Ann Thorac Surg 2001;72:S1050-S1054
© 2001 The Society of Thoracic Surgeons
Supplement: Cardiothoracic techniques and technologies
Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience
Pascal Schroeyers, MDa,
Francis Wellens, MDa,
Raf De Geest, MDa,
Ivan Degrieck, MDa,
Frank Van Praet, MDa,
Yvette Vermeulen, MSa,
Hugo Vanermen, MDa
a Department of Cardiovascular and Thoracic Surgery, Onze Lieve Vrouw Ziekenhuis, Aalst, Belgium
Address reprint requests to Dr Vanermen, Department of Cardiovascular and Thoracic Surgery, OLV Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
e-mail: hugo.vanermen{at}olvz-aalst.be
Presented at the Seventh Annual Cardiothoracic Techniques and Technologies Meeting 2001, New Orleans, LA, Jan 24–27, 2001.
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Abstract
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Background. Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery.
Methods. Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV.
Results. Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high.
Conclusions. The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.
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Introduction
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Minimally invasive cardiac surgery has evolved during recent years to a point at which it may offer benefits over conventional procedures. Different strategies have been followed with variable results. For these approaches to become generaly accepted, however, they must meet the goal of being less invasive—thus bringing improved comfort and cosmetic results as well as faster overall rehabilitation—while still achieving safety and efficacy outcomes equivalent to those of established techniques such as median sternotomy. However, the questions as to whether minimally invasive mitral valve surgery is worth the surgeon’s investment and the learning curve pitfalls [1–3] remain unanswered for now, and ideally should be answered by means of a well randomized, prospective study. Given the lack of data, we retrospectively analyzed our experience of nearly 4 years with video-assisted Port-Access (Heartport, Redwood City, CA) mitral valve surgery. In this article, we compare our surgical approach and results with the data of the literature, especially with those of The Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database, and stress the main lessons we drew from our experience and mistakes. We describe the evolution of our technique, our results, and the difficulties that we encountered, along with their solutions. Furthermore, we emphasize that it remains the surgeon’s strong conviction and firm belief that minimally invasive surgery is the best surgical approach, and that it allows the surgeon to approach patients with the same conventional operative safety as the main goals but, with truly improved postoperative comfort, cosmetic results, and shorter recovery period.
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Material and methods
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We reviewed the records of 320 patients (178 male and 142 female patients) undergoing video-assisted Port-Access cardiac surgery using the Heartport cardiopulmonary bypass (CBP) system between February 1997 and November 2000. Among these patients, 175 consecutive patients had mitral valve surgery, 4 patients in combination with the closure of an atrial septal defect (ASD). The data were collected retrospectively.
Statistical comparisons are by the unpaired t test with a probability of less than 0.01 considered significant.
As is shown in Tables 1 and 2, mitral valve repair (n = 117) or replacement (n = 57) was undertaken for various types of pathologic conditions: myxoid degeneration (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), and sclerotic disease (n = 2). One mitral valve was replaced because of an ingrowing myxoma. There was one closure of a preexisting paravalvular leak in a re-redo patient with a mechanical valve. Mitral valve insufficiency and stenosis were seen in 146 and 22 patients, respectively. Three patients underwent a primary closure of a type II ASD, and 1 patient (a 67-year-old woman) who presented with a partial atrioventricular canal defect underwent closure of an ostium primum with a pericardial patch and closure of the mitral anterior leaflet cleft.
The mean age of the patients was 59.5 years (range 24.5 to 83.8 years). All patients had normal left ventricular ejection fractions and were operated on electively. Most of them were in New York Heart Association functional class II and III. Those patients presenting with mitral valve regurgitation had a severe grade 4+ insufficiency in 70% of cases.
Surgery
Patients were positioned supine with slight elevation of the right hemithorax. All patients were intubated with a double-lumen endotracheal tube. Total cardiopulmonary bypass was used with a membrane oxygenator, centrifugal pump, assisted venous return and cold antegrade crystalloid cardioplegia. A 14F or 17F cannula (Medtronic DLP, Grand Rapids, MI) was placed percutaneously by the anesthesiologist through the right jugular vein into the upper vena cava under transesophageal echocardiographic (TEE) view. A 5-cm skin incision was made in the right inframammary groove to perform a small anterolateral "working port." A soft tissue retractor (Heartport) was inserted and no other rib retractor was used. A 5-mm port was created in the fourth right intercostal space on the front axillary line to allow thoracoscopic axial vision of the mitral apparatus. The CO2 line was attached to this port so as to have continuous flushing of the right hemithorax, including the cardiac cavities, with CO2. To introduce the handle of the left atrial retractor, a second 3-mm port was created parasternally under thoracoscopic vision, taking care to avoid the right internal thoracic artery. A third 7.5-mm port was created in the eighth right intercostal space to allow the introduction of the atrial venting cannula and the thoracic drainage tube.
