inflated using a Valsalva maneuver while the last suture in the aortotomy is tied down. The patient is placed in the Trendelenburg position, the ascending aortic vent is turned up to maximum, and the aorta is unclamped. Transesophageal echocardiography is used to ensure no air remains in the heart. The ascending aorta is checked for air bubbles before and during the leveling of the operating room table before discontinuing cardiopulmonary bypass. Aortic root sumping through the aortic root vent at 300 mL/min for 5 to 10 minutes after discontinuation of bypass is often also used until transesophageal echocardiography reveals no evidence of microbubbles. In this series of patients, we believe these maneuvers have prevented us from having any clinically observed neurologic injuries. More recently, we have flooded the incision with CO₂ gas, as CO₂ is absorbed more rapidly.

Hospital discharge was earlier in this series of minimal-access patients when compared with the control standard incision patients. It is our clinical impression that the patients tolerated the procedure better, recovered earlier, and had less of a traumatic response to the operation. Mechanical valve patients ready for early discharge were discharged on twice daily 5,000 to 10,000 international units of subcutaneous heparin, administered by a visiting nurse, until the patient’s anticoagulation was in the therapeutic range.

Furthermore, we have had patients return to work, including manual labor, within a week or two of the operation. One patient was discharged on the second postoperative day after aortic valve replacement and on the third postoperative day was back on his construction site driving a bulldozer and backhoe. A formal, randomized comparative study would be required to prove that patients have a shorter hospital stay, reduced costs, and earlier return to work.

Although these minimal-access operations can be done with a good cosmetic result, with a skin incision of 7 to 8 cm, whether postoperative discomfort and chest pain is lessened is difficult to answer. To determine whether pain was less, we compared the use of intravenous morphine or oral narcotic analgesics in the minimal-access patients with that in the control group of standard incision patients. Although morphine requirements tended to be less with minimal-access incisions, this was statistically significant only for the "J/j" incisions. There was, however, no difference in the use of oral pain medications between the two groups. A more sophisticated method of quantifying patients’ postoperative pain and discomfort in a randomized study would be required to prove pain is less in the hospital with minimal-access procedures. However, except for the patient who has a sternal nonunion after inverted "T" sternal manubrial incision, none has had any incisional pain on late follow-up, and most volunteer that they have not had any significant pain.

In summary, minimal-access procedures, particularly the "J/j" incision in our experience, even for extensive cardiac or cardioaortic procedures, are safe, give good exposure, are well tolerated, and may result in shorter hospital stays, less discomfort, and earlier return to work.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Sardari F.F., Schlunt M.L., Applegate R.L., II, Gundry S.R. The use of transesophageal echocardiography to guide sternal division for cardiac operations via mini-sternotomy. J Card Surg 1997;12:67-70.[Medline]
2. Hearn C.J., Kraenzler E.J., Wallace L.K., Starr N.J., Sabik J.F., Cosgrove D.M. Minimally invasive aortic valve surgery: anesthetic considerations. Anesth Analg 1996;83:1342-1344.[Medline]
3. Navia J.L., Cosgrove D.M., III Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:152-154.
4. Cosgrove D.M., III, Sabik J.F. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
5. Svensson L.G. Minimal-access "J" or "j" sternotomy for valvular, aortic, and coronary operations or reoperations. Ann Thorac Surg 1997;64:1501-1503.[Abstract/Free Full Text]
6. Svensson L.G. Reoperations on the aortic root and ascending aorta. Ann Thorac Surg 1997;64:986-992.[Abstract/Free Full Text]
7. Fitzgerald J.M., Tripathy U., Svensson L.G., Libertino J.A. Radical nephrectomy with vena cava thrombectomy using minimal access approach. J Urol 1998;159:1292-1293.[Medline]
8. Svensson L.G. Rationale and technique for replacement of the ascending aorta, arch and distal aorta using a modified elephant trunk procedure. J Cardiac Surg 1992;7:301-312.[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): Lars G. Svensson Richard S. D’Agostino Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Articles by D’Agostino, R. S. Search for Related Content PubMed PubMed Citation Articles by Svensson, L. G. Articles by D’Agostino, R. S.