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Ann Thorac Surg 2002;74:S1323-S1325
© 2002 The Society of Thoracic Surgeons

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Supplement: Cardiothoracic Techniques and Technologies

Mitral surgery after prior cardiac operation:port-access versus sternotomy or thoracotomy

^a Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA

* Address reprint requests to Dr Glower, Box 3851, Duke University Medical Center, Durham, NC27710, USA.
e-mail: glowe001{at}mc.duke.edu

Presented at the Eighth Annual Cardiothoracic Techniques and Technologies Meeting 2002, Miami Beach, FL, Jan 23–26, 2002.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: In reoperation for mitral valve disease, minimally invasive Port-Access (PORT) is a new alternative to standard median sternotomy (STER) or right thoracotomy (THOR); yet, the results of PORT in this setting have not been defined. The aim of this study was to evaluate the results of minimally invasive thoracotomy in reoperation for mitral valve disease.

METHODS: Retrospective results are reported for three consecutive series of patients undergoing reoperation for mitral disease using either PORT (n = 60, 1996 to 2001), THOR (n = 37, 1985 to 1997), or STER (n = 155, 1985 to 1997).

RESULTS: Red cell transfusion was 3 ± 4, 14 ± 13, and 12 ± 12 units for PORT, THOR, and STER, respectively. Chest tube output was 352 ± 361, 2048 ± 3166, and 1683 ± 3939 mL, respectively. Cardiopulmonary bypass times for these groups were 208 ± 76 vs. 158 ± 56 vs. 157 ± 53 minutes. Thirty-day mortality was 0/60 (0%), 8/37 (22%), and 21/155 (14%), respectively.

CONCLUSIONS: This early clinical experience suggests that PORT is an acceptable alternative to THOR or STERN in reoperation for mitral valve disease, with potential advantages of avoiding redo sternotomy and reducing the surgical incision. However, these benefits may come at the expense of longer cardiopulmonary bypass times.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
For many different reasons, patients requiring mitral valve operation frequently have had a previous sternotomy [1–5]. Because of the increased risk associated with redo sternotomy [1, 6], surgeons often consider a standard right anterolateral thoracotomy for redo mitral operation [2–5]. The recent description of minimally invasive right anterolateral thoracotomies [7–11] now offers another approach to redo mitral operation, avoiding redo sternotomy and also the morbidity of a standard anterolateral thoracotomy. Yet, the potential advantages and disadvantages for a minimally invasive approach to redo mitral operation have yet to be demonstrated. A retrospective analysis was therefore performed to document the results of minimally invasive thoracotomy in reoperation for mitral valve disease.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Three partially concurrent series of consecutive patients undergoing mitral valve operation with or without tricuspid operation after previous sternotomy were examined. Patients aged less than 10 years or undergoing concurrent coronary bypass or other cardiac operation were excluded. Group I (PORT, n = 60, 1996 to 2001) underwent a limited right anterolateral thoracotomy with Port-Access techniques [11–13]. Group II (THOR, n = 37, 1985 to 1997) underwent standard right anterolateral thoracotomy [2–5]. Group III (STER, n = 155, 1985 to 1997) underwent redo sternotomy. The reason for truncating the standard thoracotomy and redo sternotomy series before 2001 was that in 1997, PORT became the procedure of choice, with few patients undergoing THOR or STER after 1997 at this institution.

The PORT patients underwent a 6-cm right anterolateral thoracotomy through the fourth intercostal space [11–13]. Since 1998, PORT patients have been prepared for surgery in a fashion identical to THOR or STER except that a dual-lumen endotracheal tube or bronchial blocker was used for lung isolation. Cardiopulmonary bypass was initiated by cannulating the right femoral vein and the right femoral artery or ascending aorta. Cardiac arrest was achieved using an endoclamp in 27/60 (45%) patients. In 33/60 (55%) patients, operation was performed during ventricular fibrillation because the endoaortic clamp was unavailable (n = 2), the femoral artery or ascending aorta was unsuitable for placement of an endoclamp (n = 9), or there were patent coronary artery grafts (n = 22). Percutaneous retrograde cardioplegia was also used in 9/27 (33%) patients receiving an endoclamp [11, 12]. Dissection of the mediastinum was limited to the right lateral aspect of the ascending aorta as necessary for cannulation, and to the interatrial groove as necessary to open the left atrium.

The THOR patients underwent a full right anterolateral thoracotomy from the anterior border of the latissimus muscle to the lateral edge of the sternum in the fourth intercostal space [2–5]. Cardiopulmonary bypass was initiated by cannulating the superior and inferior venae cavae and either the femoral artery or ascending aorta. Anterograde cardioplegia with external clamping of the ascending aorta was used in 8/37 (22%) patients, whereas ventricular fibrillation were used in the remaining 29/37 (78%).

