Ann Thorac Surg 2009;87:1426-1430. doi:10.1016/j.athoracsur.2009.02.060
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Reoperative Mitral Valve Surgery by the Port Access Minithoracotomy Approach Is Safe and Effective
Steven R. Meyer, MD, PhD,
Wilson Y. Szeto, MD,
John G.T. Augoustides, MD,
Rohinton J. Morris, MD,
William J. Vernick, MD,
Deborah Paschal, CRNP,
Jeanne Fox, CRNP,
W. Clark Hargrove, III, MD*
Division of Cardiovascular Surgery, Penn Presbyterian Medical Center, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
Accepted for publication February 20, 2009.
* Address correspondence to Dr Hargrove, Division of Cardiovascular Surgery, University of Pennsylvania, Presbyterian Medical Center, Suite 2D, PHI Building, 51 N 39th St, Philadelphia, PA 19104 (Email: clark.hargrove{at}uphs.upenn.edu).
| Dr Hargrove discloses a financial relationship with Sorin.
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Abstract
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Background: Reoperative mitral valve (MV) surgery through sternotomy can be technically challenging. Limited exposure and injury to the right ventricle or patent grafts (previous coronary artery bypass graft surgery [CABG]) are potential complications upon sternal reentry. The purpose of this study was to examine the results of port access MV surgery through right minithoracotomy in patients with previous cardiac surgery performed through median sternotomy.
Methods: From 1998 through July 2007, 651 port access MV procedures were performed. In 107 patients (16.4%), previous cardiac surgery had been performed through midline sternotomy. Mean age was 67.5 ± 11.2 years, and 60.7% (n = 65) were male. Previous surgery included CABG (n = 45, 42.1%), aortic valve replacement (n = 9, 8.4%), aortic valve replacement/MV repair (n = 2, 1.9%), MV repair (n = 21, 19.6%), MV replacement (n = 5, 4.7%), CABG/MV replacement (n = 1, 0.9%), CABG/MV repair (n = 8, 7.5%), CABG/aortic valve replacement (n = 2, 1.9%), and others (n = 14, 13.1%). New York Heart Association functional classes were I (n = 2, 1.9%), II (n = 28, 26.2%), III (n = 50, 46.7%), and IV (n = 27, 25.2%). The endoaortic balloon was used in 75 patients (70.1%) and the Chitwood clamp in 11 patients (10.2%). In the remaining patients (n = 21, 19.6%), fibrillatory arrest was employed.
Results: Mitral valve repair and MV replacement were performed in 60 patients (56.1%) and 47 patients (43.9%), respectively. The 30-day mortality was 4.7% (n = 5). The mean cardiopulmonary bypass and aortic cross-clamp times were 140.8 ± 43.7 minutes and 77.0 ± 49.7 minutes, respectively. Complications included 6 reoperations for bleeding (5.6%), 1 stroke (0.9%), and 2 wound infections (1.9%). Conversion to sternotomy was required in 1 patient (0.9%) because of an acute type A dissection secondary to aortic occlusion with Chitwood clamp. The mean hospital stay was 9.6 days. During follow-up, reoperation for failure of MV repair was performed in 4 patients (3.7%).
Conclusions: Reoperative port access MV surgery can be performed with minimal morbidity and mortality. This approach may be the preferred technique for patients who require MV procedures after previous cardiac surgery performed through median sternotomy.
Reoperative cardiac surgery through a median sternotomy is technically challenging and associated with complications, including injury to the right ventricle, injury to patent coronary artery bypass grafts (CABG), and bleeding. Additionally, when performing mitral valve (MV) surgery, exposure can be limited in patients who have had prior aortic valve replacement (AVR) or in patients with patent right internal mammary artery grafts. A review of The Society for Thoracic Surgeons (STS) database reported that mortality for MV replacement increases from 5.09% to 9.25% in patients who have had a prior cardiac operation [1].
Port access mitral surgery through a limited right thoracotomy has been demonstrated to be safe with similar results to sternotomy for patients who have not had a prior sternotomy [2–4]. Moreover, it has the potential advantage of less pain, earlier recovery, improved cosmesis, and greater patient satisfaction [5–7]. Because of these outcomes, the port access approach has become the preferred approach to MV surgery for numerous institutions and may promote earlier surgery for patients with MV disease [8].
However, the role of port access surgery in reoperative cardiac surgery has been less clear. Thus, the purpose of this study was to examine the results of port access MV surgery by right minithoracotomy in patients with previous cardiac surgery performed through median sternotomy.
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Patients and Methods
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A retrospective review of a prospectively managed database was conducted. All patients with prior sternotomy subsequently undergoing MV surgery through port access right minithoracotomy between 1998 and July 2007 were identified. Standard definitions based on the STS database (versions 2.35, 2.41, 2.52) and the Guidelines for Reporting Morbidity and Mortality After Cardiac Valvular Operations were utilized [9]. Ethical approval was provided by our Institutional Review Board, and a waiver of the need for patient consent had been obtained.
