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Ann Thorac Surg 2006;81:1618-1624
© 2006 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Two Hundred Forty Minimally Invasive Mitral Operations Through Right Minithoracotomy

Department for Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany

Accepted for publication December 1, 2005.

^_* Address correspondence to Dr Aybek, Department for Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590 Frankfurt/Main, Germany (Email: tayfun{at}aybek.de).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: This study reports of our 7-year experience with minimally invasive mitral valve operations using the transthoracic clamp technique, reviewing morbidity and mortality as well as echocardiographic follow-up results.

METHODS: Between 1997 and 2004, 241 patients (121 male; aged 56 ± 14 years) underwent minimally invasive mitral valve surgery through right thoracotomy using the transthoracic clamp technique. Reconstructions were done in 199 patients, and 42 valves were replaced. Mean length of incision was 7.0 ± 1.2 cm. Mean preoperative New York Heart Association functional class was 2.6 ± 0.9.

RESULTS: Thirty-day mortality was 3.3% (n = 8). Operating, bypass, and cross-clamp times averaged 241 ± 52, 142 ± 40, and 84 ± 26 minutes, respectively. Seven patients (2.9%) had conversion to sternotomy. Nine patients (3.7%) underwent reexploration for bleeding. Mean intensive care unit and hospital stay were 18 hours and 8.1 days, respectively. Mean follow-up was 30 ± 18 months (range, 3 to 76). Echocardiographic follow-up documented persistently competent valve function in all but 6 patients who had grade III regurgitation. Five of them underwent mitral valve re-reconstruction and 1 underwent transplantation. At 76 months, freedom from nontrivial recurrent mitral regurgitation and reoperation were 92.3% and 96.2%, respectively. Actuarial survival at 76 months, including early mortality, was 90.7%. Thoracic wounds were free from infection in all patients.

CONCLUSIONS: This study demonstrates that the direct vision, transthoracic clamp technique for minimally invasive mitral valve surgery is reproducible with low mortality and morbidity rates. It results in excellent cosmesis and abolished the risk of thoracic wound infection. Results are comparable to midterm outcomes of conventional operations.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Mitral valve (MV) surgery is increasingly performed through small thoracotomies [1–4]. New technologies for cardiopulmonary bypass [5], special surgical instruments, and the use of video-thoracoscopic assistance all facilitate these procedures. It has been previously shown that improvements in surgical technique and setup allow for achievements of the same quality with minimal invasive access as conventional MV surgery with less surgical trauma, decreased pain and recovery time, and better cosmesis, resulting in improved patient satisfaction [6–8]. Our institution has focused on minimally invasive mitral valve operations through right anterior minithoracotomy using transthoracic clamping technique as described by Chitwood and associates [1].

This study reports on a single-institution experience with minimally invasive MV surgery over a 7-year period using this technique. The analysis depicts the technical aspects of the procedures and postoperative outcome, and reviews the midterm mortality, morbidity, and echocardiographic and clinical follow-up. We also aimed to demonstrate that even technically demanding MV repairs, such as sliding plasty of the posterior leaflet, anterior leaflet repair, implantation of artificial chordae, and decalcification of the posterior ring, as well as various combined procedures with tricuspid annuloplasty, atrial volume reduction, or mini-Maze operations, may be performed safely through limited incisions.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment References

 
From July 1997 to May 2004, 241 elective minimally invasive mitral surgical procedures (121 male, 120 female; mean age, 56 ± 14 years; range, 17 to 81) have been performed in our department through a right anterolateral small thoracotomy. The Institutional Ethics Commitee approved the study, and an informed consent was obtained from every patient.

Initially all patients amenable and referred to the senior author were considered except those with known iliac or peripheral artery disease. Later, a second surgeon performed part of the procedures. Patients with poor left ventricular function (ejection fraction less than 30%), and severe pulmonary hypertension (systolic pulmonary artery pressure greater than 60 mm Hg) were approached by full sternotomy or recently by partial upper sternotomy. A total of 651 mitral valve procedures (including concomitant revascularizations and aortic valve operations) were performed during the time the study was executed. We found 402 patients eligible for a minimally invasive mitral procedure, and it was performed in 83.6% (72 patients through partial upper sternotomy, 241 with transthoracic aortic clamping, and 23 with the Port-Access approach; the rest were done conventionally).

Demographic data are listed in Table 1. Most of the patients (76%) were in New York Heart Association (NYHA) functional class III and IV. Mean grade of mitral valve regurgitation at presentation was 3.1 ± 0.6. Chronic atrial fibrillation was present in 66 patients. Six of them had previously undergone cardiac surgery.

