[Minimally invasive aortic valve replacement]

Surgical Management of Minimally Invasive Aortic Valve Operations

Although there is still a role for conventional sternotomy for aortic valve replacement, minimally invasive techniques are increasing in popularity and may benefit the patient with shorter postoperative course, less morbidity, and decreased overall cost. Additionally, transcatheter procedures have recently shown promising results in high-risk patients. This article provides an overview of the development of minimally invasive aortic valve operations, including a brief history of minimally invasive approaches, surgical considerations during minimally invasive aortic valve replacement, and the technical approach to performing a hemisternotomy with aortic valve replacement. In addition, the authors review transcatheter techniques, including aortic valve replacement via a sheath placed in the apex of the left ventricle or through a sheath placed in the femoral vessels. Finally, the exciting results of the PARTNER trial and the effect of these results on the future of aortic valve surgery are discussed.

Aortic Valve Replacement through Right Minithoracotomy in 306 Consecutive Patients

Objective

To define the role and early results of aortic valve surgery through a right minithoracotomy.

Methods

A retrospective analysis was performed on 306 consecutive patients undergoing aortic valve replacement through an 8-cm right minithoracotomy in the second intercostal space. The initial experience was included. The right second and third ribs were detached from the sternum in most cases and repaired at the end of each case. Most operations were performed using anterograde and retrograde cardioplegic arrest with percutaneous femoral venous cannulation and direct aortic cannulation through the incision. Standard instruments were used with direct digital knot tying.

Results

Mean age was 65 ± 14 (range, 20–90) years. Aortic valve disease cause was calcific disease in 160 of 306 (52%) patients, bicuspid disease in 95 of 306 (31%) patients, and endocarditis in 9 of 306 (3%) patients. Previous cardiac surgery was present in 13 of 306 (4%) patients. Biologic prostheses were used in 240 of 306 (78%) patients. Median valve size was 23 mm. Mean clamp times and pump times were 103 ± 26 and 158 ± 35 minutes, respectively. Median postoperative length of stay was 5 days. Thirty-day mortality was found in 4 of 306 (1%) cases. There were no deep wound infections or mediastinitis. Stroke occurred in 5 of 306 (1.6%) patients, and new pacemaker required in 11 of 306 (4%) patients. Reoperation for bleeding occurred in 2 of 306 (1%) patients. Conversion to median sternotomy occurred in 15 of 306 (5%) patients caused by chest wall anatomy (n = 7), bleeding (n = 3), coronary disease (n = 2), or aortic disease (n = 3). Patients were allowed to return to driving or preoperative activity in 2 weeks. With a mean follow-up of 2.8 ± 2.2 years, one patient required reoperation for aortic root disease.

Conclusions

Right minithoracotomy is a safe but limited alternative to sternotomy in isolated aortic valve replacement. This approach may be particularly valuable in some higher risk, elderly patients and opens options for a hybrid approach combined with percutaneous coronary angioplasty.

Treatment of ascending aorta disease with Bentall-De Bono operation using a mini-invasive approach

BACKGROUND

Use of minimally invasive approaches in cardiac surgery is increasing, obtaining a wide consensus and representing a challenging alternative technique for many surgeons. We report our experience of the treatment of ascending aorta disease using the Bentall-De Bono procedure through a minimally invasive approach.

METHODS

Between September 1997 and June 2005 at 'Policlinico San Matteo', Pavia, we treated 40 patients affected by ascending aorta disease and aortic valve regurgitation using a Bentall-De Bono procedure through a minimally invasive approach, by means of a reversed T or J ministernotomy. Data were analyzed retrospectively. Thirty patients were men. Short-term and mid-term mortality and peroperative complications were analyzed.

RESULTS

None of the patients died during the 30-day postoperative period. The mean ICU and length of stay times were 3.3 +/- 8.2 and 9.3 +/- 7.2 days, respectively. Six patients (15%) had one or more postoperative complications. One patient (2.5%) underwent early reoperation for bleeding. None underwent a procedure-related reoperation. Mechanical ventilation was longer than 48 h in five patients (12.5%). The mean follow-up was 38.4 +/- 31 months. Survival at 1, 3 and 5 years was, respectively, 94.1, 90.6 and 90.6%. At the end of the follow-up, there were 37 survivors. Twenty-seven (73%) patients were in New York Heart Association I, six (16%) were in New York Heart Association II and four (11%) were in New York Heart Association III.

CONCLUSION

Reversed T or J ministernotomy is a feasible and secure alternative to complete sternotomy. The short incision may enhance the outcome and does not affect the survival, offering proper access to the anatomic structures.

Reversed "C" ministernotomy for aortic valve replacement

The technique of aortic valve replacement through a reversed "C" sternotomy incision is described. The sternal incision extends between the second and the fifth intercostal space and provides excellent exposure of the ascending aorta, the aortic root, and the right atrial appendage. The procedure can be performed with standard cannulation for cardiopulmonary bypass and conventional surgical instruments.

Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study

BACKGROUND

Minimally invasive aortic valve replacement reduces surgical trauma and, supposedly, postoperative pain, blood loss, and length of stay. A prospective, randomized study was designed to prove these theoretical advantages.

METHODS

Forty patients undergoing isolated, elective aortic valve replacement were randomized into two equal groups. Patients in group M underwent aortic valve replacement through a ministernotomy (reversed L or reversed C). In group S, a median sternotomy was used. The anesthetic and surgical protocol was identical for both groups. Pain was evaluated on a daily basis. Pulmonary function tests were performed preoperatively and before hospital discharge in all patients.

RESULTS

There were two deaths in each group. Cross-clamp time was longer in group M: 70 +/- 19 minutes versus 51 +/- 13 minutes in group S (p = 0.005). There were no statistically significant differences between groups M and S in pump time (95 +/- 20 minutes versus 83 +/- 19 minutes), extubation time (9.9 hours in both groups), chest drainage (479 +/- 274 mL/L 24 hours versus 355 +/- 159 mL/24 hours), transfusion requirements (27% in both groups), pain evaluation (1.34 +/- 1.3 versus 2.15 +/- 1.5), length of stay (6.2 +/- 2.3 days versus 6.3 +/- 2.5 days), and cosmetic appraisal. Forced vital capacity decreased 26% from preoperative reference values in group M and 33% in group S (p = not significant). Forced expiratory volume in 1 second decreased 22% and 35%, respectively (p = not significant).

CONCLUSIONS

This study has failed to prove the theoretical advantages of minimally invasive aortic valve replacement. With this technique, cross-clamp time is longer than with a median sternotomy.