Port access surgery has become the preferred approach for MV surgery at Penn Presbyterian Hospital and is thus was indicated for all reoperative patients requiring MV surgery. Contraindications included need for AVR or CABG and lack of adequate peripheral access. Port access surgery was performed using standardized procedures similar to those described by Casselman and colleagues [7]. The patient is intubated with a double-lumen endotracheal tube, and bilateral radial arterial lines are placed. The right internal jugular vein is cannulated with a 16F femoral cannula before draping. A small (4 cm) skin incision is made inferior to the right breast, and the chest is entered through the fourth intercostal space. A soft tissue retractor is placed through the opening, and adhesions are lysed. Femoral venous cannulation is performed with a 25F venous cannula, and femoral artery cannulation with a 21F cannula with side port for endoaortic balloon and cardioplegia. The pericardium is entered, free edges suspended, and limited lysis of adhesions performed. Cardiopulmonary bypass is initiated with active venous drainage with vacuum assist. The majority of cases are performed with endoaortic balloon clamping and antegrade cardioplegia. Positioning of the endoaortic balloon is confirmed using transesophageal echocardiography and symmetry of upper extremity arterial lines. Alternatively, a cross-clamp is applied directly to the aorta and cardioplegia administered through a separate cannula in the aortic root. In the redo situation, that does, however, entail extra dissection around the aorta. Rarely, fibrillatory arrest is used when a patent mammary is present. After the heart is arrested, the left atrium is opened along the interatrial groove and MV repair or replacement performed using standard procedures.
Statistical analysis was performed using SPSS, version 15.0 (SPSS, Chicago, IL). Continuous variables are expressed as mean ± SD. Long-term survival is expressed using Kaplan-Meier plots, and comparisons between survival curves were made with log rank (Mantel-Cox) statistics. Survival was determined by a Social Security Death Index query.
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Results
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Between November 1998 and July 2007, 651 port access MV procedures were performed. In 107 patients (16.4%), previous cardiac surgery had been performed. Patient demographics, prior procedures, and mitral pathology are summarized in Table 1. Mean age was 67.5 ± 11.2 years, and 60.7% of patients (n = 65) were male. New York Heart Association (NYHA) functional classes were as follows: I (n = 2, 1.9%), II (n = 28, 26.2%), III (n = 50, 46.7%), and IV (n = 27, 25.2%). Previous surgery included CABG (n = 45, 42.1%), AVR (n = 9, 8.4%), AVR/MV repair (n = 2, 1.9%), MV repair (n = 21, 19.6%), MV replacement (n = 5, 4.7%), CABG/MV replacement (n = 1, 0.9%), CABG/MV repair (n = 8, 7.5%), CABG/AVR (n = 2, 1.9%), and others (n = 14, 13.1%).
The endoaortic balloon and the Chitwood clamp were used in 75 patients (70.1%) and 11 patients (10.2%), respectively (Table 2). In the remaining 21 patients (19.6%), fibrillatory arrest was employed. The mean cardiopulmonary bypass time was 140.8 ± 43.7 minutes, and the aortic cross-clamp time was 77.0 ± 49.7 minutes. Mitral valve repair was possible in 60 patients (56.1%), and MV replacement was required in the remaining 47 (43.9%). Of the repairs, 39 (36.4%) were simple (annuloplasty only), and the remaining 21 (19.6%) were more complex and included quadrangular resection, sliding annuloplasty, chordal transfer, and GoreTex (W.L. Gore & Assoc., Flagstaff, AZ) neochordae. Additional procedures included oversewing of left atrial appendage, tricuspid valve repair (ring annuloplasty in all cases), and closure of patent foramen ovale. Coronary artery bypass grafting was not performed in any of the cases.
Postoperative outcomes are summarized in Table 3. The 30-day mortality was 4.7% (n = 5). Complications included reoperation for bleeding (n = 6, 5.6%), stroke (n = 1, 0.9%), and wound infection (n = 2, 1.9%). Both wound infections were groin infections. Conversion to sternotomy was required in 1 patient (0.9%) owing to an acute type A dissection secondary to aortic occlusion with Chitwood clamp. The mean hospital stay was 9.6 ± 6.4 days. In follow-up, reoperation for failure of MV repair was performed in 4 patients (3.7%). Of those undergoing MV repair, 40 (66.7%) had no residual mitral regurgitation, 19 (31.7%) had mild residual regurgitation, and only 1 (1.7%) had moderate residual regurgitation (Fig 1). Survival at 1, 5, and 8 years was 89.4%, 76.3%, and 51.8%, respectively (Fig 2A). There were only 5 remaining cases for analysis at 8 years. There was no significant difference (p = 0.762) in long-term survival for mitral repair versus replacement (Fig 2B).
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Fig 2. (A) Long-term survival for all patients undergoing mitral valve (MV) surgery through port access right minithoracotomy after prior sternotomy. (B) Comparison of survival for same cohort for mitral valve repair versus replacement.
