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Original Articles: Adult Cardiac

Invited Commentary

Department of Cardiac Surgery, Leipzig Heart Center, Struempellstrasse 39, Leipzig 04289, Germany

(Email: michael.borger{at}med.uni-leipzig.de).

Lee and colleagues [1] have reviewed their 11-year period experience with 141 consecutive patients who underwent minimally invasive tricuspid valve (TV) surgery through a mini-thoracotomy. Nearly three-quarters of the patients underwent concomitant mitral valve surgery. The authors achieved very good results in these frequently challenging patients, with a perioperative mortality rate of 2% and an acceptable re-thoracotomy rate for bleeding of 6%. Long-term results were favorable, with no reoperations for TV disease, but it should be noted that echocardiographic data was available in less than one-half of the patients.

One interesting observation from the current study was a significantly higher stroke rate in patients undergoing femoral artery cannulation in comparison with those undergoing direct cannulation of the ascending aorta. This observation, and improvements in port-access technology, resulted in the authors abandoning femoral artery cannulation in more recent years. However, experience from our center with more than 2,500 patients undergoing minimal invasive mitral valve surgery would suggest that femoral cannulation is very safe in patients without peripheral vascular disease. In addition, port-access cannulation of the ascending aorta can be technically challenging and can result in its own catastrophic events.

The authors found that the mini-thoracotomy approach provided a very good view of the TV anatomy and was particularly helpful in patients with a history of previous cardiac surgery. They were able to avoid snaring the cavae in several redo patients by minimizing vacuum-assisted venous drainage. Although this technical tip can be very helpful in patients with extensive adhesions around the cavae, care must be taken to avoid excessive venous air because of its known ability to result in cerebral microembolization and possible effects on neuropsychological function [2].

Although the current study may be the largest to date on minimally invasive TV surgery, the conclusions that can be drawn remain limited by the lack of a control group. Therefore, it is impossible to make comparisons with conventional TV surgery through a sternotomy. A review of the literature, however, would suggest that perioperative morbidity and mortality from the current series compare very favorably with those series using a conventional sternotomy approach. Two possible exceptions would be the prolonged cardiopulmonary bypass (CPB) times (mean, 216 minutes) and relatively low TV repair rate (61%) noted in the series from Lee and colleagues. The low morbidity and mortality rates would suggest that the patients tolerated the prolonged CPB times without major problems, but formal neuropsychological testing was not performed. The relatively low TV repair rate, particularly in view of the fact that 90% of patients had functional tricuspid regurgitation, is potentially worrisome because many studies have shown an increased perioperative and long-term complication rate associated with TV replacement. The authors attributed their decreased TV repair rate to a relatively low threshold for performing TV replacement to lower the risk of recurrent tricuspid regurgitation. However, data from other centers where a large number of minimally invasive TV operations were performed would be helpful to determine if a decreased TV repair is somehow related to the surgical technique itself.

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1. Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience Ann Thorac Surg 2009;88:1845-1850.[Abstract/Free Full Text]
2. Borger MA, Peniston CM, Weisel RD, Vasiliou M, Green REA, Feindel CM. Neuropsychological impairment after coronary bypass surgery: effect of gaseous emboli during perfusionist interventions J Thorac Cardiovasc Surg 2001;121:743-749.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael A. Borger Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Borger, M. A. Search for Related Content PubMed PubMed Citation Articles by Borger, M. A. Related Collections Valve disease Related Article