Ann Thorac Surg 1998;66:1400-1401
© 1998 The Society of Thoracic Surgeons
Case Reports
Less invasive aortic root replacement
Stephen Westaby, FRCSa,
Takahiro Katsumata, MD, PhDa,
Ahmed Arifi, FRCSa
a Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, Oxford, England, United Kingdom
Accepted for publication April 18, 1998.
Address reprint requests to Mr Westaby, Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, England
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Abstract
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We performed aortic root replacement using partial upper sternotomy in a patient with Marfan’s syndrome. This approach was necessary because of severe pectus excavatum and spinal deformities. Although this method is technically feasible, we would not advocate it for routine use.
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Introduction
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Less invasive valve operations are being used increasingly, although their value remains to be proven. Avoidance of full sternotomy prevents a technical challenge and raises safety issues, not least of which is the limited access in the event of hemorrhage in the intensive care unit. Cosgrove and Sabik [1] recently reported a series of aortic valve replacements performed through a right-sided parasternal incision. This was followed by reports of partial sternotomy incisions [2–4]. Potential benefits include better stability of the thoracic cage, less impairment of respiratory function, and expedited recovery. The cosmetic benefits are secondary to safety. In this report we describe limited-access aortic root replacement in a patient with Marfan’s syndrome. The value of this approach is considered.
The 23-year-old patient with Marfan’s syndrome presented with symptomatic aortic regurgitation (New York Heart Association functional class III) and aortic root aneurysm. His mother with Marfan’s syndrome died at the age of 29 years of severe scoliosis and respiratory failure. Our patient had a scoliosis operation with Harrington rod insertion at the age of 14 years. He had severe pectus excavatum with mediastinal shift and contact of the lower sternum with the spine (Fig 1). The heart was displaced into the left hemithorax, and the right atrium was compressed between the sternum and spine. Echocardiography and nuclear magnetic resonance imaging showed a 6-cm aortic root aneurysm with severe (4+) aortic regurgitation. The aorta tapered to normal size (20 mm) 3 cm proximal to the innominate artery.
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Fig 1. (A) Magnetic resonance imaging shows an enlarged aortic root and compression of the right atrium. (B) The lower sternum contacts the spine, with the heart completely displaced into the left hemithorax.
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We suggested simultaneous repair of the aortic root and pectus excavatum, but this was refused by the patient, who did not wish to change his overall appearance. We were obliged to replace the aortic root alone through a limited upper sternotomy (Fig 2) after concern that the alternative "bucket handle" bilateral anterior thoracotomy may cause respiratory problems.
A midline skin incision was made from the level of the suprasternal notch superiorly to just before the beginning of the sternal excavation inferiorly. The upper sternum (to the third intercostal space) was divided with horizontal transection to both sides as described by Sardari and colleagues [4]. Neither internal thoracic artery was divided. Exposure of the aortic root was acceptable, despite displacement into the left hemithorax by the chest wall deformity. Pericardial stay sutures were used to improve access. Cardiopulmonary bypass was established with an ascending aortic cannula and a two-staged single venous cannula, both inserted through the partial sternotomy wound. After the aorta was cross-clamped, the left ventricle was vented via the right upper pulmonary vein. Cardioplegia was given directly into the coronary ostia after the aneurysm was opened. Decompression of the huge aortic root aneurysm allowed the valve annulus to be delivered into the wound. The coronary ostia were then mobilized from the aorta, and the root was replaced with a 25-mm Carbo-seal (Sulzer-Carbomedics Inc, Austin, TX) composite graft. The coronary arteries were reimplanted, the left first and the right after the distal anastomosis. After an ischemic period of 64 minutes, the patient was weaned from cardiopulmonary bypass uneventfully. A single drainage tube was placed in the pericardium, and the chest closed with steel wires. Apart from the limited access, the conduct of the operation was unchanged from our usual approach.
The patient was extubated 1 hour postoperatively and made a rapid and uncomplicated recovery. He was discharged on the 5th postoperative day, taking warfarin, with an international normalized ratio of 2.5.
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Comment
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After the initial enthusiasm for minimally invasive coronary artery bypass procedures, the limited-access approach for aortic valve replacement has been advocated by several groups. Three incisions have been employed to access the aortic root: the right parasternotomy [1], lower partial sternotomy [2], and upper partial sternotomy with or without sternal transection [3, 4]. The upper partial sternotomy was deemed the only realistic option for our patient given the anatomic and pathophysiologic limitations of his severe Marfan’s deformities. We were aware that the sternal turnover or eversion technique [5] for repair of pectus excavatum offers excellent exposure to the heart and great vessels, but this was eliminated by the patient’s refusal.
Partial sternotomy incisions may have both physiologic and psychological benefits, but limited cardiac exposure poses new challenges and concerns about safety. Mitchell and colleagues [6] recently reported hemodynamic problems from mechanical compression of the right ventricle against the sternum after aortic valve replacement via the right parasternal incision. We are also aware of unreported fatalities resulting from difficulties in secondary exposure during postoperative bleeding. In our practice with fast-track recovery, partial upper sternotomy for aortic valve replacement has not provided either earlier extubation or earlier hospital discharge [7]. The issue of postoperative pain is difficult to assess, as is the psychology of rapid recovery and return to work. The ability to provide complete sternal stability after median sternotomy should be within the capability of every trained cardiac surgeon, and sternal complications may eventually be just as likely after partial sternotomy. Having performed full aortic root replacement through limited access out of necessity, we are not enthusiastic to repeat this operation. Root replacement requires a degree of precision that is impaired rather than enhanced by a small incision. We suspect that the risks of the procedure may well outweigh the benefits.
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References
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- 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]
- Moreno-Cabral R.J. Mini-T sternotomy for cardiac operations. J Thorac Cardiovasc Surg 1997;113:810-811.[Free Full Text]
- Tam R.K.W., Garlick R.B., Almeida A.A. Minimally invasive redo aortic valve replacement. J Thorac Cardiovasc Surg 1997;114:682-683.[Free Full Text]
- 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]
- Wada J., Ikeda K., Ishida T., Hasegawa T. Results of 271 funnel chest operations. Ann Thorac Surg 1970;10:526-532.[Medline]
- Mitchell M.B., Brown J.M., London M.J. Cardiac entrapment during minimally invasive aortic valve replacement. Ann Thorac Surg 1997;64:1171-1173.[Abstract/Free Full Text]
- Westaby S., Pillai R., Parry A., et al. Does modern cardiac surgery require conventional intensive care?. Eur J Cardiothorac Surg 1993;7:313-318.[Abstract]
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L. K. von Segesser, S. Westaby, J. Pomar, D. Loisance, P. Groscurth, and M. Turina
Less invasive aortic valve surgery: rationale and technique
Eur. J. Cardiothorac. Surg.,
June 1, 1999;
15(6):
781 - 785.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