The STERN patients underwent a redo sternotomy. After cannulating the ascending aorta and the inferior and superior venae cavae, the heart was arrested with cardioplegia in 147/155 (95%) patients. The remaining 8/155 (5%) patients underwent ventricular fibrillation.

All values are expressed as mean ± standard deviation.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
In terms of general patient characteristics, all three groups of patients were comparable, other than a more recent year of operation in PORT patients (Table 1). Each group had patients with up to three prior operations, with the mean number of prior procedures being 1.3, 1.7, and 1.2 in the PORT, THOR, and STER groups, respectively. Although all patients had prior cardiac operations, a previous mitral valve procedure had been done in 36/60 (60%), 28/37 (76%), and 129/155 (83%) of PORT, THOR, and STER patients, respectively.

In-hospital mortality was 0/60 (0%), 8/37 (22%), and 21/155 (14%) for PORT, THOR, and STER, respectively. Causes of death in THOR or STER included direct or indirect consequences of intraoperative bleeding in 10/29 (35%) cases, and early bleeding may have contributed to delayed death in other cases. Patients in THOR or STER groups who died had 22 ± 15 units of blood transfusion versus 11 ± 11 units in the THOR or STER survivors.

Chest tube output was 352 ± 361, 2048 ± 3166, and 1683 ± 3939 mL, and mean red cell transfusion was 3, 14, and 12 units for the PORT, THOR, and STER groups, respectively. Complications of reoperation for bleeding occurred in 1/60 (2%), 5/37 (14%), and 8/155 (5%), and stroke occurred in 4/60 (7%), 2/37 (5%), and 7/155 (5%) in PORT, THOR, and STER patients, respectively. Femoral arterial cannulation had been used in 4/4 PORT patients with perioperative stroke. Mediastinitis occurred only in the STER group (2/155 [1%]).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
These results suggest that minimally invasive right thoracotomy using Port-Access is a reasonable alternative to redo sternotomy or standard right thoracotomy for patients with previous sternotomy requiring mitral operation with or without tricuspid valve procedures. Even in first-time mitral operations, Port-Access may have advantages over sternotomy in terms of more rapid recovery, less sepsis and wound complications [14], less bleeding [14], and less postoperative pain [15]. In the setting of prior sternotomy, any right thoracotomy (including Port-Access) may minimize risk of cardiac injury upon entering the chest [2–6]. Advantages of Port-Access relative to standard thoracotomy include less tissue trauma with the expectation of less pain and pulmonary morbidity, less need for mediastinal dissection to achieve arterial and venous cannulation, and greater ease of achieving anterograde and retrograde cardioplegia. In fact, the primary advantage of PORT over THOR or STER in reoperation for mitral valve procedures may be minimization of surgical dissection in previously operated fields, thus decreasing intraoperative and postoperative bleeding and decreasing resultant chest tube output, transfusion, and ultimately mortality. This hypothesis is supported in the current series by the significant transfusion requirements in THOR or STER patients who died and by the prominent role of bleeding as a cause of death in THOR and STER patients.

This study demonstrates the utility of Port-Access or other small thoracotomies for redo mitral operation with lower mortality, less blood loss, and less transfusion than redo sternotomy or standard right thoracotomy. The disadvantages of Port-Access relative to redo sternotomy or standard thoracotomy may be longer cardiopulmonary bypass times (although total surgical procedure times may not be different), additional expense of the disposable and nondisposable instrumentation required for Port-Access, and the learning curve associated with Port-Access. Many of the advantages of Port-Access may also apply to small thoracotomies with external aortic clamping [8–10]. Nonetheless, Port-Access has a definite advantage over other small thoracotomies with external aortic clamping [8–10] in that Port-Access requires less aortic dissection to achieve aortic control along with anterograde and retrograde cardioplegia, at the expense of the additional hardware needed for Port-Access. The difficulties in the early experience with Port-Access of aortic dissection or need for subsequent mitral valve reoperation were not seen in this series encompassing a later time period [16].

Relative indications for Port-Access therefore might include any patient with previous sternotomy requiring mitral valve surgery with or without tricuspid operation. Relative contraindications might include previous right thoracotomy (although 3/60 [5%] PORT patients in this series had had previous right thoracotomy). With Port-Access, direct aortic cannulation requires one lung ventilation [13], so that a patient with contraindication to femoral cannulation and inability to achieve one lung ventilation would not be ideal candidates for Port-Access.

The obvious limitation of this study is the potential for patient selection bias in a retrospective, nonrandomized study. However, the patient groups were comparable and all of recent time frame. Although the mortality for mitral operation has not significantly changed over the entire time frame of the study [17], other factors such as the increasing use of aprotinin in recent years could have influenced the results. Nonetheless, this study is able to demonstrate reasonable safety of minimally invasive thoracotomy as an additional tool in approaching patients requiring redo mitral valve surgery with or without tricuspid operation. Indeed, patients undergoing a reoperative mital procedure may be a patient subset most likely to benefit from a Port-Access approach.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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