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Ann Thorac Surg 2000;69:977-978
© 2000 The Society of Thoracic Surgeons

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Correspondence

Minimally invasive, but too many infections

^a Department of Thoracic and Cardiovascular Surgery, University Hospital, 14000 Caen, France

To the Editor

We are writing in response to the article of Mächler and colleagues [1] regarding the minimally invasive approach to aortic valve operations. In their randomized prospective study, the authors proved that the advantages of a less invasive aortic valve operation include reduced trauma from incision and duration of ventilation, decreased blood loss, and postoperative pain, all that with a cosmetically attractive result. Nevertheless, we would like to make some comments. The authors reported in the group treated with the ministernotomy approach (60 patients) two cases of early endocarditis, one case of late (12 months) endocarditis, and two cases of wound infection. This cumulative rate (8.3%) of infection is considered to be unrelated to the new procedure, but it seems to be much higher than that of the standard sternotomy group or compared with the statistics of the STS surgical database. As we can see in most of the less invasive approaches, the surgical compromize between minimal incisions and best exposure is not so easy to find. Sometimes, reducing the incisions led to an increase in technical difficulties, especially in exposing the region in which the surgery took place. To enhance the exposure, different maneuvers are used: the pericardial edges are heavily suspended to the skin layers; the aorta is exteriorized but the skin is lowered towards the mediastinum with the potential for intraoperative contamination. Sometimes, the venous cannula is brought to the right appendage through a separate small skin incision. All these maneuvers and others could be at risk for contamination, especially when the povidone-iodine drape is incompletely adherent to the skin layer. Theoretically, a less invasive approach, with a short incision, with a reduced mediastinal dissection and exposure, could help prevent external contamination and infection. Definitively, a low rate of infection could be observed in the series of patients.

Our experience with a less invasive approach to valve operations [2], based today on more than 250 patients, shows an important reduction of the infection rate. The technical aspects of the surgical technique already have been reported, and all steps attempt to avoid the maneuvers at risk of external contamination.

In conclusion, we congratulate Mächler and colleagues for their excellent work and ask them if they agree with our technical considerations.

References

1. Mächler H.E., Bergmann P., Anelli-Monti M., et al. Minimally invasive versus conventional aortic valve operations. Ann Thorac Surg 1999;67:1001-1005.[Abstract/Free Full Text]
2. Massetti M., Babatasi G., Lotti A., et al. Less invasive cardiac operations through a median sternotomy. Ann Thorac Surg 1998;66:1050-1054.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Massimo Massetti Eugenio Neri Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Massetti, M. Articles by Khayat, A. Search for Related Content PubMed Articles by Massetti, M. Articles by Khayat, A. Related Collections Related Article