Surgical Technique
A small thoracotomy was performed in the fourth intercostal space through a 5- to 10-cm (7.0 ± 1.2 cm) right submammary skin incision in all patients. The right femoral vessels were exposed through a transverse incision, and Port-Access 22F or 25F venous cannulas (Ethicon, Somerville, NJ) were introduced under TEE guidance for cardiopulmonary bypass. The femoral artery was cannulated using flexible arterial cannulas (20F to 22F [DLP; Medtronic, Minneapolis, MN] or 16F to 18F [Research Medical; Edwards Lifesciences, Irvine, CA]). In case of severe femoral artery scleroses, the thoracotomy was extended to 10 cm, and direct aortic (n = 3) cannulation was performed through the surgical field. In 3 patients with insufficient venous return, the superior vena cava was cannulated through the thoracotomy. A straight cardioplegia needle was secured with a double pursestring suture. The ascending aorta was occluded transthoracically with a specially designed cross-clamp (Scanlan, Saint Paul, MN) through a 5-mm incision in the third or fourth intercostal space. Antegrade cold blood cardioplegia was administered into the aortic root under direct vision. The surgical field was constantly flushed with CO₂ at a 2 L/min rate through a Verres needle that was covered with a sponge to increase CO₂ concentration and reduce gaseous emboli [9].

In 18 cases, a video camera (Storz, Tuttlingen, Germany) was placed through a 10-mm port in the third intercostal space, which served as an ideal light source and provided additional visualization. This was used early in the series or selectively for demonstrative reasons. An intercostal block with 100 mg bupivacain was routinely administered in the third to fifth interspace before chest closure.

Atrial size reduction was achieved by occluding the left auricle from the inside with a pursestring suture. With a continuous suture, the left lateral atrial wall was folded. Septum and roof were plicated as well [10]. Ablation was performed with a high-frequency probe (Osypka Medical GmbH, Rheinfelden-Herten, Germany) connecting both ends of the atriotomy and isolating the left atrial isthmus.

The various surgical procedures performed are listed in Table 2.

Echocardiography was performed with a Vingmed System 5 (GE Medical Systems, Waukesha, WI) ultrasound machine. Data were recorded preoperatively by transthoracic echocardiography (TTE) and intraoperatively by TEE. Postoperatively TTE was performed before discharge from hospital, and at 1 and 5 years after surgery. Examination included two-dimensional, M-mode, continuous wave, pulsed and color Doppler analyses. All evaluations were carried out according to standard techniques recommended by the American Society of Echocardiography [12]. The structure of any echocardiographic assessment includes examination of the pericardial cavity, myocardial contractility, and ventricular dimensions as well as the structure and function of the valve.

Postoperative Anticoagulation
All patients were maintained on coumarin therapy for 6 weeks to 3 months after the operation. It was prescribed to discontinue medication in patients with sinus rhythm and patients who had undergone reconstruction or bioprosthetic valve replacement. In patients with atrial fibrillation or mechanical valve replacement, or both, oral anticoagulation was maintained. However, postoperative medication was at the discretion of referring cardiologists.

Data Analysis
All data were collected in a FileMaker-based database (FileMaker 6.0; Santa Clara, CA). Data are presented as mean values ± SD. Testing of variables was compared by paired t test. A p value of less than 0.05 was chosen to define statistical significance. The statistical analysis was performed with the StatView software package Version 5.0.1 (SAS Institute, Cary, NC). Survival and freedom from event probabilities were estimated with the standard nonparametric Kaplan-Meier method [13].

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
The mitral valve was repaired in 199 patients. Repairs included quadrangular resection (n = 150), reconstruction of the anterior leaflet with triangular resection or patch plasty (n = 15), sliding plasty (n = 61), artificial chordae replacement (n = 29), and decalcification of the posterior annulus (n = 12; Fig 1). The annuloplasty was performed with a running suture in 137 patients [14], with a Carpentier prosthetic ring in 39 cases, and a Cosgrove prosthetic ring in 23 cases. The mitral valve was replaced using a mechanical prosthesis (n = 27 [Mira; Edwards LifeSciences]) or biological valves (n = 8 [Supra-Annular Valve; Edwards Lifesciences]) as well as stentless biological mitral valve (n = 7 [Quattro; St. Jude Medical, Fullerton, CA]). Additional procedures are listed in Table 2. In 44 patients, a radiofrequency ablation in combination with atrial size reduction was performed.

View larger version (91K): [in this window] [in a new window]   Fig 1. (A) Operative situs and exposure of the mitral valve through a 6-cm incision. After decalcification of the posterior annulus, the defect was closed with autologous pericardial patch, and the annulus was reinforced using a flexible prosthetic ring. (B) Removed calcified mural annulus from the same patient.

