HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chang, Y.-S. Articles by Tan, P. P.C. Search for Related Content PubMed PubMed Citation Articles by Chang, Y.-S. Articles by Tan, P. P.C.

Ann Thorac Surg 1999;68:40-45
© 1999 The Society of Thoracic Surgeons

---

Original Articles

"I" ministernotomy for aortic valve replacement

^a Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
^b Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan

Address reprint requests to Dr Lin, Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, 199, Tun-Hwa North Rd, Taipei, Taiwan 105

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement.

Methods. Eighteen patients were operated on by means of an "I" ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an "I" median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto–right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia.

Results. Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses.

Conclusions. Our experience demonstrates that the "I" ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Aortic valve replacement is traditionally performed with median sternotomy, extracorporeal circulation, aortic cross-clamping, and cardioplegic arrest. However, the poor cosmetic effect and possible complications of median sternotomy are occasionally troublesome.

The concept of minimally invasive surgical approaches has been introduced recently in the surgical treatment of coronary artery disease [1–4], atrial septal defect [5, 6], ventricular septal defect [7], and mitral valve lesions [8–11]. These procedures have been performed through minithoracotomy with or without the guidance of video-assisted endoscope. The minimally invasive nature of these operations can lessen incisional pain, minimize incisional length, enhance functional recovery, and shorten hospital stay.

Minimally invasive operations in correction of aortic valve lesions have recently been performed through right parasternal incision [12, 13], right minithoracotomy [14], transsected sternum [15], or "J" upper ministernotomy [15]. In this report we reviewed and compared our initial results of aortic valve replacement through an "I" ministernotomy at the midportion of the sternum to those through a full median sternotomy.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Eighteen randomly selected patients, 11 men and 7 women, 25 to 73 years old (mean, 55.1 years), were operated on for isolated aortic stenosis (10 patients) or aortic regurgitation (8 patients) through an "I" ministernotomy at Chang Gung Memorial Hospital, Taipei, Taiwan (MINI group). Patients associated with coronary artery disease, mitral or tricuspid valvular disease, severe aortoiliac occlusive disease, or severe atherosclerotic disease of the ascending aorta were excluded from this approach. Echocardiographic examination and cardiac catheterization were performed for diagnosis. The ejection fraction ranged from 35% to 66% (50% ± 9%) (Table 1).

Written consent was obtained from the patient and the family members before the operation.

Aortic valve replacement through "I" ministernotomy
After induction of general anesthesia, transesophageal echocardiographic monitoring was set up. The anesthetic agents and techniques were the same in patients of the MINI group and the FS group. The patient was put in a supine position with exposure of the left groin, for femoral cannulation, if necessary. An 8- to 10-cm incision was made over the midportion of the sternum from the upper margin of the third rib to the lower margin of the fifth rib (Fig 1A). The sternum was split by oscillation saw from the second to the fifth intercostal space. On the upper and lower end of the ministernotomy, the sternum was transversely divided to make an "I" ministernotomy (Fig 1B). Care was taken to preserve bilateral internal thoracic arteries. A sternal spreader was used to expose the pericardium (Fig 1C). After pericardiotomy, the intrapericardial ascending aorta and right atrium were well exposed (Fig 1D). Systemic heparin (250 U/kg) was administered at this time.

View larger version (110K): [in this window] [in a new window]   Fig 1. "I" ministernotomy. (A) An incision was made over the midportion of the sternum from the upper margin of the third rib to the lower margin of the fifth rib. (B) The sternum was split longitudinally from the second to the fifth intercostal space. On the upper (the second intercostal space) and the lower end (the fifth intercostal space) of the ministernotomy, the sternum was transversely divided. (C) A pediatric sternal spreader was used to expose the pericardium. (D) Aorta was exposed and encircled after pericardiotomy.

