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Ann Thorac Surg 1999;67:1806-1807
© 1999 The Society of Thoracic Surgeons

How to Do It

Reversed "C" ministernotomy for aortic valve replacement

Alejandro Aris, MD, PhDa

a Cardiac Surgery Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Accepted for publication November 27, 1998.

Address reprint requests to Dr Aris, Cardiac Surgery Service, Hospital de la Santa Creu i Sant Pau, San A.M. Claret 167, 08025 Barcelona, Spain
e-mail: aaris{at}hsp.santpau.es


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
The technique of aortic valve replacement through a reversed "C" sternotomy incision is described. The sternal incision extends between the second and the fifth intercostal space and provides excellent exposure of the ascending aorta, the aortic root, and the right atrial appendage. The procedure can be performed with standard cannulation for cardiopulmonary bypass and conventional surgical instruments.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Several minimally invasive valve operations have been described recently [1–3]. The techniques, named after several alphabetical characters (L, T, J, j, C, etc), provide access to cardiac valves without opening the sternum entirely. After an initial experience with aortic valve replacement through a transverse sternotomy at the level of the third intercostal space [4], I have adopted the reversed "C" incision for minimally invasive aortic valve replacement. The rationale of this approach is to avoid splitting the upper part of the sternum.

The patient is draped in the usual fashion for median sternotomy. Before this, two external defibrillation paddles are placed at both sides of the chest. The skin incision is 8–10 cm long, starting at the level of the angle of Louis. Two parallel incision are made in the sternum, starting at the right border of the second and fifth intercostal spaces and extending to the midline. The two incisions are connected with the use of an oscillating saw (Fig 1). In stocky patients with short chests, the horizontal incisions can be started at the level of the first and fourth intercostal spaces. The first intercostal space is also used when a complete exposure of the ascending aorta is needed. A small retractor is placed between both sternal edges. By freeing the anterior aspect of the intercostal muscles, the retractor can be opened considerably. No attempts are made to identify the right internal mammary artery, since with this approach, it is not disturbed. After opening of the pericardium and with properly placed traction sutures, the ascending aorta, the aortic root, and the tip of the right atrial appendage are clearly exposed (Fig 2). Cannulation of the ascending aorta is done as usual. A two-stage, wire-reinforced flattened cannula (VC2; Medtronic DLP, Grand Rapids, MI) is introduced through the atrial appendage. Both cannulae exit through the incision. After institution of cardiopulmonary bypass, the aorta is cross-clamped and opened. The aortic valve is resected and three stay sutures are placed at the commissures. Traction on these sutures facilitates the access to the valvular plane. At present, only antegrade blood cardioplegia through the coronary ostia has been used for myocardial protection. However, a retrograde cardioplegia cannula can be inserted blindly in the coronary sinus. Very seldom, blood return to the left heart may obstruct vision of the operative field. In these cases, a soft cardiac sump (12012; Medtronic DLP) can be dropped into the ventricle through the aortic orifice. The prosthesis is implanted in the usual fashion. Deairing is accomplished by tapping the tip of the ventricle with a malleable retractor before closure of the aortotomy. In addition, with the patient in the Trendelenburg position, the aortic clamp is left occluding the ascending aorta partially after it has been released. Air bubbles remaining in the ventricle can be trapped with this maneuver. It is advisable to place to temporary pacemaker electrode in the right ventricle before discontinuation of cardiopulmonary bypass, when the heart is still empty. Defibrillation, if necessary, is done externally, since the incision does not allow proper placement of the internal paddles, even the pediatric size. One chest tube is left over the aorta, exiting through the right chest. Closure of the chest is accomplished with three sternal wires. Two are placed vertically into the sternal flap. A third figure-of-eight wire secures the sternum medially. This technique has been used in 10 aortic valve replacements with excellent exposure in all cases, with an average aortic cross-clamp time of 66 ± 10 minutes and cardiopulmonary bypass time of 90 ± 15 minutes.



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  		Fig 1. The sternal incision extends from the second to the fifth intercostal space. In individuals with a short chest, the first and fourth spaces can be used (dotted line).

 


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  		Fig 2. View of the ascending aorta, aortic root, and tip of the right atrial appendage through the incision.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
The concept of the reversed "C" sternal incision is not new. Svensson has described a more extensive sternotomy with a "j" configuration, up to the sternal notch. In his original report [3] he describes a variant method ("J") in which the sternal manubrium is left intact. He uses transversal incisions at the level of the first and fourth intercostal spaces, which gives an excellent exposure of the ascending aorta. I use this approach on patients with short chests, but the fifth intercostal spaces gives a better access to the right atrial appendage. The "J/j" incision hasgiven better results, with less morphine requirements and shorter operative stay when compared with other techniques of minimal-access aortic and valve operations [5]. Kasegawa and colleagues [1] reported a similar approach, but their incision extended to the base of the xiphoid process. Only one aortic valve replacement was performed. The advantage of the reversed "C" technique is that it provides excellent aortic valve exposure, leaving intact the upper and lower ends of the sternum. This is an important concept, based on the theory of "the dome and the suspension bridge." The chest cavity can be compared with a dome with a suspension bridge resting over its top (Fig 3). Windows can be opened safely on a dome, as Michelangelo did in St. Peter’s Cathedral when Cardinal Corvino dissaproved his project, arguing that it would be "too dark," but a section of major support structures can render it unstable. The small incision in the sternum leaves the chest cavity largely intact. A decrease in postoperative bleeding and discomfort, as compared with the standard median sternotomy, may be expected.



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  		Fig 3. The chest cavity can be compared with a dome with a suspension bridge over its top. Windows can be opened safely without compromising its stability.

 
The technique offers several advantages over other minimally invasive techniques. The right internal mammary artery is not sacrificed, the procedure can be carried out with conventional operative equipment, and conversion to medial sternotomy is easy. Extension to the first intercostal space exposes the entire ascending aorta.

Until scientific studies validate the superiority of minimally invasive aortic valve operations [6], the reversed "C" incision offers an excellent alternative to other existing methods.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Kasegawa H., Shimokawa T., Matsushita Y., Kamata S., Ida T., Kawase M. Right-sided partial sternotomy for minimally invasive valve operation: "open door method". Ann Thorac Surg 1998;65:569-570.[Abstract/Free Full Text]
  2. Moreno-Cabral R.J. Mini-T sternotomy for cardiac operations. J Thorac Cardiovasc Surg 1997;113:810-811.[Free Full Text]
  3. Svensson L.G. Minimal-access "J" or "j" sternotomy for valvular, aortic and coronary operations. Ann Thorac Surg 1997;64:1501-1503.[Abstract/Free Full Text]
  4. Aris A., Padró J.M., Cámara M.L. Sustitucion valvular aortica minimamente invasiva. Rev Esp Cardiol 1997;50:750-753.
  5. Svensson L.G., D’Agostino R.S. Minimal-access aortic and valvular operations, including the "J/j" incision. Ann Thorac Surg 1998;66:431-435.[Abstract/Free Full Text]
  6. Antunes M.J. Minimally invasive valve surgery: reality, dream or utopia?. J Heart Valve Dis 1998;7:358-359.[Medline]



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This Article
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