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Ann Thorac Surg 2009;87:704-708. doi:10.1016/j.athoracsur.2008.11.059
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Mitral Valve Replacement Through a Minimal Right Vertical Infra-axillary Thoracotomy Versus Standard Median Sternotomy

Dongjin Wang, MDa, Qiang Wang, MDa, Xiubin Yang, MDb, Qingyu Wu, MDc, Qingguo Li, MDa,*

a Department of Thoracic Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Peoples Republic of China
b Department of Cardiovascular Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing, China
c Heart Center, the First Hospital of Tsinghua University, Beijing, China

Accepted for publication November 24, 2008.

* Address correspondence to Dr Li, Department of Thoracic Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Peoples Republic of China (Email: lqg0235062{at}163.com).


   Abstract
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 Abstract
Introduction
 Material and Methods
 Results
 Comment
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Background: Minimally invasive valve surgery is becoming a safe and cosmetic alternative to standard median sternotomy (SMS). This retrospective study reviews our results and experience with a right vertical infraaxillary thoracotomy (RVIAT) technique for mitral valve replacement (MVR) compared with SMS.

Methods: Between December, 2003 and February, 2007, 192 patients underwent MVR through RVIAT (group 1). This group was compared with 203 patients who underwent MVR using SMS during the same period (group 2).

Results: Hospital mortality was 1 of 192 (0.5%) patients in group 1 and 1 of 203 (0.5%) patients in group 2 (p > 0.05). There was no late death in either group. The mean length of incision was significantly shorter in group 1 than that in group 2 (8.7 ± 2.2 cm vs 23.5 ± 2.5 cm, p < 0.05). The time to establish cardiopulmonary bypass was longer in group 1 (35.8 ± 7.6 vs 28.3 ± 6.5 minutes, p < 0.05). Group 1 had less chest drainage than group 2 (171 ± 21 vs 336 ± 46 mL, p < 0.05) and required less blood transfusion (159 ± 19 vs 446 ± 16 mL, p < 0.05). Postoperative mechanical ventilation time was also less in group 1 (4.5 ± 1.2 vs 6.5 ± 3.2 hours, p < 0.05). There were no statistical differences in aortic cross-clamp time, cardiopulmonary bypass time, and total operation time between the two groups.

Conclusions: The RVIAT can be performed with favorable cosmetic and clinical results. It provides a good alternative to standard median sternotomy for MVR.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
With the rapid development of surgical techniques and the assistance of advanced instrumentation, the clinical results of cardiac surgery have been dramatically improved in recent years. As a result, cosmetic and psychologic implications of surgery have assumed increasing importance in the same time frame [1] and a variety of minimally invasive cardiac surgical techniques have been developed, including parasternal incision [2], right thoracotomy [3], port-access surgery [4, 5], and video-assisted methods [6, 7].

Previously in our department, right vertical infra-axillary thoracotomy (RVIAT) had been employed to repair congenital heart defects such as atrial septal defects [8] and atrioventricular septal defects [9]. During the past four years, the aesthetic technique was used to perform mitral valve surgery for selected patients. This retrospective study reviews our results and experiences with the RVIAT technique for mitral valve replacement (MVR) compared with standard median sternotomy (SMS).


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Between December, 2003 and February, 2007, 192 patients received MVR through RVIAT (group 1). During this same period, 203 patients were admitted for MVR using the SMS [10] (group 2). Patients were selected for either surgical technique (whether RVIAT or not) by the same chief surgeon with patients' agreement. Patients who required aortic valve surgery according to preoperative echocardiography or with body mass index (BMI) greater than 30 kg/m2 were not recommended for RVIAT. No randomization was involved and this cohort of patients was reviewed retrospectively. All patients underwent MVR with or without tricuspid valvuloplasty by the same surgical team. Institutional Review Board approval was obtained for the study.

