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Ann Thorac Surg 2001;71:810
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 4 Silverstein, 3400 Spruce St, Philadelphia, PA 19104, USA
e-mail: michael.acker{at}uphs.upenn.edu
Port access valvular surgery usually substitutes some sort of small right anterior thoracotomy for standard sternotomy. It’s purported by its opponents that avoidance of a sternotomy leads to improved cosmesis, less pain, decreased length of stay, decreased hospital cost, and faster recovery. Such claims, as is generally true for the field of minimally invasive cardiac surgery, are primarily based on relatively small series that are uncontrolled and mainly observational. There is little in published reports that actually compares the two approaches in any sort of objective, randomized fashion.
This is an impressive series by one of the most experienced groups in port access valvular surgery and represents one of the largest controlled comparison of port access valvular surgery with standard sternotomy. They found evidence supporting decreased lengths of stay, decreased blood use, and a surprising decreased septic complication rate. There were no differences in mortality or any major vascular complications.
Although the groups were matched for a number of preoperative parameters, a retrospective analysis such as this introduces inherent biases secondary to time differences over which each group was analyzed. Over the last several years the introduction of fast tracking, pathways, and different anesthetic techniques has led to a decreased length of stay in all types of heart surgery, not just port access. The same can also be argued for blood use.
In a smaller retrospective controlled comparison between port access and a conventional approach by the Loyola group (n = 92), they found that port access increased surgical complexity (increased cardiopulmonary bypass time, increased total operating room times) and had no effect on time to extubation, incidence of atrial fibrillation, or length of stay in the intensive care unit [1]. However, they did find a slight decrease in the length of stay in the port access group. Although the risk of vascular complications with port access remains small, there is a small but definite increased risk of aortic dissection, as well as other vascular complications with retrograde placement of the endo clamp, as well as femoral artery arterial cannulation.
The real importance of port access surgery today is as a precursor to future of robotic cardiac surgery. It represents an investment in the future, and its study and evolution must be supported. However, port access valvular surgery represents an unproved marginal benefit to the patient. There is a large learning curve that increases the risk to patients at new centers. Just because something can be performed does not mean it should be, nor does it mean that it can be performed safely by all surgeons in varying settings. Marketing pressures that lead to premature dissemination of new technologies and evolving procedures before safety and benefit have been demonstrated must be minimized and avoided. The entire field of minimally invasive cardiac surgery is rapidly growing. Unfortunately, there is still no prospective randomized multicenter study to demonstrate whether the claims made by industry and industry-backed programs are accurate. There is a crying need for such a study before time-tested approaches are abandoned.
References
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