In 3 patients, the circumflex coronary artery was occluded. In 1 of them, once the occlusion was confirmed angiography, conventional coronary artery bypass grafting through median sternotomy was performed. The other 2 were hemodynamically stable, and revascularization procedures did not seem appropriate. All of these patients had a suture annuloplasty performed, 1 had extended resection of anterior commissure, and another had an aberrant origin of the circumflex artery. This complication occured randomly in time.

Nine reexplorations (3.7%) for bleeding were performed. In 6 cases, the reexploration was possible through the same thoracotomy. Bleeding sources included cardioplegic cannulation site in three, intercostal artery in 2, and left atrial suture line in 1; however, in 3 cases, conversion to median sternotomy was required because of ventricular rupture after annulus decalcification in 1, late tamponade in a redo procedure in 1, and subclavian artery injury during insertion of a central venous line on intensive care unit in 1.

Thirty-day mortality was 3.3% (n = 8). One patient who underwent mitral and tricuspid repair for endocarditis and had an infected pacemaker lead explanted died of sepsis-induced multiorgan failure on postoperative day 14. A second patient died of ventricular fibrillation and low cardiac output syndrome on the first postoperative day after quadrileaflet stentless MVR, tricuspid repair, and Maze procedure. The 3 patients converted to median sternotomy as described above finally died as a consequence of bleeding complications. The rest of the patients died of low cardiac output and sepsis after primary respiratory insufficiency.

Mean postoperative ventilation time was 7.6 ± 11 hours; duration of intensive care unit stay was 18 ± 14 hours, and postoperative hospital stay was 8.1 ± 2.4 days. Chest tube drainage averaged 264 ± 112 mL in the initial 24 hours postoperatively. Mean length of skin incision was 7.0 ± 1.2 cm (Fig 1A). All patients had uneventful thoracic wound healing, except 3 who developed intercostal lung herniation. One of them required surgical repair.

In 4 patients, we observed a lymph fistula or superficial groin infection. One patient with lymph fistula required revision of the surgical wound in the groin.

In the patients who underwent MVR, TTE control before discharge showed regular function of the various types of implanted valves with trivial paravalvular leak in 1 patient. The echocardiographic controls after mitral repair displayed a completely sufficient valve in all patients, except 8 patients (4.1%) with trivial and 8 patients (4.1%) with mild residual regurgitation.

Patient Survival and Clinical Follow-Up
Mean follow-up was 30 ± 18 months (range, 3 to 76) and was completed in 99.1% of surviving patients (n = 233). We analyzed a total of 541 patient years for the purposes of this study. There were 6 late deaths. The causes were severe pneumonia (n = 1), cancer (n = 1), sudden cardiac death (n = 2), and left heart failure (n = 2). Actuarial survival at 76 months, including early mortality was 90.7% (Fig 2). During follow-up, there was 1 thromboembolic event resulting in temporary neurologic deficit in patient with atrial fibrillation and quadrileaflet valve prosthesis.

View larger version (15K): [in this window] [in a new window]   Fig 2. Kaplan-Meier estimation and survival plot. (pts = patients.)

Reoperation
Six patients required reoperation during follow-up. Four months after surgery, 1 patient presented with endocarditis of the mitral valve; a re-reconstruction was performed through median sternotomy. In all others, annulus redilatation after suture annuloplasty occurred, and additional leaflet prolapse was observed in 2. In all patients who returned for reoperation, secondary repair was achieved except in 1. One patient had heart transplantation after 4 years owing to end-stage heart failure. Overall, freedom from reoperation at 76 months was 96.2%.

Echocardiographic Results
Echocardiographic examinations were performed in all surviving patients before discharge (n = 233), at 1 year (n = 141), and 5 years (n = 22). Echocardiographic follow-up was performed in our outpatient clinic in 78% of patients. The patients with repaired valves had low mean mitral transvalvular gradients, measuring 2.3 ± 1.0 mm Hg at 1 year and 2.2 ± 1.0 mm Hg at 5 years. Accordingly, the calculated mitral valve area was 3.4 ± 1.0 cm² and 3.2 ± 0.8 cm² at 1- and 5-year follow-up, respectively (Table 3). The degree of the mitral valve insufficiency was significantly reduced early postoperatively. The mean postoperative value averaged 0.3 ± 0.6 in contrast to the preoperative value of 3.1 ± 0.6 (p < 0.01).

View larger version (17K): [in this window] [in a new window]   Fig 3. Freedom from nontrivial mitral regurgitation (MR). (pts = patients.)