The two groups were well-matched for age, New York Heart Association class etiology, ejection fraction, and valve lesions (listed in Table 1). More female patients were recruited in group 1 (67.7% in group 1 vs 49.8% in group 2, p < 0.05). There were fewer atrial fibrillation patients in group 1 (27.1% in group 1 vs 34.0% in group 2, p < 0.05).


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  		Table 1 Demographic Data and Diagnoses of the Two Patients Groups
 
The RVIAT surgical technique has been previously described [8, 9]. Patients were positioned with the right side elevated 60 degrees. The right arm was put over the head with shoulder-joint abducted approximately 120 degrees and elbow joint in right angle position. The skin incision began at the third intercostal space along the right midaxillary line extending to the fifth intercostals space along the preaxillary line, which formed a right vertical infraaxillary incision. The length of the incision was approximately 7 to 10 cm but varied depending upon patients' physical characteristics such as body height and weight.

The thoracic cavity was entered through the fourth intercostal space. The lung was retracted posteriorly using wet sponges to expose the pericardium. The pericardium was opened 2 cm anterior to the phrenic nerve, superiorly to the pericardial reflection and inferiorly to the diaphragm, to provide enough exposure of the ascending aorta and inferior vena cava. Pericardial traction stay sutures were placed at the superior, middle, and inferior aspects of the incision. The superior pericardial stay stitches were placed on partial pleura of ribs to elevate the aorta into the operative field. The cannulation of the inferior vena cava, superior vena cava, and ascending aorta were performed as described previously [8, 9]. The mitral valve replacement was performed through the transeptal approach or the interatrial groove when the left atrium was large enough and tricuspid valvuloplasty was not needed. The heart function and prosthesis function were monitored by transesophageal echocardiography. Pacing wires were routinely set on the ventricle of the heart in case of emergency need. After the completion of MVR, the pericardium and the thoracotomy were closed in the common fashion with a single right pleural drain.

Postoperative Anticoagulation Strategy
Application of low molecular weight heparin (LMWH) began after the drainage (less than 2 mL/kg per hour), oral warfarin starting on postoperative day 1, and the continuation of LMWH until a therapeutic international normalized ratio (2.0 to 2.5) had been achieved. Warfarin was prescribed for life-long anticoagulant therapy for patients with mechanical valves and three months for bioprosthetic valves. Bridging anticoagulant therapy with LMWH was undertaken when interruption of oral anticoagulation therapy was required.


   Results
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 Material and Methods
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Comment
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All of the patients received mitral valve replacement with or without tricuspid valvuloplasty. There were no other concomitant procedures in either group, and no patients in either group required emergency femoral cannulation.

The mean length of incision in group 1 was significantly shorter than that in group 2 (8.7 ± 2.2 cm vs 23.5 ± 2.5 cm; p < 0.01). There was no statistical difference in aortic clamp time, cardiopulmonary bypass time, or total operation time between the two groups. The time to establish cardiopulmonary bypass in group 1 was significantly longer than that in group 2. Mechanical ventilation time, the amount of chest tube drainage, and blood transfusion were less for group 1. Hospital stay was shorter for group 1 compared with group 2 (Table 2). Score on the visual analogue scale [11] was lower in group 1, although this difference did not achieve statistical significance (p > 0.05). Patients returned to normal activity more quickly with RVIAT than sternotomy despite the marked variance in group 1.


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  		Table 2 Results
 
There was one hospital death in group 1 due to multiple organ failure, and one in group 2 due to renal failure. There were no other early complications in group 1, and one reoperation for bleeding and one sternum infection in group 2. Mean follow-up duration was 36.1 months (range, 14 to 52), and follow-up rate was 93%. There were no paravalvular leaks or late death in either group during the follow up. One case of cerebral hemorrhage 6 months after surgery was observed in group 1 and no anticoagulation-associated complications occurred in group 2.