View larger version (119K): [in this window] [in a new window]   Fig 2. (A) Cardiopulmonary bypass was established through cannulation of the distal portion of the ascending aorta (arrow) and auricle portion of the right atrium (arrowhead). (B) In patients without aortic regurgitation, blood cardioplegic solution was infused into the aortic root (arrow) after aortic cross-clamping. (C) Transverse aortotomy was performed. (D) Calcified bicuspid aortic valve was well-exposed.

Aortic valve replacement through full median sternotomy
The standard techniques of median sternotomy were used in patients of the FS group [16]. After induction of general anesthesia, transesophageal echocardiographic monitoring was set up. The patient was put in a supine position. A straight vertical midline skin incision was made from one finger’s breadth below the suprasternal notch to a point 1 to 3 cm below the tip of the xiphoid process. The lower part of the incision was carried through the linea alba. The sternum was then split in the midline by electric saw, and the rib spreader was inserted and opened. The pericardium was then opened and pericardial stay sutures were applied. Cardiopulmonary bypass was established through cannulation of the distal part of the ascending aorta and right atrium. A membrane oxygenator (Maxima Plus oxygenation system, Medtronic, Inc) was used. Systemic hypothermia (28.1° ± 1.0°C) was initiated immediately after the start of extracorporeal circulation. After the heart fibrillated, the aorta was cross-clamped. The heart was protected by intermittent perfusion with blood cardioplegic solution into the coronary artery orifices or coronary sinus. Topical cooling of the heart was not applied. The heart was soon arrested and cooled. A suction catheter was inserted into the right superior pulmonary vein to decompress the heart. The aortic valve was excised after oblique aortotomy and was replaced under direct vision with conventional instruments.

The aortotomy was then closed with running suture. The pulmonary venotomy was also closed. Warm blood cardioplegia was infused into the aortic root or coronary sinus. The patient was turned to a Trendelenburg position. A venting needle was inserted at the aortic root. Removal of air was then performed with expansion of both lungs, suction of the venting needle, and compression of the heart. The aortic cross-clamp was then removed. Sinus rhythm recovered spontaneously and cardioversion was not necessary in most patients. Extracorporeal circulation was terminated after rewarming of the patient. The pericardium was not closed. A small dosage of sodium nitroprusside was infused. Cardiotonic drugs were used in 3 patients. Intraaortic balloon pumping was not used. Transesophageal echocardiography performed after termination of extracorporeal circulation showed good prosthetic function without paravalvular leakage in all patients. Temporary pacemaker wires and drainage tubes were set up routinely. Hemostasis was easily achieved. The sternum and skin incision were closed as usual.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Aortic valve replacements were performed in all patients. Conversion to full sternotomy did not occur in any patient of the MINI group. The length of skin incision was significantly shorter in patients of the MINI group (Table 2). The aortic cross-clamping time was 40 to 78 minutes (65 ± 8 minutes, mean ± standard deviation) in patients of the MINI group and was 30 to 52 minutes (40 ± 5 minutes) in those of the FS group (p < 0.05) (Table 2). The total bypass time was 55 to 90 minutes (77 ± 7 minutes) in patients of the MINI group and 45 to 69 minutes (53 ± 6 minutes) in those of the FS group (p < 0.05). All patients regained consciousness without any neurologic deficits shortly after arriving at the intensive care unit. Cardiotonic drugs were required in 2 patients of the MINI group and in 3 patients of the FS group. The endotracheal tube was removed 4 to 14 hours (8.1 ± 2.3 hours) after arriving at the intensive care unit in the MINI group and 4 to 36 hours (15.7 ± 5.5 hours, p < 0.01) in those of the FS group. The intensive care unit stay was 1 to 3 days (1.5 ± 0.6 days) in patients of the MINI group and 1 to 5 days (2.5 ± 0.4 days, p < 0.05) in those of the FS group.

View larger version (122K): [in this window] [in a new window]   Fig 3. Picture of incision taken 1 month after operation.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Traditionally, standard aortic valve replacement required a long and painful median sternotomy incision. The results are generally good. However, the incisional pain, poor cosmetic effect, and possible complications of median sternotomy are occasionally troublesome.

