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Ann Thorac Surg 2009;87:709-714. doi:10.1016/j.athoracsur.2008.11.053
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Minimally Invasive Mitral Valve Surgery After Previous Sternotomy: Experience in 181 Patients

Joerg Seeburger, MD*, Michael A. Borger, MD, PhD, Volkmar Falk, MD, PhD, Jurgen Passage, MBBS, FRACS, Thomas Walther, MD, PhD, Nicolas Doll, MD, PhD, Friedrich W. Mohr, MD, PhD

Heart Center, Leipzig University, Leipzig, Germany

Accepted for publication November 19, 2008.

* Address correspondence to Dr Seeburger, Heart Center, Leipzig University, Struempelstrasse 39, Leipzig, 04289, Germany (Email: j.seeburger{at}web.de).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Comment
 References
 
Objective: This study evaluated the results for minimally invasive mitral valve (MV) surgery in patients who had undergone previous cardiac operations through a sternotomy.

Methods: From March 1, 1999 to January 2008, minimally invasive MV reoperations were performed in 181 consecutive patients (110 men) with a mean age of 64.5 ± 12 years. A right-sided lateral minithoracotomy with femoral cannulation for cardiopulmonary bypass (CPB) was used. The principal indication was symptomatic severe mitral regurgitation (mean grade, 3.0 ± 0.8). Previous procedures were isolated coronary bypass grafting (CABG) in 76 (42%), isolated valve operation, 55 (30%); combined CABG and valve, 16 (9%); and other cardiac operations, 34 (19%). MV replacement was previously performed in 19 patients and MV repair in 31. Mean preoperative left ventricular ejection fraction was 0.54 ± 0.16.

Results: MV repair, including repeat repair, was performed in 109 patients (60%) and MV replacement in 72 (40%). Operations were performed during ventricular fibrillation in 140 (77%), and a transthoracic aortic cross-clamp was used in 31 (17%). Ten patients (6%) underwent beating heart operations with CPB support. Mean total operating time was 176 ± 50 min. Mean CPB time was 135 ± 40 min. Thirty-day mortality was 6.6%. Early echocardiographic follow-up revealed excellent valve function in most patients.

Conclusion: A minimally invasive approach is a useful alternative for patients requiring a MV procedure after a previous cardiac operation, particularly in patients with patent coronary bypass grafts or previous aortic valve replacement. Very good perioperative results can be achieved with this method.


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Comment
 References
 
Cardiac surgery centers around the world face an increasing number of patients with indications for redo surgery because patients continue to live longer postoperatively and as bioprosthetic valves become increasingly popular. Redo cardiac surgery patients in general represent a clinical challenge due to an increased rate of perioperative morbidity and mortality [1–6]. Reoperative mitral valve (MV) operations can be particularly difficult in patients with patent coronary bypass grafts, where the risk of graft injury is a significant concern, or previous aortic valve replacement, where exposure of the MV through a sternotomy can be very challenging. Redo sternotomy may also be difficult in patients with vascular structures (brachiocephalic vein, ascending aorta, right ventricle) that lie directly behind the sternum or in patients who had previous sternal wound infections or chest radiotherapy. To improve patient care and reduce the perioperative and intraoperative risk of resternotomy, new treatment strategies may be required for such patients.

As an alternative approach to conventional operations through a median sternotomy, a right-sided thoracotomy can be performed to minimize the risk of damage to critical structures that lie directly behind the sternum. Although an anterolateral thoracotomy with central cannulation has been used for many years for redo MV operations [7, 8], such an approach is associated with the morbidity of a full thoracotomy incision. We therefore developed a minimally invasive technique consisting of a small muscle-sparing incision, thoracoscopic assistance, and femoral cannulation for cardiopulmonary bypass (CPB). We have used this approach as our procedure of choice in patients requiring a redo-MV operation since the late 1990s [9, 10]. This study was conducted to evaluate our experience with minimally invasive MV operations in patients who have undergone previous cardiac procedures through a sternotomy incision.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Comment
 References
 
Patients
Between March 1999 and January 2008, a minimally invasive technique was used for MV disease in 181 consecutive patients who had previously undergone cardiac operations through a sternotomy. The minimally invasive procedure through a right lateral minithoracotomy was our preferred approach for all patients who required a redo MV operation with or without other procedures that can be performed through a minimally invasive approach, such as tricuspid valve surgery, closure of a patent foramen ovale or atrial septal defect, or atrial fibrillation ablation.