   Comment
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
As the physiologic results of valve surgery have improved dramatically in recent years, perhaps only nonaesthetic scarring is all that remains to be improved regarding mitral valve surgery and its follow-up. Therefore, the cosmetic effect of the procedure gains increased attention, and various alternatives with favorable clinical results to the standard median sternotomy have been developed for mitral valve surgery that can avoid the characteristic unsightly, long midline scar [12–18].

In our department, RVIAT has been used for repair of atrial septal defect and partial atrioventricular septal defect, and has proved to be a safe and cosmetic alternative to median sternotomy [8, 9]. With the accumulated experience, application of the incision has been consciously extended to mitral valve replacement since 2003. The current study provides details of early and longer term results from RVIAT and median sternotomy in comparison.

Aortic cannulation is one of the most critical steps in the operation. It takes more time to establish cardiopulmonary bypass through RVIAT (p < 0.05), but it is safe if carefully managed for selected patients. In our experience, two long vascular clamps are used, one for pulling the aortic cannulation site down and the other for holding the head of the aortic cannula for cannulation (Fig 1). In addition, patients with body mass index (BMI) greater than 30 kg/m2 were not recommended for RVIAT because increasing BMI makes aortic cannulation more demanding. In our practice, aortic cannulation can be done without increasing morbidity and mortality. Once the cardiopulmonary bypass was established smoothly, RVIAT increased neither aortic-clamp time nor total operating time (p > 0.05) with excellent visualization of the mitral valve (Fig 2).


Figure 1
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  		Fig 1. Demonstration of the critical step of aortic cannulation with the help of two long vascular clamps.

 

Figure 2
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  		Fig 2. Demonstration that mitral valve replacement can be performed with good visualization.

 
The cosmetic advantage of RVIAT is the short incision which is often invisible under the armpit (Fig 3). The blood transfusion and chest drainage were significantly less with RVIAT, probably due to the avoidance of sternotomy, which may contribute to the quick recovery to normal activity in the group of patients undergoing RVIAT (p < 0.05). In addition, the RVIAT for MVR did not increase early complications. Though the spreading of the ribs is considered more painful than sternotomy, the score of the visual analogue scale to measure postoperative pain in group 1 was unexpectedly lower, though not statistically different. We inferred that there may be a bias (the extent to which is unknown) for the patients in group 1, who were informed of the minimal right vertical infraaxillary thoracotomy preoperatively.


Figure 3
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  		Fig 3. Result of skin incision after mitral valve replacement through right vertical infraaxillary thoracotomy (14 months after surgery).

 
Our approach is here compared with several newer techniques for minimally invasive heart surgery to demonstrate the reason we introduced RVIAT in our center. The internal mammary artery is prone to be damaged and cannulation of the femoral artery is usually required for parasternal incision, as reported by Navia and Cosgrove [2] and Cosgrove and Sabik [19]. The right anterolateral thoracotomy can avoid the use of femoral artery cannulation but sometimes results in thorax deformity and injury of the mammary gland of young female patients [20]. Specific instruments, additional expenses in the operating room, and the risk of aortic dissection deriving from cannulation of the femoral artery are shortcomings of port access, which had been considered to be a safe and promising technique for mitral valve surgery [4, 5]. Partial sternotomy can be performed with acceptable clinical results, avoiding femoral artery and vein cannulation, but a midline scar is not popular, especially with young female patients [21].

The RVIAT can avoid the potential disadvantages of some other minimally invasive approaches including femoral artery cannulation and its complications, extra expense for special surgical instrumentation, infection of the sternum with standard sternotomy, and injury to the mammary gland. Acceptable results were achieved for appropriate patients without increasing morbidity and mortality. Undoubtedly there is a learning curve to handle the technique smoothly, but the procedure is familiar to cardiac surgeons and easy to grasp with the experience accumulated from relatively simple cardiac defections [8, 9].