From the experience of minimally invasive cardiac surgical approaches in the treatment of coronary artery disease [1–4], congenital heart diseases [5–7], and mitral valve lesions [8–11], minimally invasive surgical techniques can be applied to replace those well-established, safe, and minimally complicated standard procedures, without compromising treatment and safety. In our preliminary experience of 18 minimally invasive aortic valve replacements, there were no operative deaths, no wound complications, and no neurologic deficits. The incision length was significantly shorter, and all patients were satisfied with the cosmetic healing. These indicate that minimally invasive aortic valve replacement is a safe and effective procedure.

There are several ways to perform aortic valve replacement with minimally invasive procedures [12–15]. The aortic valve can be approached through a right parasternal incision [12, 13]. An incision was made in the upper right parasternal area and the second and third costal cartilages were excised. Cardiopulmonary bypass was established, usually by femoro-femoral cannulation. This approach offers a great deal of flexibility and minimal trauma, but requires the use of peripheral cannulation in most instances [15]. The right internal mammary artery was damaged in most instances.

The aortic valve can be accessed through a transsected sternum [15]. In this approach, the bilateral internal thoracic arteries are divided, and a complete transverse sternotomy is made at the third intercostal space. The advantages of this approach include the use of intrathoracic cannulation and avoidance of femoral artery and femoral vein cannulation. The disadvantage is that both the right and left internal thoracic arteries are divided, so that it is not possible to use these arteries for future coronary artery bypass grafting, although the chance of needing them is low [15].

The third technique is the "J" upper ministernotomy [15]. In this upper chest incision, the top of the sternum is exposed, an upper sternotomy is made and extended to the third or fourth intercostal space, and then the incision is extended by performing a T-incision into the interspace to allow for retraction of the right-hand aspect of the upper sternum and manubrium laterally. In this manner, the full extent of the aortic root can be exposed and manipulated. Cannulation of the ascending aorta, right atrium, or innominate vein can be performed. This approach, although somewhat more traumatic, is excellent for reoperations or complicated root reconstruction and does not require femoro-femoral cannulation [15]. However, incision on the upper chest is not ideal for cosmesis. Furthermore, cannulation of the coronary sinus for retrograde delivery of the cardioplegic solution may be difficult.

In this report, 18 patients were operated on successfully by "I" ministernotomy for aortic valve lesions. The advantage of this approach is that the full length of the intrapericardial ascending aorta, part of the right ventricle, and most of the right atrium were well exposed and easily accessible. Cannulation of the ascending aorta and right atrium were easy. Access to the coronary sinus for retrograde delivery of cardioplegic solution was also feasible. The upper and lower parts of the thoracic cage remain intact and stable. This might be helpful in reducing wound pain during chest physical therapy and in prevention of postoperative respiratory failure. All patients were satisfied with the good cosmesis of the incision. Short-term results were good.

The major advantages of minimally invasive aortic valve replacement are that it does not compromise the quality of the operation yet it allows for a faster recovery and reduced overall cost including reduced intensive care unit stay, length of hospital stay, less after hospital rehabilitation, and that undefinable, incalculable entity called return to productivity [15]. The early and medium-term results in our study and other series [12–15] are encouraging. However, general application as a routine procedure needs further long-term analysis of a larger series.

