Ann Thorac Surg 2002;73:1657-1658
© 2002 The Society of Thoracic Surgeons
How to do it
Port-access approach for combined aortic and mitral valve surgery
Alan P. Kypson, MDa,
Donald D. Glower, MD*a
a Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
Accepted for publication December 3, 2001.
* Address reprint requests to Dr Glower, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710 USA
e-mail: glowe001{at}mc.duke.edu
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Abstract
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A technique is described for combined aortic and mitral valve operation utilizing the minimally invasive Port-Access technique. Two patients are repaired with excellent chest wall healing and avoidance of sternotomy.
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Introduction
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The minimally invasive Port-Access approach to cardiac valvular surgery utilizes a small right thoracotomy, cardiopulmonary bypass, or endovascular aortic occlusion. Reports from various institutions demonstrate the efficacy of this approach when dealing with isolated mitral or aortic pathology [1–3]. However, reports of combined aortic and mitral valve surgery utilizing the Port-Access approach are rare [4]. Described below is a technique that allows for double valve replacement utilizing technical advances in minimally invasive cardiac surgery.
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Technique
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After intubation with a single lumen endotracheal tube, an 8-cm right anterolateral thoracotomy is performed over the third intercostal space (Fig 1A).
The third and fourth ribs are detached from the sternum, and the right internal mammary artery is divided. A reusable chest retractor (Heartport Inc, Redwood City, CA) provides upward lift on the second and third ribs. The pericardium is opened vertically to the base of the innominate artery, exposing the ascending aorta, carefully avoiding the phrenic nerve. Retraction sutures are placed circumferentially, securing the pericardial edge to the skin incision.
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Fig 1. (A) Right anterolateral mini-thoracotomy incision over the third intercostal space with the third and fourth ribs detached from the sternum. (B) Surgeon’s view of both aortic (AV) and mitral (MV) prosthetic valves sewed into place. Aortic cannula enters through a separate port site and is not visualized. (AX = aortic cross-clamp; CSC = coronary sinus catheter; LVV = left ventricular vent; SVCC = superior vena cava cannula; T = tourniquets around inferior vena cava and superior vena cava.)
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After heparinization, venous access is obtained by passing a percutaneous wire from the right femoral vein into the superior vena cava using transesophageal echocardiography. A 25F venous catheter (QuickDraw; Heartport Inc) is passed over the wire into the femoral vein using serial dilators. The tip of the venous cannula is placed at the junction of the superior vena cava and the right atrium. Vacuum assist is used to provide total drainage of the atrium.
A 16-gauge needle is passed through the first intercostal space in the mid-clavicular line, with the needle directed toward the chosen aortic cannulation site 1 to 1.5 cm proximal to the base of the innominate artery. An 11.5-mm port is then inserted along the path of the 16-gauge needle after withdrawing it. The aortic cannula and introducer (Straight Shot; Heartport Inc) is inserted through the port and points directly at the chosen cannulation site. Two concentric pursestrings of pledgeted 2-0 polyester are placed at the cannulation site. Using a retractable blade incorporated into the aortic cannula introducer, the cannula is passed through the port into the pursestring and the aorta. It is secured with plastic tourniquets that are brought through the 11.5-mm port.
Once on cardiopulmonary bypass, a 28F angled venous cannula is placed in the superior vena cava through a pursestring at the base of the superior vena cava. The femoral venous cannula is retracted into the inferior vena cava after placing tourniquets around the superior and inferior vena cavae. A left ventricular vent is placed via the right superior pulmonary vein. Cardiac arrest is achieved by flexible external aortic crossclamp applied directly to the ascending aorta below the arterial cannulation site. Antegrade cardioplegia is delivered through a 4-0 polypropylene pursestring in the ascending aorta, then the cannula is removed from the field. Retrograde cardioplegia is delivered via previously placed coronary sinus catheter. With cardiac arrest achieved, the patient is typically cooled to 28°C. The operative field is flooded with CO2 at 1 to 2 liters per minute.