After general heparinization, arterial and venous cannulations were performed in the right groin using the Seldinger technique to avoid clamping and arteriotomy. The image of a free-floating guide on TEE is important to ascertain the gentle, safe passage of the soft-tip guidewire and its advancement into the descending aorta. Arterial cannulas (21F and 23 F) were introduced over a guidewire after using a dilator. The Y-arm allowed safe introduction of the EndoClamp (Heartport, Inc, Redwood City, CA). The venous cannulation was performed the same way, and the tip of the venous cannula (21F to 28 F) was placed into the right atrium under TEE control (Fig 1).
The EndoClamp was adequately positioned using TEE and the balloon was inflated. In some cases adenosine was injected at the tip of the balloon to achieve a brief cardiac arrest before balloon inflation and to prevent the balloon from migrating toward the brachiocephalic trunk during inflation. After aortic occlusion, antegrade cold crystalloid cardioplegia was delivered at the balloon tip. The left atrium was then opened parallel to the interatrial septum. In mitral valve replacement, the posterior leaflet was preserved entirely when possible while the anterior leaflet was resected and the anterior papillary muscles resuspended. All mitral valve repairs were performed following the standard Carpentier techniques, and with polytetrafluoroethylene chordae replacement in most of the anterior valve prolapse. An annuloplasty ring (Physio-Ring, Baxter Healthcare, Irvine CA) was used in all but 1 patient (Table 2). A temporary bipolar pacing wire was placed on the diaphragmatic side of the left ventricle before the aortic cross-clamp was released. Air was removed by insufflating the lungs and simultaneous reduction of venous drainage with the patient in the Trendelenburg position. Proper retrograde deairing was achieved with a transvalvular vent catheter; meanwhile air was removed from the aorta by suction through the distal lumen of the endoaortic clamp. The femoral artery and vein were repaired after decannulation by simple tying of the U-stitches and pursestring stitches, respectively. The pericard was closed with a single stitch and the chest wound without pericostal stitches after inserting a small drainage tube.
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Results
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In our experience with video-assisted Port-Access mitral valve surgery, the total operating room time, perfusion time, and cross-clamp time decreased with our growing experience and remained stable after a period of 18 months, given a team learning curve of 70 patients. Perioperative data as well as postoperative reinterventions and complications are listed in Table 3. The overall experience data are split up into a learning-curve group of patients (n = 70) and an advanced-experience group of 105 patients. In addition, the results, mortality, and morbidity of mitral valve replacement and repair are compared with those of the STS Database Fall 2000 and with 1997 when data for Fall 2000 were not available (Table 4). In our experience, overall mortality was 1.1% (n = 2). One patient died of low cardiac output syndrome on postoperative day 5 after a failed attempt at repair for Barlow’s disease, for which he underwent an early replacement through median sternotomy. One patient died after repair of a dissected ascending aorta due to the EndoClamp. Four patients (2.3%) had conversion to median sternotomy, 2 for a dissected ascending aorta due to the EndoClamp and 2 because it was impossible to safely cannulate the femoral artery. There were no cases of perioperative myocardial infarction, no cerebrovascular accident due to thromboembolic events (although 1 patient experienced a stroke after aortic dissection), no postoperative peripheral ischemia, and no deep venous thrombosis after cannulation. Revision for bleeding was performed through the same video-assisted Port-Access approach in all but 1 patient, in whom excessive bleeding at the site of a temporary pacemaker wire necessitated median sternotomy. Five patients developed acute renal failure with 2 patients needing hemodialysis. Atrial fibrillation was seen in 24 patients and was medically treated. There were no thoracic wound complications or groin infections. In our early experience, 2 patients developed a groin lymphocele. All patients had a high degree of satisfaction in terms of comfort and cosmesis.
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Table 3. Perioperative Data and Morbidity in Authors’ Overall Experience, Learning Curve, and Advanced Experience
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Table 4. Perioperative Data and Morbidity Comparison Mitral Valve Repair and Mitral Valve Replacement With the Society of Thoracic Surgeons Database Fall 2000
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At follow-up, all patients had improved in their clinical and New York Heart Association functional class. One patient died after 37 months of an unknown cause. Three patients developed late mitral endocarditis. Two patients underwent mitral valve replacement at a mean of 8 months after a repair procedure, and 1 received medical treatment. There were no late thrombo-embolic events.