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Comment
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Reoperative MV surgery is associated with the potential for a number of complications, including injury to the right ventricle, injury to patent grafts (previous CABG), and bleeding. In a detailed review of the STS database, it was demonstrated that the risk of mortality for isolated MV replacement increased from 5.09% to 9.25% in the presence of a previous cardiac operation [1]. These findings were confirmed in a more recent review of the same database that demonstrated that reoperation was associated with significantly increased mortality for all valve operations (odds ratio 1.61; p < 0.001) [10]. In a recent review of 188 patients undergoing reoperation for failed MV repair for degenerative disease, Dumont and colleagues [11] report a mortality rate of 4.3%, all among patients having replacement.
Minimally invasive mitral surgery can be performed using a variety of approaches, has a number of advantages, and has been gaining increasing acceptance. In a review of 689 patients, including 353 minimally invasive MV repair/replacements performed through a lower ministernal incision, Cohn and colleagues [5] reported that minimally invasive surgery was associated with a mortality rate similar to that for open sternotomy cases, reduced length of intensive care unit and hospital stays, fewer blood transfusions, and a faster return to normality compared with conventional operative approaches [5]. Similarly, Yamada and colleagues [6] reported that minimally invasive cardiac surgery was associated with earlier recovery of daily activities and improved quality of life in the early perioperative period Casselman and associates [7], in reviewing 187 totally endoscopic MV repairs, reported that 93% of patients were highly satisfied with minimal postoperative pain and 98% believed their scar was esthetically pleasing. Moreover, this study confirmed the effectiveness and durability of this procedure, with a freedom from reoperation of 93.3% ± 2.6% at 4 years and a mean degree of mitral regurgitation at follow-up of zero. Greelish and colleagues [12] reported a similar freedom from reoperation of 92% at 5 years among 358 minimally invasive MV patients [8]. These reoperation rates are comparable to those of large series of mitral repair and replacement performed through a midline sternotomy [12].
These studies all described minimally invasive mitral surgery in patients without prior sternotomy. In the current study, we demonstrated that the port access right minithoracotomy approach to MV surgery in patients who have undergone prior sternotomy is safe and effective. We were able to perform this procedure with a 4.7% mortality and a 56.1% repair rate. These findings are comparable to those of other studies. Onnasch and coworkers [13] reported a 5.1% mortality rate and a 49% repair rate for 39 patients undergoing redo MV surgery. Bolotin and colleagues [14] compared MV surgery with either minimally invasive techniques (n = 38) or redo sternotomy (n = 33) for patients who had undergone prior sternotomy. That study confirmed that the minimally invasive approach was safe (mortality 5.7% and 5.9%, respectively; p = 0.976) and effective, with reduced postoperative intubation time (p = 0.008), reduced transfusion requirements (p = 0.001), and reduced hospital length of stay (p = 0.001) when compared with redo sternotomy.
A recent report from the Cleveland Clinic challenges the use of the right thoracotomy for MV surgery in patients with prior sternotomy [15]. The investigators compared 2,444 patients undergoing MV procedures through repeat median sternotomy, with 80 patients undergoing repeat cardiac surgery through right thoracotomy. The hospital mortality rate was similar between groups (6.7% versus 6.3%; p = 0.9). The stroke rate was significantly lower in the sternotomy group (2.7% versus 7.5%; p = 0.006). The exact reason for increased stroke with thoracotomy was not clear but was suspected to be due to retrograde atheroemboli from groin cannulation, air introduced during lapses in fibrillatory arrest, or difficulty deairing at the end of the case. Minimally invasive incisions were excluded from the study because they were developed only recently, encompass a variety of different approaches, and were used infrequently. Casselman and associates [16], conversely, recently reported the results of 80 mitral and tricuspid procedures through a right video-assisted approach after previous cardiac surgery. Operative mortality was 3.8% (European System for Cardiac Operative Risk Evaluation predicted a mortality of 16.0%), and neurologic events occurred in 2 patients (2.5%). Mitral valve repair was performed in 45%, MV replacement in 50%, and tricuspid valve replacement in 5%. There was 1 late reoperation at 5 years.
There was only 1 conversion to sternotomy for an acute type A dissection. Otherwise, it was possible to perform all cases through right thoracotomy. Contraindications to port access mitral surgery include lack of femoral arterial or venous access. Femoral arterial access problems can be overcome by using axillary arterial cannulation or bilateral cannulation of arteries with smaller arterial cannulas. That problem did not occur in our series. Extensive pleural adhesions could be prohibitive, but again, were not observed in this series.
There are several limitations to this study. It is a case series with no comparison cohort. Follow-up data regarding MV function are limited. However, the study does provide evidence that this procedure is safe and effective when compared with STS database data.
In summary, the port access approach to MV repair or replacement in patients who have had prior cardiac surgery through a midline sternotomy is safe and effective. Given the known risks associated with repeat sternotomy and documented patient preference for post access surgery, the port access approach may be the optimal approach to take with this challenging group of patients.
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Acknowledgments
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The authors are grateful to Katherine Cornelius and Mary McKenna for assistance in data collection and retrieval.
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References
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Abstract
Introduction