In conclusion, RVIAT can be performed with favorable cosmetic and accepted clinical results for mitral valve replacement. The technique is a promising alternative to standard median sternotomy and merits further study.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Massetti M, Nataf P, Babatasi G, Khayat A. Cosmetic aspects in minimally invasive cardiac surgery Eur J Cardiothorac Surg 1999;16(suppl 2):S73-S75.[Medline]
  2. Navia JL, Cosgrove III DL. Minimally invasive mitral valve operations Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
  3. Aybek T, Dogan S, Risteski PS, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy Ann Thorac Surg 2006;81:1618-1624.[Abstract/Free Full Text]
  4. Glower DD, Landolfo KP, Clements F, et al. Mitral valve operation via port access versus median sternotomy Eur J Cardiothorac Surg 1998;14(suppl 1):S143-S147.[Medline]
  5. Dogan S, Aybek A, Risteski PS, et al. Minimally invasive port access versus conventional mitral valve surgery: prospective randomized study Ann Thorac Surg 2005;79:492-498.[Abstract/Free Full Text]
  6. Reichenspurner H, Detter C, Deuse T, Boehm DH, Treede H, Reichart B. Video and robotic-assisted minimally invasive mitral valve surgery: a comparison of the port-access and transthoracic clamp techniques Ann Thorac Surg 2005;79:485-491.[Abstract/Free Full Text]
  7. Lin PJ, Chang CH, Chu JJ, et al. Video-assisted mitral valve operations Ann Thorac Surg 1996;61:1781-1787.[Abstract/Free Full Text]
  8. Yang X, Wang D, Wu Q. Repair of atrial septal defect through a minimal right vertical infra-axillary thoracotomy in a beating heart Ann Thorac Surg 2001;71:2053-2054.[Abstract/Free Full Text]
  9. Yang X, Wang D, Wu Q. Repair of partial atrioventricular septal defect through a minimal right vertical infra-axillary thoracotomy J Card Surg 2003;18:262-264.[Medline]
  10. Douglas Jr JM. Median sternotomyIn: Sabiston Jr DC, editor. Atlas of Cardiothoracic Surgery. Philadelphia: Saunders; 1995. pp. 40-44.
  11. Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales Pain 1994;56:217-226.[Medline]
  12. Grossi EA, Galloway AC, LaPietra A, et al. Minimally invasive mitral valve surgery: a 6-year experience with 714 patients Ann Thorac Surg 2002;74:660-664.[Abstract/Free Full Text]
  13. Casselman FP, Van Slycke S, Wellens F, et al. Mitral valve surgery can now routinely be performed endoscopically Circulation 2003;108(suppl 1):I148-I154.
  14. Mohr FW, Onnasch JF, Falk V, et al. The evolution of minimally invasive mitral valve surgery–two years experience Eur J Cardiothorac Surg 1999;15:233-239.[Abstract/Free Full Text]
  15. Chitwood Jr WR, Elbeery JR, Chapman WH, et al. Video-assisted minimally invasive mitral valve surgery: the micro-mitral operation J Thorac Cardiovasc Surg 1997;113:413-414.[Free Full Text]
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  17. Cosgrove III DM, Sabik JF, Navia JL. Minimally invasive valve operations Ann Thorac Surg 1998;65:1535-1539.[Abstract/Free Full Text]
  18. Mohr FW, Falk V, Diegeler A, Walther T, van Son JA, Autschbach R. Minimally invasive port-access mitral valve surgery J Thorac Cardiovasc Surg 1998;115:574-576.
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  20. Bleiziffer S, Schreiber C, Burgkart R, et al. The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis J Thorac Cardiovasc Surg 2004;127:1474-1480.[Abstract/Free Full Text]
  21. Rodríguez JE, Cortina J, Pérez de la Sota E, Maroto L, Ginestal F, Rufilanchas JJ. A new approach to cardiac valve replacement through a small midline incision and inverted L shape partial sternotomy Eur J Cardiothorac Surg 1998;14(suppl 1):S115-S116.[Medline]



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