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Comment
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The right anterolateral thoracotomy has always appeared to be a good alternative to median sternotomy because the incision provides a straight access line toward the left atrium. The growing popularity of minimally invasive cardiac surgery has given a boost to thoracotomy as the ideal approach [1–4]. In 1996, Carpentier and colleagues [2] performed the first video-assisted mitral valve repair through a limited anterolateral thoracotomy, followed by Chitwood and associates [4], who performed a mitral repair under direct vision. In 1998, Mohr and colleagues [3] reported the first large series of Port-Access mitral valve surgery. In a prospective study comparing pain and quality of life after minimally invasive versus conventional surgery, these authors reported that patients having a limited lateral thoracotomy have the same or more pain during the first postoperative days, with pain levels only starting to decrease from the third postoperative day onward [5]. There were no differences in quality of life, postoperative wound healing, or stability of the bony thorax; however mobility was achieved earlier in the minimally invasive surgery group. In a comparative study between Port-Access and less invasive valve surgery, Arom and associates [6] showed that Port-Access patients returned to work about 3 weeks earlier. As compared to other series [2–4, 6], our minimally invasive approach seems to be less aggressive: the thoracotomy incisions were smaller (5 cm vs 6 to 8 cm) and, more importantly, the use of any rib retractor was avoided. The limited "working port" and the lack of direct vision with this approach forced us to rely on video assistance. Because the large vessels are not easily accessible, a new method to achieve cardiopulmonary bypass was needed: the Heartport CPB system. We developed a minimally invasive atraumatic technique for groin cannulation. The limited skin incision (2.5 cm) and the use of the Seldinger technique avoid extensive groin dissection and clamping of the femoral vessels. Since we have been using this approach, none of the patients had wound infection, lymphocele, or arteriovenous fistula. Furthermore, we have not encountered limb ischemia or deep venous thrombosis. Nevertheless, endoaortic occlusion and femoral artery cannulation still carry some morbidity (aortic dissection), especially in patients with peripheral vascular disease. To prevent dissection, we avoid percutaneous femoral artery cannulation and use a small incision instead. To avoid aortic dissection with the Endoclamp, we strongly recommend the use of a guidewire both to cannulate and to guide the Endoclamp; we also use softer guidewires such as the Terumo angiographic catheter with fluoroscopy (Terumo Cardiovascular, Ann Arbor, MI), especially in patients with tortuous iliaca arteries. The Endoclamp should never be introduced without confirming perfect positioning of the guidewire with TEE. Conversion to sternotomy should not be looked at as a complication or failure; on the contrary, it should always be considered as an alternative when groin cannulation is not straightforward. Following these safety rules, we have been able to avoid aortic dissection (which we consider to be a pitfall), as part of our learning curve.
Deairing of the cardiac cavities is also a critical issue for the neurologic outcome of the patients, which we solved by flooding the thoracic cavity with CO2 and by ensuring complete deairing with TEE. On the other hand, Schneider and colleagues [7] reported that, despite different air removal procedures, they observed no significant differences in the embolic stress rates between patients operated on through Port-Access or conventional surgery.
One might consider our experience with 70 patients over an 18-month period to represent a long learning curve; however this technique introduces several new challenges, which require time and experience to master perfectly and safely. This new approach to mitral valve using Port-Access surgery forces the surgeon to rely entirely on video-assisted visualization, to develop superior eye–hand coordination to work with the newer, shafted instruments, and to become acquinted with the necessary TEE images. With more experience, as shown in Table 3, both perfusion and cross-clamp time significantly decreased but still remained longer than for conventional sternotomy. However, the total hospital stay was comparable to that in the STS Database [8]. Futhermore, the overall mortality and morbidity data presented in this study compared favorably with the data of the STS, and also improved with experience (Table 3). Low mortality, low incidence of postoperative atrial fibrillation, decreased number of patients with prolonged ventilation, low incidence of perioperative stroke, and absence of myocardial infarction and postoperative sternal wound infections are possible advantages associated with the technique.
In conclusion, based on our experience we recommend the following: (1) Perform Port-Access cardiac surgery with a monitor for the surgeon, giving a reliable TEE image of aorta and cardiac cavities. (2) Use video-assisted visualization with excellent color, contrast, and resolution so as to be able to work through the smallest possible "working port" without using rib retraction. (3) Use the Seldinger technique, as it is the only safe way to perform groin cannulation and to ensure adequate endo-clamp positioning. (4) Get accustomed to the use of shafted instruments and knot pusher to perform video-assisted Port-Access mitral valve surgery.
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References
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Carpentier A., Loulmet D., Carpentier A., et al. Chirurgie à coeur ouvert par vidéo-chirurgie et mini-thoracotomie: premier cas (valvuloplastie mitrale) opéré avec succès. CR Acad Sci Paris, Life 1996;319:219-223.
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Mohr F.W., Falk V., Diegeler A., Walther T., van Son J.A., Autschbach R. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:567-576.[Abstract/Free Full Text]
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Chitwood W.R., Jr, Wixon C.L., Elbeery J.R., Moran J.F., Chapman W.H., Lust R.M. Video assisted minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg 1997;114:773-782.[Abstract/Free Full Text]
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Walther T., Falk V., Metz S., et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67:1643-1647.[Abstract/Free Full Text]
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Arom K.V., Emery R.W., Kshettry V.R., Janey P.A. Comparison between port-access and less invasive valve surgery. Ann Thorac Surg 1999;68:1525-1528.[Abstract/Free Full Text]
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Data Analyses of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database. The Tenth Year-Fall 2000:77–88 (Table 4), 144 (Table 7) and 1997 STS US Cardiac Surgery Database.
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Top
Abstract
Introduction