Excluded from the current study were those patients who required concomitant coronary artery bypass grafting (CABG), aortic valve replacement, ascending aorta replacement, or ventricular aneurysmectomy required redo MV operations through a sternotomy. Also excluded were patients who underwent a previous right lateral thoracotomy because of extensive adhesions that exist in the pleural space. Conventional redo MV procedures through a sternotomy were performed in 555 patients during the study period.

The 181 patients undergoing minimally invasive redo MV operations were a mean age of 64.5 ± 12 years, and 110 (61%) were men. The mean preoperative left ventricular ejection fraction was 0.54 ± 0.16%. Preoperative patient characteristics are detailed in Table 1. The principal indication for operation was symptomatic severe mitral regurgitation (mean grade, 3.0 ± 0.8). Most patients had myxomatous disease or isolated annular dilation. Details on MV pathology are further described in Table 2. Ethics approval without individual patient consent was granted from the local Ethics Committee.


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  		Table 1 Preoperative Characteristics of 181 Patients Undergoing Redo Minimally Invasive Operation
 

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  		Table 2 Mitral Valve Pathology of 181 Patients Undergoing Redo Minimally Invasive Operation
 
Previous Operations
Overall, 167 patients (92.3%) had previously undergone one cardiac operation, 13 patients (7.2%) had two operations, and 1 patient (0.5%) had three operations. A total of 76 patients (42%) underwent previous isolated CABG, 55 (30%) had isolated valve operations, 16 (9%) had combined CABG and valve procedures, and 34 (19%) had other cardiac operations. MV interventions had previously been performed in 50 patients (27.6%), of which 31 were repairs and 19 were replacements. A total of 28 patients (15.5%) had previously undergone aortic valve replacement. A preoperative CT scan was performed in all patients to assess thoracic anatomy and patency of femoral vessels.

Surgical Technique
Our minimally invasive surgical approach has been described in detail elsewhere [9, 10]. All patients underwent cannulation of the femoral vessels for institution of CPB. A right muscle-sparing minithoracotomy measuring 4 to 8 cm in length was used in all patients. In those patients in whom the aorta could be safely dissected, the ascending aorta was cross-clamped with a transthoracic clamp, and antegrade cardioplegia was administered. Patients in whom the ascending aorta could not be safely mobilized underwent operation on a fibrillatory or beating heart during full CPB support. The 76 patients with patent mammary artery grafts also underwent the procedure during ventricular fibrillation. The systemic temperature was cooled to 34°C rectally in all patients, except those who required ventricular fibrillation and underwent systemic hypothermia at 28° C.

Visualization of the MV was performed with direct vision and with thoracoscopic assistance. Specialized surgical tools were used for tissue handling and suturing (Geister Inc, Tuttlingen, Germany). Standard MV repair or replacement techniques were used. Some patients with MV prolapse underwent traditional quadrangular leaflet resection MV repair [11], whereas most underwent insertion of premeasured Gore-Tex (W. L. Gore and Associates, Inc, Flagstaff, AZ) neochordae with preservation of all native leaflet tissue using the Loop technique [12, 13]. The surgical field was flooded with carbon dioxide, and air was removed through the cardioplegia cannulation site on the anterior surface of the ascending aorta or through the left atriotomy before closure.

Statistical Analyses
Categoric variables are expressed as proportions and continuous variables as mean ± standard deviations. All analyses were performed using JMP 7.0 software (SAS Institute, Cary, NC). Guidelines for reporting morbidity and mortality after cardiac valvular operations were followed [14].


