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Ann Thorac Surg 1999;67:1328-1332
© 1999 The Society of Thoracic Surgeons

Original Articles

Minimally invasive mitral valve surgery: the subxiphoid approach

Haldun Y. Karagoz, MDa, Kemal Bayazit, MDa, Bektas Battaloglu, MDa, Murat Kurtoglu, MDa, Gökhan Özerdem, MDa, Beyhan Bakkaloglu, MDb, Beril Sönmez, MDb

a Department of Cardiovascular Surgery, Guven Hospital, Ankara, Turkey
b Department of Anesthesiology, Guven Hospital, Ankara, Turkey

Accepted for publication October 18, 1998.

Address reprint requests to Dr Karagoz, Cankaya Cad 4/2, Cankaya 06680, Ankara, Turkey


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. This report describes mitral valve replacement using a unique subxiphoid approach with a lower ministernotomy and a skin crease incision and compares the operative and echocardiographic results to patients undergoing mitral valve replacements using previously described strategies.

Methods. Fifty-four patients underwent mitral valve replacement using a subxiphoid approach (group 1); 32 patients underwent mitral valve replacement, 11 patients underwent mitral valve replacement + tricuspid reconstruction, 2 patients underwent mitral valve replacement + tricuspid valve replacement, and 9 patients underwent mitral reconstruction. This group of patients was compared to 11 patients who underwent mitral valve replacement through a superior ministernotomy (group 2) and 29 patients who underwent mitral valve replacement with full median sternotomy (group 3, 22 mitral valve replacements, 2 mitral valve replacements + tricuspid reconstruction, 2 mitral reconstructions, and 3 mitral reconstructions + tricuspid reconstruction).

Results. There was no operative mortality in all groups. The operation lasted significantly longer in group 2 patients compared to group 1 and 3 patients (p < 0.01). Postoperative mediastinal drainage was significantly lower in groups 1 and 2 (p < 0.001). Pain assessment revealed no difference between the groups. Three patients in group 1 presented with pericardial effusion. Except for this complication, early postoperative echocardiographic findings of the patients were similar in all three groups. All patients were in New York Heart Association functional class I or II at the second postoperative month, irrespective of the surgical technique used.

Conclusions. There was no prominent superiority of the ministernotomy approaches over the standard median sternotomy approach. However, the reliability of the subxiphoid approach is documented echocardiographically and any type of mitral replacement can be performed with this approach.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
There has been recent enthusiasm regarding minimally invasive cardiac procedures [1–7]. To be considered minimally invasive, a surgical technique should meet the following criteria: (1) it should not compromise the reliability of the cardiac repair (ie, a standard or perfect operation should be performed); (2) it should not violate chest wall integrity substantially; and (3) it should not use femoral cannulation/intervention, as this may lead to retrograde aortic dissection [6]. Bearing these basic principles in mind, we had devised a subxiphoid approach to operate on certain subsets of patients. This report describes our experience in patients undergoing mitral valve replacement with a subxiphoid approach and compares this group of patients with patients who underwent mitral valve replacement either with a superior ministernotomy or full median sternotomy.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
From December 1996 to August 1997, 54 patients underwent mitral valve replacement (MVR) using a subxiphoid approach, with a skin crease transverse incision and a lower ministernotomy (group 1). This group of patients was compared to 11 patients who underwent MVR through a superior ministernotomy (group 2) and 29 patients who underwent MVR with full median sternotomy (group 3). All operations were performed in the same time frame. Preoperative characteristics of the patients are depicted in Table 1 and surgical procedures used are depicted in Table 2.


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  		Table 1. Preoperative Variables

 

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  		Table 2. Surgical Procedures Used

 
Patient selection
All patients had a diagnosis of rheumatic in origin and were referred to us with an indication for MVR. These were consecutive patients and represent all patients undergoing MVR in the depicted time period. Patients were fully informed about the pros and cons of the three abovementioned techniques, including that the ministernotomy techniques are new and long-term results are not yet available. Selection of the surgical approach was dictated by patient preference.

Surgical technique
All operations in the three groups were performed using standard cardiopulmonary bypass and myocardial protection techniques. All patients were monitored with intraoperative transesophageal echocardiography for technical assessment and deairing guidance.

