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Ann Thorac Surg 1999;67:1333
© 1999 The Society of Thoracic Surgeons
a Department of Surgery, East Carolina University School of Medicine, Greenville, North Carolina27858, USA
Invited commentary
Dr Karagoz and colleagues have compared the subxiphoid incision to both a ministernotomy and a full sternotomy for mitral valve replacement. In their series they either repaired or replaced 56 mitral valves using a lower ministernotomy with subxiphoid entry. Although each of the other patient cohorts was relatively small (full sternotomy, n = 29, superior ministernotomy, n = 11), they have made valid comparisons, and determined that little difference existed between the approaches regarding patient recovery and postoperative pain. However, when compared with a full sternotomy, the subxiphoid approach did render less perioperative bleeding. Also, they consider their method more cosmetically acceptable than either the upper ministernotomy or full sternal division. Through the subxiphoid approach, these surgeons were able to do almost any type of mitral operation safely, including repairs and multivalve operations. However, the number of repairs (n = 9) was small and the complexity of these repairs minimal.
This article highlights the unresolved issue of the best approach to the heart for mitral valve replacement as most techniques now render safe effective operations. We all are looking for the method that allows the most rapid restoration of "normalcy" while preserving the best operation possible. With the advent of minimally invasive approaches, some older thoracic incisions, popularized by our cardiac forefathers, have been modified, ie, the minithoracotomy. Our group has chosen this latter method for isolated mitral valve replacement, as we truly believe this to be less invasive than sternal or subxiphoid methods. Moreover, a very small atriotomy can be made in comparison to the cardiac incision required herein or with many ministernotomies. Having said this, we also are becoming more impressed with how minimally invasive procedures have encouraged many of us to progressively mollify or "soften" our full sternotomy operations. When surgeons develop a minimally invasive operative philosophy, successive full sternotomies seems to be done with less trauma; that is, with less skin incision, less sternal spreading, less tissue dissection, greater cell saving, and yes, in many circumstances less pump time. Thus, this surgeon is not surprised by the findings of Dr Karagoz, as his last sternotomy operation must have been different than ones early in his series. Assuredly, his last full sternotomy must have been less traumatic after he began minimally invasive mitral valve replacements. Dr Karagoz has echoed a cry that continues to be heard: Is minimally invasive mitral replacements worth it? Is there really less pain and faster recovery? The answer will only be determined by a large and truly randomized study of all of these methods that include the 4 to 6-cm minithoracotomy, which we believe to have primacy for patient recovery. To believe is not enough—cardiothoracic surgeons still must prove!
Related Article
Ann. Thorac. Surg. 1999 67: 1328-1332.
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