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Comment
 References
 
MV repair, including repeat repair, was performed in 109 patients (60%) and MV replacement in 72 (40%), with just over one-half of MV replacement patients receiving a biologic valve (Table 3). MV repeated repair was possible in 15 of 31 patients (48.2%) who had undergone a previous MV repair; the others required MV replacement. The frequency of various MV repair techniques is summarized in Table 3. In 4 patients, MV replacement was performed during the same operation after an unsatisfactory repair procedure.


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  		Table 3 Operative Data of 181 Patients Undergoing Redo Minimally Invasive Operation a
 
The operation in 140 patients (77%) was performed during ventricular fibrillation, and a transthoracic aortic crossclamp was used in 31 (17%). The remaining 10 patients (6%) underwent operations on the beating heart with full CPB support. The mean total operating time was 176 ± 50 minutes, and mean CPB time was 135 ± 40 minutes (Table 3). Concomitant operative procedures are summarized Table 3.

Conversion to sternotomy was required in 3 patients during the procedure: 1 due to aortic dissection secondary to femoral cannulation, 1 due to atrioventricular disruption, and 1 due to extensive adhesions on the chest wall. These patients subsequently died on postoperative days 0, 41, and 63.

The 30-day mortality rate was 6.6% (12 of 181). Causes of death were low cardiac output syndrome in 4 patients, hemorrhage in 2, acute respiratory distress syndrome in 2, gastrointestinal ischemia in 2, sepsis in 1,and asystole in 1. Early reoperations (≤ 30 days) were performed in 6 patients (3.3%). The indication for reoperation was recurrent mitral regurgitation in 5, of which 4 underwent MV replacement and 1 patient had MV repeat repair using the edge-to-edge technique. The remaining patient was diagnosed with acute endocarditis of the MV and thus underwent MV replacement. Reoperations for bleeding were necessary in 22 patients (12.1%). Renal failure with hemodialysis occurred in 9 patients (5%). Neurologic impairment was observed in 10 patients (5.2%), consisting of stroke in 3.8% and transient ischemic attack or encephalopathy in 1.4%. Mean hospital stay was 16.3 ± 12.5 days (Table 4). Predischarge echocardiography showed a mean mitral regurgitation grade of 0.3 ± 0.6.


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  		Table 4 Clinical Outcomes and Early Postoperative Complications of 181 Patients Undergoing Redo Minimally Invasive Operation
 

   Comment
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Comment
References
 
A redo cardiac procedure is generally associated with a higher risk of morbidity and mortality than the first operation, particularly for the MV position [1, 2]. The increased risk of reoperation is mainly due to risk of injury to major vascular structures or patent coronary grafts during sternal reentry. Exposure of the MV, however, can also be particularly problematic during a redo operation because of extensive pericardial adhesions or because of a previously implanted aortic valve prosthesis. Such difficulties can lead to limited cardiac dissection and exposure, increased risk of bleeding, injury to patent coronary grafts, and insufficient myocardial protection.

To minimize these risks, the minimally invasive approach has been increasingly used for redo MV procedures. Casselmann and colleagues [15] examined their results for 80 consecutive patients undergoing video-assisted redo MV procedures and found a perioperative mortality rate of 3.8% for these high-risk patients. Using a similar operative technique, Bolotin and colleagues [16] demonstrated a mortality rate of 5.7% in 38 patients undergoing minimal invasive redo MV procedures. Burfeind and colleagues [17] compared 60 patients undergoing redo port-access MV procedures with 37 patients operated on through a full thoracotomy or 155 with a sternotomy [17]. The minimally invasive group had less perioperative bleeding, lower transfusion requirements, and a lower operative mortality (0% vs 22% for thoracotomy and 14% for sternotomy). However, the CPB times for the minimal access patients were approximately 50 minutes longer than the other two groups. Although these studies demonstrated very favorable results for the minimally invasive approach, they are limited by their relatively small sample sizes. We therefore sought to address our results for minimally invasive MV reoperations in a relatively large group of patients.

