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Ann Thorac Surg 1998;66:1106-1109
© 1998 The Society of Thoracic Surgeons

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Supplement

Valve operations through a minimally invasive approach

^a Department of Cardiovascular Surgery, Institute of Cardiology and Cardiovascular Surgery, Favaloro Foundation, Buenos Aires, Argentina

Address reprint requests to Dr Weinschelbaum, Department of Cardiovascular Surgery, Institute of Cardiology and Cardiovascular Surgery, Favaloro Foundation, Belgrano 1746, 1093 Buenos Aires, Argentina
e-mail: (weins001{at}ffinme.edu.ar)

Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV", New Orleans, LA, Jan 24, 1998.

Abstract

Background. We analyzed in-hospital results of 87 patients undergoing minimally invasive valvular operations (right parasternal incision through third and fourth cartilages).

Methods. Age was 21 to 84 years (mean, 56.2 ± 16); 45 patients (51.7%) were female. Five (5.7%) had a previous valvular operation and 8 (9.2%) had severe left ventricular dysfunction. Valve diseases were as follows: aortic in 35 patients (40.2%), mitral in 44 (50.5%), double in 5 (5.7%), tricuspid regurgitation in 2 (2.2%), and mitral periprosthetic leak in 1 (1.1%).

Results. Nineteen mitral repairs (21.9%), 22 replacements (25.3%), 1 leak closure (1.1%), 1 tricuspid repair (1.1%), and 1 replacement (1.1%) were performed. Thirty-one patients (35.7%) underwent aortic replacement, 2 (2.3%) aortic decalcification, 1 (1.1%) subaortic membrane resection, 4 (4.6%) a double-valve procedure, and 5 (5.7%) a single-valve operation combined with myocardial revascularization. In-hospital mortality was 5.7% (5 patients). Univariate analysis was significant for previous operation, New York Heart Association class IV and severe ventricular dysfunction. Multivariate analysis was significant for previous operation and severe ventricular dysfunction. Atrial fibrillation (12.6%) was the most frequent complication. Postoperative stay was 6.5 ± 6 days.

Conclusions. The minimally invasive approach is a useful technique in valvular surgery. Patients with a previous valvular operation, severe ventricular dysfunction, and New York Heart Association class IV dyspnea have higher in-hospital mortality.

Less invasive cardiac surgery has emerged as a new and substantially different approach to a variety of cardiovascular surgical procedures. However, the largest experience in this field is related to coronary artery bypass grafting. Recently, Cosgrove and associates [1, 2] introduced the minimally invasive approach to valve operations with good results. The limited clinical experience [3], is the principal impediment to making firm conclusions about the utility of this approach. In addition, the variables associated with higher risk in this procedure are unknown. We report our experience with valve operations through a minimally invasive approach and analyze different variables associated with hospital mortality.

Material and methods

Population
Between August 1996 and January 1998, 87 consecutive patients with valvular disease underwent operation with a minimally invasive approach. Mean age was 56.2 ± 16 years (range, 21 to 84 years), and 45 patients (51.7%) were women. Table 1 shows the clinical features of the population. The surgical indications were aortic valve disease in 35 patients (40.2%), mitral valve disease in 44 (50.6%), double-valve disease in 5 (5.7%), tricuspid regurgitation in 2 (2.3%), and paraprosthetic mitral leak in 1 (1.1%) (Table 2).

View larger version (131K): [in this window] [in a new window]   Fig 1. Incision for minithoracotomy in valve operations. The broken line shows the skin incision in the midline for cosmetic reasons. The solid line indicates the cutdown trajectory through the insertion of the third and fourth cartilages in the sternum.

View larger version (84K): [in this window] [in a new window]   Fig 2. (A) Device to move the sternum upward 2 to 3 cm. (B) Device placed in the surgical position that provides enough space for placement of the aortic clamp.

Statistical methods
Preoperative and intraoperative variables were analyzed using a Student t test, ², and linear regression analysis. These variables included age, sex, reoperation, prior acute myocardial infarction, New York Heart Association class, atrial fibrillation, concomitant myocardial revascularization, duration of cross-clamping and cardiopulmonary bypass, and left ventricular systolic function.

