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Ann Thorac Surg 1999;67:1328-1332
© 1999 The Society of Thoracic Surgeons
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
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Abstract |
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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.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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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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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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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.
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Results |
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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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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.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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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.
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Acknowledgments |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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References |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
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