The minimally invasive approach to the MV has been our procedure of choice since the late 1990s and can be particularly beneficial in redo patients. During the 9-year period of the current study, we performed 181 minimally invasive redo MV operations, which is among the largest series to date of reoperative minimally invasive MV operations. Although this technique is our procedure of choice, it cannot be performed in patients requiring concomitant cardiac procedures other than tricuspid valve operations, atrial fibrillation ablation, or closure of an atrial septal defect or patent foramen ovale. In addition, patients who have previously received a right-sided thoracotomy are excluded because of difficulty mobilizing the lung.

Only 3 patients (1.7%) required intraoperative conversion to sternotomy, and only 1 patient (0.6%) sustained an injury to a major vascular structure. Our major vascular injury rate compares very favorably with a recent publication from Ellman and colleagues [18], where they observed a cardiac injury rate of 9.1% in patients undergoing redo sternotomy.

We observed an acceptable perioperative mortality rate of 6.6% in the current study. Our observed mortality rate also compares favorably with reoperative MV series that were performed through a median sternotomy. For example, Borger and colleagues [1] reported a 9.0% risk of mortality in 513 patients undergoing repeat MV repair or replacement. Akins and colleagues [2] observed a 6.8% mortality rate in 219 patients undergoing redo MV replacement [2]. However, both of these series included patients undergoing concomitant cardiac procedures such as CABG or aortic valve replacement. Although 15% of our patients underwent concomitant procedures such as tricuspid valve surgery or closure of an atrial septal defect/patent foramen ovale, a more suitable comparison might be to a series of isolated redo MV procedures through a sternotomy. Along these lines, Jamieson and colleagues [3] observed a 6.3% mortality rate in 414 patients undergoing isolated redo MV replacement, and Gill and colleagues [4] reported a 14.2% mortality rate for isolated redo MV patients operated on through a sternotomy. Although it is difficult to make comparisons with published reports because of differences in patient populations, we can safely conclude that our observed mortality rate of 6.6% for the minimally invasive approach confirms that it is a safe alternative to redo MV interventions through a sternotomy.

In our opinion, the minimally invasive approach results in good perioperative outcomes for three reasons: (1) excellent exposure of the MV, (2) good myocardial protection, and (3) decreased risk of major vascular injury, all of which are discussed in further detail.

The right-sided lateral minithoracotomy for MV exposure allows a direct view of the posteriorly positioned MV, including the valvular and subvalvular apparatus, without a significant amount of tissue dissection. Good exposure through a sternotomy can be particularly challenging in patients who have undergone previous aortic valve replacement, which is not an issue for the minimally invasive approach (Fig 1).


Figure 1
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  		Fig 1. Computed tomography scan of a patient who previously underwent three cardiac operations. Note the compression of the right ventricle against the posterior sternum (top arrow) and the direct view from the lateral thorax to the mitral valve (left arrow).

 
Good myocardial protection can also be an advantage of the minimally invasive technique and may explain our relatively low 7.2% rate of observed low cardiac output syndrome. The risk of injury to patent bypass grafts is almost negligible; therefore, antegrade cardioplegia can be administered through the ascending aorta and patent vein grafts. Although it may be difficult to dissect the ascending aorta away from the pulmonary artery through a right thoracotomy, this part of the procedure is not always necessary. One option is to perform endovascular occlusion of the ascending aorta, as described by Casselmann and colleagues [15]. Another is to cool the patient systemically and induce ventricular fibrillation, as was used in the current study for patients with patent mammary artery grafts. Thomson and colleagues [19] described another option that consists of an MV procedure on the beating heart without cross-clamping the aorta; however, with this option it can be difficult to adequately visualize the MV in the presence of aortic valve incompetence, and prevention of air embolization can be a particular challenge.

Finally, a decreased risk of major vascular injury is another possible explanation for our respectable observed mortality rate. Gaining access to the MV with a minimal amount of tissue dissection can be usually achieved relatively easily because of the direct access to the left atrium and because the right side of the mediastinum is usually free of adhesions. In addition, it is not necessary to free the right ventricle or the innominate vein from the sternum, nor to mobilize patent coronary bypass grafts. Cannulation of the femoral vessels eliminates issues related to exposure of the aorta and right atrium and allows CPB to be initiated before the thorax is opened. All of these issues make the risk of major vascular injury, which was observed in only 1 patient (0.6%) in the current study, very unlikely through a minimally invasive approach.