Results

The surgical procedures are summarized in Table 3. The duration of cardiopulmonary bypass and aortic cross-clamping in patients with a single-valve operation was 116 ± 31 minutes and 87 ± 28 minutes, respectively; in double-valve procedures, 131.1 ± 49 and 98.5 ± 16 minutes, respectively; and in operations with concomitant myocardial revascularization, 147.5 ± 43.3 and 103 ± 17 minutes, respectively. In 1 patient it was necessary to convert to a medial sternotomy because of technical difficulties.

All patients showed normal valvular function on the intraoperative transesophageal echocardiogram. However, 2 patients with mitral regurgitation and anterior and posterior leaflet dysfunction who underwent mitral valve repair had development of severe mitral regurgitation, as shown in the echocardiographic study prior to discharge. The mean postoperative stay was 6.5 ± 6 days (range, 3 to 60 days). Sixty-three patients (72.4%) were discharged before the seventh postoperative day.

Comment

The goals of the minimally invasive surgical approach are more rapid recovery, shorter hospital stay, less patient morbidity, faster return to routine activity, increased patient comfort compared with standard procedures, cosmetic benefit, and cost containment [3]. However, the experience with valve operations through this approach is still very limited, and the advantages of this method are unknown.

In our experience, hospital mortality and morbidity were comparable to those reported for valve procedures with the median sternotomy approach [5]. In addition, the factors that adversely affected the hospital results were similar to those seen with the conventional approach [5]. The most important predictor of perioperative mortality was prior cardiothoracic surgical procedure (p = 0.003). This variable increased the risk substantially. In 1 patient, aortic clamping was impossible because the aorta was firmly adherent to the sternum.

The degree of technical difficulty depended in many instances on the distance between the valve annulus and the incision. This usually involved patients with a large anteroposterior thoracic diameter and some in whom marked enlargement of the ventricular or atrial cavity or both cavities had distorted the position of the annulus. We recommend preoperative assessment of the position of the valve annulus with respect to the thoracic wall with techniques such us helicoidal tomography and take this variable into account when deciding which approach to use.

Valvular performance in both the intraoperative transesophageal echocardiographic study and in the study prior to discharge was optimal in all patients with single-valve or double-valve replacement. In patients with mitral regurgitation and degenerative compromise of the posterior leaflet, the outcome was successful, but in 2 patients with disease of both leaflets, the valve repair failed. The failure probably was due to poor visualization of the anterior mitral subvalvular apparatus through this approach. We suggest use of the technique in patients with disease of the posterior leaflet only.

This approach permitted successful single- or double-valve replacement or repair, and combined revascularization of the right coronary artery when the lesion was in the proximal third. When revascularization of the left anterior descending coronary artery was needed, an additional minithoracotomy was done simultaneously. As with minimal surgical intervention for myocardial revascularization, the smaller incision results in less trauma and less pain. Patients recover more rapidly and are discharged earlier. In addition, the smaller incision reduces the risks of wound infection and blood loss.

In conclusion, a minimally invasive approach for valve operations is a useful technique for the surgical treatment of valvular disease. Patients with previous valve operations, with severe ventricular dysfunction, and in New York Heart Association class IV have higher hospital mortality.

References

1. 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]
2. Navia J.L., Cosgrove D.M., III Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
3. Minale C., Reifschneider H.J., Schmitz E., Uckmann F.P. Single access for minimally invasive aortic valve replacement. Ann Thorac Surg 1997;64:120-123.[Abstract/Free Full Text]
4. Guiraudon G.M., Ofiesh J.G., Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058-1062.[Abstract/Free Full Text]
5. Bojar R.M. Adult cardiac surgery. Boston: Blackwell Scientific Publications, 1992:155-240.

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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): Ernesto Weinschelbaum Roberto Favaloro Victor Caramutti Alejandro Bertolotti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Weinschelbaum, E. Articles by Fraguas, H. Search for Related Content PubMed PubMed Citation Articles by Weinschelbaum, E. Articles by Fraguas, H.