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Ann Thorac Surg 2007;84:1071
© 2007 The Society of Thoracic Surgeons

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Correspondence

Minimally Invasive Aortic Valve Replacement: A Word of Caution

Department of Cardiac Surgery, Cardiology Institute, University of Debrecen, Moricz Zs krt 22, Debrecen, H-4032 Hungary

(Email: zsoltlnagy{at}hotmail.com).

To the Editor:

We read with great interest the article by Bakir and colleagues [1]. At our department, the upper partial "J" sternotomy for aortic valve replacement was introduced in late 1996. From January 1997 until December 2001, 205 of 757 patients for isolated primary aortic valve replacement had minimal access sternotomies (27%). The average age of the 205 patients was 57.2 ± 13 years. In all cases conventional cardiopulmonary bypass was established, cannulating the ascending aorta and venous return from the right atrium, using 29/29F two stage venous cannula and vacuum-assisted drainage. Sixty-five bioprostheses (including 13 stentless valves) and 126 mechanical valves were implanted. Twelve other patients had successful aortic valve repair, and there was one subvalular membrane resection and also one myectomy from the left ventricular outflow tact. The operation included annular enlargement with pericardial patch in four cases, and the reduction of the dilated ascending aorta in nine cases. Our hospital mortality was 1.5%.

The authors have discussed the difficulties with removing the air from the heart through the mini sternotomy. In our experience, removal of air through the aortotomy with aortic root venting and partial clamping of the ascending aorta gave sufficient clinical results with no significant neurologic problems during the postoperative course. However, venting the heart could be difficult through the mini incision. The only comfortable way of venting the heart, if necessary, is to place the vent in the main pulmonary artery, which unfortunately does not work as well as the left ventricular vent (either through the apex or through the left superior pulmonary vein). Also, defibrillating the heart may be troublesome in some cases. In our series there were 3 patients with a massive left ventricular hypertrophy and a body mass index greater than 30 who could not be defibrillated using the external defibrillation pads; therefore these patients required urgent conversion to a full median sternotomy. Unfortunately 1 of these patients required inotropic support medication and an intraaortic balloon pump to discontinue the cardiopulmonary bypass, and this patient subsequently died from multiorgan failure.

Our experience supports the finding that aortic valve replacement with all kinds of prostheses including subvalvular and supravalvular procedures can be performed through the partial upper "J" sternotomy, but careful patient selection is mandatory. However, as with other authors [2, 3], we could not find specific advantage of the mini approach in comparison with the conventional sternotomy in our series; therefore the procedure was slowly abandoned in 2002.

	References

Top References

 

1. Bakir I, Casselman FP, Wellens F, et al. Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients Ann Thorac Surg 2006;81:1599-1604.[Abstract/Free Full Text]
2. Masiello P, Coscioni E, Panza A, Triumbari F, Presiosi G, DiBenedetto G. Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy Cardiovasc Surg 2002;10:333-338.[Medline]
3. Corbi P, Rahmati M, Donal E, et al. Prospective comparison of minimally invasive and standard techniques for aortic valve replacement: initial experience in the first hundred patients J Card Surg 2003;18:133-139.[Medline]

This article has been cited by other articles:

				F. P. Casselman, I. Bakir, F. Wellens, I. Degrieck, F. Van Praet, and H. Vanermen Reply Ann. Thorac. Surg., September 1, 2007; 84(3): 1071 - 1072. [Full Text] [PDF]

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): Zsolt L. Nagy Arpad Peterffy Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nagy, Z. L. Articles by Peterffy, A. Search for Related Content PubMed PubMed Citation Articles by Nagy, Z. L. Articles by Peterffy, A. Related Collections Valve disease Related Article