Standard MV repair techniques can be performed through the minimally invasive approach in patients who have undergone previous cardiac operations. In the current study, MV repair was performed in 60% of the total patient population and repeat repair was possible in 48% of patients who had a previous repair. In addition, we are comfortable with the use of ventricular fibrillation, which was used in most cases, even though 51% (Table 1) of our patients had previous CABG. Our low incidence of low cardiac output syndrome demonstrates that this is a safe method of myocardial protection in such patients.

One limitation of the current study is that we could not compare patients undergoing minimally invasive redo MV procedures vs those undergoing conventional operations through a repeat sternotomy, because the minimally invasive approach was performed in all patients who required an isolated MV operation (or MV intervention combined with procedures that can be performed through a minithoracotomy) during the study period.

Conventional redo MV operations through a sternotomy, however, was performed only in those patients who required concomitant procedures such as aortic valve replacement, coronary bypass grafting, ascending aortic intervention, or left ventricular aneurysmectomy. Given that such concomitant procedures are known to significantly increase the complexity and risk of MV operations, we did not believe that a comparison of our minimally invasive and conventional patients would be a fair "apples-to-apples" comparison.

The lack of a control group and the retrospective nature of this study make it difficult to precisely determine the relative benefit of our minimally invasive approach. However, comparisons with the literature reveal that our results are at least comparable with those obtained during conventional redo MV operations, and therefore our technique represents a viable alternative to repeat sternotomy. The minimally invasive approach may be particularly helpful in patients who are at high risk for repeat sternotomy, including multiple previous operations, patent bypass grafts, and vascular structures that are adherent to the posterior sternum. To more precisely compare the two techniques, however, a randomized controlled trial will be required.

In conclusion, minimally invasive redo MV operations can be safely performed with a low incidence of major vascular injury and perioperative mortality. The approach through a right lateral minithoracotomy can be particularly beneficial in patients who are at high risk for a redo sternotomy procedure. A high rate of MV repair and repeat repair can be achieved through this approach, with a low rate of postoperative low cardiac output syndrome. We therefore conclude that the minimally invasive MV operation represents a safe and effective alternative to conventional redo sternotomy surgery.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Comment
 References
 

  1. Borger MA, Yau TM, Rao V, Scully HE, David TE. Reoperative mitral valve replacement: importance of preservation of the subvalvular apparatus Ann Thorac Surg 2002;74:1482-1487.[Abstract/Free Full Text]
  2. Akins CW, Buckley MJ, Daggett WM, et al. Risk of reoperative valve replacement for failed mitral and aortic bioprostheses Ann Thorac Surg 1998;65:1545-1551.[Abstract/Free Full Text]
  3. Jamieson WR, Burr LH, Miyagishima RT, et al. Reoperation for bioprosthetic mitral structural failure: risk assessment Circulation 2003;108:II98-II102.[Medline]
  4. Gill IS, Masters RG, Pipe AL, Walley VM, Keon WJ. Determinants of hospital survival following reoperative single valve replacement Can J Cardiol 1999;15:1207-1210.[Medline]
  5. Glower DD, Siegel LC, Frischmeyer KJ, 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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  10. Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation—results of 1339 consecutive patients Eur J Cardiothorac Surg 2008;34:760-765.[Abstract/Free Full Text]
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  12. Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops Ann Thorac Surg 2000;70:2166-2168.[Abstract/Free Full Text]
  13. Seeburger J, Kuntze T, Mohr FW. Gore-Tex chordoplasty in degenerative mitral valve repair Sem Thorac Cardiovasc Surg 2007;19:111-115.[Medline]
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  15. Casselman FP, La Meir M, Jeanmart H, et al. Endoscopic mitral and tricuspid valve surgery after previous cardiac surgery Circulation 2007;11(116):I270-I275.
  16. Bolotin G, Kypson AP, Reade CC, et al. Should a video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery? J Heart Valve Dis 2004;13:155-158.[Medline]
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