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
In 1996, several groups began to investigate the possibility of performing primary valve surgery through incisions smaller than traditional median sternotomy [1–4]. The parasternal approach, as described by Cosgrove necessitates partial rib resection. Loulmet and colleagues [2] promoted various types of partial sternotomies, which endanger the continuity of the right internal thoracic artery. We used a small anterolateral thoracotomy in the fourth intercostal space, which does not interrupt the osseous continuity of the chest, and thus maintains its integrity. Despite an average skin incision of 7 cm, a larger thoracotomy is possible, providing excellent exposure of the mitral valve, avoiding overstretching of ribs and chest wall tissue. That has been found to be partly responsible for reduced postoperative pain in most cases [15]. After our initial experience with the Port-Access technique, we have addopted the transthoracic clamp technique for primary elective mitral valve repairs [16, 17]. The small incisions were cosmetically appealing to patients, but the major question remaining was whether the same quality of operative treatment could be done through these small incisions.

The present study documents the safety of minimally invasive mitral valve surgery with transthoracic aortic clamping in 241 patients. In our study, patients had predominant degenerative etiology of the mitral regurgitation. This may favorably influence results, as degenerative valves have been shown to have best perioperative outcome and superior midterm and long-term repair prognosis in comparison with other etiologies. The initial intention was to reduce overall and especially pulmonary complication rate by limiting surgical trauma. Proven advantages remained subtle [17] so that we became more restrictive in performing demanding procedures in high-risk patients as surgical times were somewhat prolonged compared with the sternotomy approach. Currently, we approach high-risk patients and such with combined tricuspid disease through partial upper sterotomies as this allows routine cannulation and good and simple access, and adds sternal stability. In this group of patients, cosmesis is not an issue. Overall mortality and morbidity data compare favorably with the data of the STS database and some groups in Europe [18, 19], and also improved with experience. All deaths in our series occurred in patients with combined procedures and were not related to the specific technique. After the initial experience, we have adopted additional surgical procedures such as atrial size reduction and radiofrequency ablation for the treatment of chronic atrial fibrillation as well as tricuspid valve repair.

Potential disadvantages of minimally invasive mitral valve surgery include impaired visualization of the valve and increased complexity, aortic dissection caused by retrograde cannulation or flow, difficulty in deairing, and increased costs. One inherent limitation of the minimally invasive mitral valve operation is the difficulty of visualizing or accessing all segments of the mitral valve. The TEE is especially beneficial in better understanding the mechanism of mitral valve failure and thus planning the necessary technical steps [20, 21]. Additional traction sutures on the anterior ring and posterior wall allow access to all parts of the valve even when it cannot be exposed optimally. In patients with a shallow chest, the plane of the mitral valve is oblique and causes such difficulties. Although limited exposure in some cases causes problems, badly exposed valves are also encountered in conventional approaches. Especially in male patients with a deep chest, the exposure from the right side may be easier than through sternotomy in our experience. A study to answer this question is currently being performed in our department.

It is open for speculation whether the four intraoperative conversions to MVR could have been avoided by a conventional approach through a median sternotomy. As we were able to perform extended procedures like ring decalcifications with patch reconstructions and implantations of artificial chordae, access is not a principal hurdle.

The rather high number of circumflex artery lesions in our series has to be commented on. All patients underwent the technique of mural annulus shortening suture annuloplasty first described by Frater and Sisto [22]. Although other factors such as atrial size reduction with exclusion of the left atrial appendage or the limited exposure could be responsible, we are convinced that the suture annuloplasty is the main reason. We have not observed a single instance of circumflex artery injury after ring implantation. In addition, a similar circumflex artery lesion was observed in an additional case operated on through median sternotomy and a pediatric case with partial suture annuloplasty in atrioventricular canal repair.

The use of CO₂ insufflation has markedly reduced both the amount of air in cardiac chambers and the number of air emboli. To achieve significant concentrations in the operative field, the application technique has to be optimized [9].

Follow-up results indicated that this surgery provides satisfactory midterm results in the treatment of mitral valve disease. The reoperation rate was 1.7%, which is comparable to the results shown in the STS database or reported elsewhere [18, 19]. All noninfected, reoperated patients had primary suture annuloplasty for mitral annulus remodeling. Intraoperatively, we have observed redilation of the annulus in all patients. Our observation is in accordance with the finding of Cohn and colleagues [23]. They have reported that the lack of ring annuloplasty is a independent risk for reoperation.

Echocardiographic midterm results show low mean transvalvular gradients and large valve opening areas for repairs. Comparable echocardiographic data are reported for conventional mitral surgery [24–26]. Overall, freedom from nontrivial mitral regurgitation at 76 months was 92.3%. This, again, is comparable to results reported for conventional procedures [26, 27].

Mitral valve surgery through a small anterolateral thoracotomy using the transthoracic clamp is a good alternative to conventional surgical accsess. Excellent cosmetic results and avoidance of the sternal complications are major advantages even after performing technically demanding mitral procedures. As clinical and echocardiographic outcome and midterm follow-up results compare favorably with those of series reported for a conventional or hemisternotomy approach [28], this technique deserves a place in the surgical armamentarium for mitral valve treatment to improve patient satisfaction.

	References

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