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Ann Thorac Surg 2003;75:1360
© 2003 The Society of Thoracic Surgeons
Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
e-mail: sursimkw{at}nus.edu.sg
To the Editor:
We read with interest the article by Bonacchi and colleagues [1], who demonstrated that ministernotomy for valve replacement has added advantages apart from cosmetic concerns. In their randomized study comparing patients undergoing either ministernotomy or median sternotomy, they found the benefits of the former included early extubation, reduced mediastinal drainage, decreased need of transfusion, reduced requirement of postoperative pain relief, and improved recovery of respiratory function.
In our experience, we have observed lesser impairment of lung function after minimal-access valve replacement compared with conventional surgical intervention. We compared preoperative and postoperative incentive spirometric results in patients undergoing mitral valve replacement (MVR) or aortic valve replacement (AVR) with either a conventional median sternotomy (group 1) or a minimal-access inverted J sternotomy (group 2) at the National University Hospital, Singapore, from July 1994 to January 1999. For the inverted J sternotomy, a midline skin incision was made. The sternum was cut in the midline from the xiphoid process to the second intercoastal space, and then extended to the right. Of the 10 patients in group 1, 6 underwent MVR and 4, AVR. In group 2, 5 patients underwent MVR and 4, AVR.
There were no significant differences in cardiopulmonary bypass time, cross-clamp time, or operating time between groups 1 and 2. There were no conversions to full sternotomy in group 2.
Comparison of the preoperative maximal inspiratory volume between group 2 (1,667 mL ± 172 mL) and group 1 (1,475 mL ± 160 mL) revealed no significant difference (p = 0.345). In contrast, the results of the postoperative maximal inspiratory volume for groups 1 and 2 all revealed significantly better lung function for patients who underwent the inverted J sternotomy: on the evening of the first postoperative day (POD), 972 mL ± 179 mL versus 490 mL ± 50 mL; on the morning of the second POD, 1,083 mL ± 200 mL versus 615 mL ± 81 mL; on the evening of the second POD, 1,172 mL ± 185 mL versus 715 mL ± 84 mL; and on the morning of the third POD, 1,278 mL ± 158 mL versus 865 mL ± 62 mL (all, p < 0.05). Furthermore, 78% of the patients in group 2 reached 50% or more of preoperative lung function by the first POD compared with only 10% of those in group 1. By the third POD, 67% of group 2 patients had achieved 80% or more of preoperative lung function compared with 20% of patients in group 1.
In contrast to the positive results obtained by us and by Bonacchi and co-workers [1], others [2, 3] have reported no difference in improvement in postoperative lung function after minimal-access surgical procedures. Aris and associates [2] did a comparative study of ministernotomy (n = 12) versus median sternotomy (n = 14) for patients undergoing AVR and concluded that "a minimally invasive approach does not prevent postoperative pulmonary dysfunction." Similarly, Bauer and coauthors [3] found no difference in improvement in postoperative lung function in a comparative study of ministernotomy (n = 50) versus median sternotomy (n = 50) in patients undergoing coronary artery bypass operations.
After a minimally invasive approach, patients have greater stability of the sternum and tend to have less chest wall motion during inspiration. This may account for the lesser impact and increased recovery of respiratory function.
In our experience, minimal-access valve operations, result in cosmetically satisfactory scars, less pain, and a shorter hospital stay. Lung function recovers more quickly, and avoiding division of the manubrium gives the chest more support. The minimal-access approach is a viable, safe, and potentially more effective method of entry into the thorax and a useful technique in the armamentarium of the cardiac surgeon.
References
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