Subxiphoid approach (group 1)
A transverse skin incision of 4 to 5 cm is performed over the superior rim of the xiphoid process, parallel to the skin crease (Fig 1). A few centimeters of skin is undermined below and above the incision. An inverted J-type ministernotomy is performed from the left edge of the xiphoid process up to the left fourth intercostal space. A pediatric sternal retractor is used to expose the heart (Leibinger, Muhleim-Stetten, Germany). The ascending aorta is cannulated with a straight tipped 20F arterial cannula (William Harvey arterial perfusion cannula; C.R. Bard, Inc, Tewksbury, MA). The inferior vena cava is cannulated with a 32F or 37F venous cannula (Medtronic DLP, Grand Rapids, MI). The cannula is passed from a separate inferior stab wound, which would later be used to insert the chest tube (Fig 2).



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  		Fig 1. Postoperative photograph showing a skin incision for a subxiphoid approach to mitral valve replacement.

 


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  		Fig 2. Completed cannulation for cardiopulmonary bypass in a subxiphoid approach to mitral valve replacement (IVC = inferior vena cava; SVC = superior vena cava.)

 
Initially, the superior vena cava was cannulated with a 37F balloon-tipped venous cannula (Medtronic DLP) in 8 patients, and directly with a 31F right angled cannula (Medtronic DLP) from a separate stab wound in 2 patients. Cannulation of the superior vena cava was later deemed unnecessary. In the rest of the patients, the superior vena cava was not drained directly, but rather was snared after aortic cross-clamping. Venous decompression of the upper body was accomplished by an 8.5F introducer sheath (Daig, Minnetonka, MN) introduced into the right internal jugular vein and connected to the venous reservoir of the pump oxygenator by the anesthesiologist. A separate puncture in the left internal jugular vein was used to monitor the venous pressure constantly. An aortic needle was used for cardioplegia delivery and aortic venting.

After institution of cardiopulmonary bypass, both vena cavae are snared by surgical tapes. The aorta is cross-clamped with a straight clamp (Martin, Tuttlingen, Germany) in an oblique manner.

A curved right atrial incision is performed, starting a few centimeters below the right atrial appendage, curving upward and ending near the inferior vena caval cannula. Mitral valve is exposed through a curved incision in the interatrial septum, starting from the insertion point of the right superior pulmonary vein, passing along the superior border of the fossa ovalis, and ending beneath the coronary sinus. Care is given to leave adequate tissue above the mitral valve annulus for placement of retractors, if necessary. Three or four stay sutures are placed at the lateral margin of the incision, pulling the interatrial septum upward and to the left.

Mitral valve exposure is usually adequate with the septal stay sutures in place. Additional exposure is gained by retracting the superior and lateral edges of the interatrial septum by malleable Marberger hilar retractors (Leibinger) (Fig 3). Mitral valve repair or replacement is performed using essentially the same surgical techniques as would be done conventionally with a full median sternotomy. Interatrial septum is closed using a single layer of 4:0 polypropylene continuous suture. Aortic cross-clamp is released after closure of the interatrial septum. Air is evacuated from the left heart chambers through a needle inserted into the left ventricle from beneath the septal leaflet of the tricuspid valve and directly from the interatrial septum. Aortic needle is used for aortic venting. Tricuspid valve is inspected on the beating heart, and repaired or replaced as necessary. Additional deairing is performed by needle insertion into the roof of the left atrium and into the left ventricle, transseptally, without lifting the heart.



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  		Fig 3. Intraoperative photograph of the exposure of the mitral valve in a subxiphoid approach to mitral valve. Photograph shows assessment of the valve after mitral repair.

 
In the first 19 patients in this group, a fast-tract protocol was used (ie, extubation in the operation room, minimal intensive care unit stay [6 to 13 hours], and hospital discharge on postoperative days 2 or 3). The remainder of the patients was treated according to standard postoperative care protocols.

Superior ministernotomy approach (group 2)
The operation is performed through a 7- to 8-cm longitudinal midline skin incision. A J-type ministernotomy is performed from the manubrium sterni to the third or occasionally the fourth right intercostal space. The rest of the operation is performed as described by Gundry [7] and Sardari [8] and their colleagues.

Conventional operation (group 3)
The operation is performed using conventional techniques with full midline sternotomy. Bicaval cannulation is used, and the mitral valve is exposed through a left atriotomy performed in the interatrial groove.