In conclusion, minimally invasive aortic valve replacement approached through "I" ministernotomy can be performed safely, easily, and effectively, with good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Benetti F.J., Ballester C. Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. Experience in 2 cases. J Cardiovasc Surg 1995;36:159-161.[Medline]
2. Acuff T.E., Landreneau R.J., Griffith B.P., Mack M.J. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
3. Lin P.J., Chang C.H., Chu J.J., et al. Video-assisted coronary artery bypass grafting during hypothermic fibrillatory arrest. Ann Thorac Surg 1997;63:1113-1117.[Abstract/Free Full Text]
4. Lin P.J., Chang C.H., Chu J.J., et al. Minimally access surgical techniques in coronary artery bypass grafting for triple vessels disease. Ann Thorac Surg 1998;65:407-412.[Abstract/Free Full Text]
5. Chang C.H., Lin P.J., Chu J.J., et al. Video-assisted cardiac surgery in closure of atrial septal defect. Ann Thorac Surg 1996;62:697-701.[Abstract/Free Full Text]
6. Chang C.H., Lin P.J., Chu J.J., et al. Surgical closure of atrial septal defect. Surg Endosc 1998;12:820-824.[Medline]
7. Lin P.J., Chang C.H., Chu J.J., et al. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect. Ann Thorac Surg 1998;65:165-170.[Abstract/Free Full Text]
8. Lin P.J., Chang C.H., Chu J.J., et al. Video-assisted mitral valve surgeries. Ann Thorac Surg 1996;61:1781-1787.[Abstract/Free Full Text]
9. Tsai F.C., Lin P.J., Chang C.H., et al. Video-assisted cardiac surgery. Chest 1996;110:1603-1607.[Abstract/Free Full Text]
10. Carpentier A., Loulmet D., Carpentier A., et al. First open heart operation (mitral valvuloplasty) under videosurgery through a minithoracotomy. C R Acad Sci Paris 1996;319:219-223.
11. Navia J.L., Cosgrove D.M., III Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
12. 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]
13. 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]
14. 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]
15. Cohn L.H., Adams D.H., Couper G.S., Bichell D.P. Minimally invasive aortic valve replacement. Semin Thorac Cardiovasc Surg 1997;9:331-336.[Medline]
16. Kirklin J.W., Barratt-Boyes B.G. Hypothermia, circulatory arrest, and cardiopulmonary bypass. In: Kirklin J.W., Barratt-Boyes B.G., Blackstone E.H., Jonas R.A., Kouchoukos N.T., eds. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:61-127.

This article has been cited by other articles:

				A. Zierer, G. Wimmer-Greinecker, S. Martens, A. Moritz, and M. Doss Is transapical aortic valve implantation really less invasive than minimally invasive aortic valve replacement? J. Thorac. Cardiovasc. Surg., November 1, 2009; 138(5): 1067 - 1072. [Abstract] [Full Text] [PDF]

				S. Perrotta and S. Lentini Ministernotomy approach for surgery of the aortic root and ascending aorta Interactive CardioVascular and Thoracic Surgery, November 1, 2009; 9(5): 849 - 858. [Abstract] [Full Text] [PDF]

				M. L. Brown, S. H. McKellar, T. M. Sundt, and H. V. Schaff Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J. Thorac. Cardiovasc. Surg., March 1, 2009; 137(3): 670 - 679.e5. [Abstract] [Full Text] [PDF]

				B. Murtuza, J. R. Pepper, R. DeL Stanbridge, C. Jones, C. Rao, A. Darzi, and T. Athanasiou Minimal Access Aortic Valve Replacement: Is It Worth It? Ann. Thorac. Surg., March 1, 2008; 85(3): 1121 - 1131. [Abstract] [Full Text] [PDF]

				C. Weissman Pulmonary Complications After Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2004; 8(3): 185 - 211. [Abstract] [PDF]

				R. Sharony, E. A. Grossi, P. C. Saunders, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, P. Ursomanno, F. G. Baumann, A. C. Galloway, and S. B. Colvin Minimally Invasive Aortic Valve Surgery in the Elderly: A Case-Control Study Circulation, September 9, 2003; 108(90101): II-43 - 47. [Abstract] [Full Text] [PDF]

				M. Bonacchi, E. Prifti, G. Giunti, G. Frati, and G. Sani Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study Ann. Thorac. Surg., February 1, 2002; 73(2): 460 - 465. [Abstract] [Full Text] [PDF]

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chang, Y.-S. Articles by Tan, P. P.C. Search for Related Content PubMed PubMed Citation Articles by Chang, Y.-S. Articles by Tan, P. P.C.