A transverse aortotomy is performed in the ascending aorta, extended down towards the noncoronary cusp. The diseased valve is excised. Attention is then turned to the mitral valve. With the caval tourniquets secured, a vertical incision is made in the right atrium. The interatrial septum is then opened from the medial base of the superior vena cava to the inferior rim of the septum secundum. An intraatrial blade retractor (Heartport Inc) is placed into the left atrium to provide exposure of the mitral valve. The retractor is brought out through a separate stab incision. The mitral valve is repaired or replaced in a standard fashion. A knot tier and long instruments (Heartport Inc) may be necessary for suture placement and tying at the mitral valve. The left ventricular vent is placed through the mitral valve into the left ventricle, and the interatrial septum is closed in two layers of running 2-0 polyester suture. Attention is then turned to the aortic valve and, using standard techniques, the prosthesis is sewn into place (Fig 1B). Standard instruments and digital knot tying are adequate. The aortotomy is closed in two layers with a running polypropylene suture. A standard aortic root vent is replaced through a 4-0 polypropylene pursestring in the ascending aorta.
Transesophageal echocardiography is used to monitor the left atrium and ventricle for the presence of air. The lungs are manually inflated to clear any trapped air from the pulmonary venous bed. The patient is rocked back and forth, and the heart is handled with a sponge stick to dislodge any trapped air. Suction is placed on the aortic root and left ventricular vents. Once deairing procedures are complete, the aortic cross-clamp is removed, the patient is ventilated and warmed to 36°C, at which point cardiopulmonary bypass is discontinued. The aortic cannula is removed and the aortic pursestrings are secured with direct manual tying through the thoracotomy. The venous cannula is removed and the puncture site closed with 2-0 absorbable suture in the subcutaneous tissue followed by a 3-0 absorbable subcuticular suture.
A right pleural chest tube is placed through a separate stab incision. A silicone elastomer sump catheter is placed through the right pleura into the pericardium and brought out through a separate stab incision as well. A second chest tube can be placed in the pericardium which is loosely closed. The thoracotomy incision is closed in a standard fashion using two figure-of-eight #4 sternal wires to reattach the third and fourth costal cartilages to the sternum.
To date, this approach has been employed for combined aortic and mitral valve disease in 2 patients. One patient was a 56-year-old man with osteogenesis imperfecta, pectus carinatum, and previous sternotomy who was felt to be high risk for redo sternotomy. The second patient was a 46-year-old woman with rheumatic heart disease who was concerned about cosmesis. Both patients healed well.
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Comment
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The conventional median sternotomy may cause significant surgical trauma and morbidity. Obese patients and diabetics are particularly prone to sternal infection and instability. The minimally invasive thoracotomy approach described here may have several advantages over median sternotomy as have been suggested for minimally invasive thoracotomies for single aortic and mitral valve operation. These potential advantages include better cosmesis, avoidance of prior sternotomy incision, quicker return to normal activity, less incisional pain, less blood loss, and less wound infections [2, 5]. Relative contraindications to this approach include need for coronary bypass grafting, severe pectus excavatum, aortic diameter greater than 4 cm, or consideration of complex aortic valve procedures such as root replacement or use of a stentless prosthesis. Nevertheless, results presented herein demonstrate the safety and technical feasibility of this approach.
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Acknowledgments
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We thank Stan Coffman for his time and wonderful illustrations.
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References
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Chitwood W.R., Jr, Wixon C.L., Elbeery J.R., Moran J.F., Chapman W.H.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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Cohn L.H., Adams D.H., Couper G.S., et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg 1997;226:421-428.[Medline]
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Glower D.D., Siegel L.C., Frischmeyer K.J., et al. Predictors of outcome in a multicenter Port-Access valve registry. Ann Thorac Surg 2000;70:1054-1059.[Abstract/Free Full Text]
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Colvin S.B., Grossi E.A., Ribakove G., Galloway A.C. Minimally invasive aortic and mitral valve operation. Oper Tech Card Thorac Surg 2000;5:212-220.
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Grossi E.A., Galloway A.C., Ribakove G.H., et al. Impact of minimally invasive valvular heart surgery: a case-control study. Ann Thorac Surg 2001;71:807-810.[Abstract/Free Full Text]
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Abstract
Introduction