In all groups, MVR was performed with pledget-supported interrupted sutures and tricuspid valve replacement was performed with continuous 2:0 polypropylene suture. St. Jude Medical mechanical prostheses (St. Jude Medical, Inc, St. Paul, MN) were used in all patients.

Preoperative, operative, and postoperative variables were compared between the three groups. Postoperative pain assessment was achieved by the aid of visual analog scales [9]. Visual analog scale evaluations were performed at 2 hours after extubation and at every 12 hours until hospital discharge. All patients were called for echocardiographic evaluation on postoperative week 3 and the second month.

For all statistical analyses, Data Desk software (version 6.0) was used and p values of less than 0.05 were considered significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Except for a female dominance in group 1, preoperative characteristics of the three groups were not significantly different.

Perioperative variables are depicted in Table 3. Aortic cross-clamp time, cardiopulmonary bypass time, and total operation time were significantly longer in group 2 as compared to group 1 and 3 patients. Postoperative mediastinal drainage was significantly lower in groups 1 and 2 patients. Intensive care unit stay and postoperative discharge days were not significantly different among the three groups.


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  		Table 3. Perioperative Variables

 
There was no operative mortality in all groups. One patient in group 1 developed posterior ventricular rupture after MVR. In this patient, mitral valve annulus was heavily calcified. Extensive debridement of the calcified tissue was the probable cause of the posterior rupture. Her incision was converted to full median sternotomy and an extracardiac repair was accomplished. Her postoperative course was uneventful. This was the only major morbidity in group 1. Except for this complication, there has been no other morbidity in all groups such as stroke or reexploration for bleeding.

Three patients in group 1 (5.5%), 1 patient in group 2 (9%), and 2 patients in group 3 (6.8%) required positive inotropic support at the termination of cardiopulmonary bypass (p = not significant). Conversion of preoperative atrial fibrillation to sinus rhythm was observed significantly in all groups after the operation (p < 0.001 in all groups). Use of intravenous medication for postoperative control of arrhythmias were needed in 4 patients in group 1 (7.4%), 1 patient in group 2 (9%), and 2 patients in group 3 (6.8%) (p = not significant).

Pain assessment by visual analog scale method revealed no difference between the groups. Mean visual analog scale scoring was 2.7, 2.9, and 2.7, respectively, in groups 1, 2, and 3 (no pain = 0, worst possible pain = 10). All groups recovered similarly in the early postoperative period, and full recovery was achieved at the second postoperative month in all patients.

All patients were in New York Heart Association functional class I or II at the second postoperative month, irrespective of the surgical technique used.

Echocardiographic evaluation at the postoperative third week and second month was obtained in 100% of patients. Three patients in group 1 presented with pericardial effusion in their third week visit. All three patients belonged to the fast-tract subgroup and their effusions were drained surgically from the same incision. Except for this complication, early postoperative echocardiographic findings of the patients were similar in all three groups. There were no anatomic or physiologic abnormalities detected in patients who underwent MVR. There was no periprosthetic leak or prosthetic malfunction. There were no interatrial shunts detected in group 1 patients from their transseptal incisions. The patient who underwent mitral valve reconstruction with chordal transfer in group 1 presented with mild mitral regurgitation and a mean diastolic gradient of 6 mm Hg at her third week visit, which decreased to 4 mm Hg at the second month visit. All other patients with mitral valve repair in groups 1 and 3 had reasonably well functioning valves. Among the tricuspid valve repair patients, 1 patient in group 1 and another patient in group 3 presented with moderate tricuspid insufficiency without clinical significance. In the 3 patients in group 2 with neglected tricuspid insufficiency, the degree of regurgitation was regressed by their second postoperative month visit.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
In patients who undergo minimally invasive valve replacement, the small skin incision itself should not prompt a fast-tract approach. Unlike minimally invasive coronary bypass procedures performed without cardiopulmonary bypass, these patients undergo essentially the same operation with the same cardiopulmonary bypass trauma as the patients operated on with full median sternotomy. We had observed 3 patients with pericardial effusions in the first 19 consecutive patients in group 1, in whom chest tubes were removed 6 to 8 hours after the operation. Although mediastinal drainage was almost negligible in these patients, early removal of the chest tubes was deemed responsible for the accumulation of pericardial effusion. After we had abandoned the fast-tract protocol and treated these patients in a conventional manner (ie, removal of chest tube after 12 to 14 hours), we have not observed this complication again.

Chest wall integrity is preserved substantially with the subxiphoid approach. Only a small window is separated from the sternum, which preserves clavicular–sternal–rib cage continuity. Also, an inverted J-type ministernotomy is very easy to reapproximate and is relatively painless. Another advantage of the J ministernotomy is the preservation of the internal thoracic arteries. We have seen no injury to these precious vessels.

Avoidance of superior vena caval cannulation is an important step in simplifying a complex operation. Space gained by the lack of the superior vena caval cannula facilitates exposure and a straightforward operation from an already small incision. We have not observed any adverse effect of this approach. A similar technique has also been reported [10, 11].

The Gundry-type superior ministernotomy technique has been a standard for aortic valve-related pathologies in our practice. However, MVR with this approach is associated with some problems. The heart is virtually out of sight in this operation and the surgeon is dependent on transesophageal echocardiography to a great extent [8]. At least in our hands, the operation for the mitral valve is somewhat prolonged. Right atrium and tricuspid valve is also out of sight, which is another disadvantage of this approach. Associated tricuspid insufficiency is frequently encountered in our patient population, who is predominantly rheumatic in origin. In this regard, trans-right atrial MVR with the subxiphoid approach offers almost complete coverage of tricuspid pathologies (Table 2).

This study could demonstrate no prominent advantages of the ministernotomy strategies over a conventional full median sternotomy approach. The benefits of a full sternotomy with easy access for cannulation and generous exposure are also apparent. However, the advent of new technologies will possibly facilitate minimally invasive approaches as well. In this respect, robotic technologies, malleable catheters for venous drainage and arterial return, developments in assisted (suction) drainage, and new specialized instruments can be considered [11–13]. Because no significant difference in terms of postoperative morbidity or pain had emerged between the three groups of patients, the impressive cosmetic result of the subxiphoid approach may be an incentive to use this operation by itself (Fig 1). However, cosmetics should not be a primary goal in open heart operations.

In a minimally invasive approach, an already standardized and very successful operation should not be compromised. The principal aim should be to perform a perfect operation. A mini-incision cannot justify performing a suboptimal or less reliable procedure. The type of operation that one might perform should not be changed because of the minimally invasive approach (ie, repair versus replacement or complicated repair versus replacement).

The subxiphoid approach presented in this report is a "normal" operation with a mini-incision being performed with current standardized and reproducible methodology. The reliability of this operation is documented echocardiographically and any type of mitral operation can be performed with this approach.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
This manuscript was kindly prereviewed by Bruce W. Lytle, MD. We acknowledge his contribution to the preparation of this manuscript.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Chitwood W.R., Jr, Elbeery J.R., Moran J.F. Minimally invasive mitral valve repair using transthoracic aortic occlusion. Ann Thorac Surg 1997;63:1477-1479.[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. Tsai F.C., Lin P.J., Chang C.H., et al. Video-assisted cardiac surgery. Preliminary experience in reoperative mitral valve surgery. Chest 1996;110:1603-1607.[Abstract/Free Full Text]
  4. Benetti F.J., Mariani M.A., Rizzardi J.L., Benetti I. Minimally invasive aortic valve replacement. J Thorac Cardiovasc Surg 1997;113:806-807.[Free Full Text]
  5. Fann J.I., Pompili M.F., Stevens J.H., et al. Port-access cardiac operations with cardioplegic arrest. Ann Thorac Surg 1997;63:S35-S39.
  6. Mohr F.W., Falk V., Diegler A., et al. Minimally invasive port-access-mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:567-574.[Abstract/Free Full Text]
  7. Gundry S.R., Shattuck O.H., Sardari F.F., et al. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
  8. 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 Cardiol Surg 1997;12:67-70.
  9. Paige D., Cioffi A.M. Pain assessment and measurement. In: Sinatra R.F., Hord E.H., Ginsberg B., Preble L.M., eds. Acute pain. St. Louis: Mosby-Year Book, 1992:70-77.
  10. Flege J.B., Jr, Wolf R.K. Venous drainage to the heart-lung machine via the internal jugular vein. Ann Thorac Surg 1997;63:861.[Abstract/Free Full Text]
  11. Doty D.B., DiRusso G.B., Doty J.R. Full-spectrum cardiac surgery through a minimal incision:mini-sternotomy (lower-half) technique. Ann Thorac Surg 1998;65:573-577.[Abstract/Free Full Text]
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This Article
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