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J Thorac Cardiovasc Surg 1998;115:246-247
© 1998 Mosby, Inc.
BRIEF COMMUNICATIONS |
Brisbane, Australia
From the Department of Cardiac Surgery, The Prince CharlesHospital, Brisbane, Australia.
Received for publication July 14, 1997 Accepted for publication August 18, 1997 Address for reprints: Robert Tam, FRACS, Department of CardiacSurgery, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Australia,Q 4032.
Navia and Cosgrove
1have described a minimally invasive approach to mitral valve surgery. This hasthe disadvantages of sacrificing the internal thoracic artery, resecting twocostal cartilages leaving a flail segment, and requiring femoral arterycannulation to establish cardiopulmonary bypass. Others approach the aortic andmitral valves via upper partial sternotomy with either a partial or completehorizontal transection of the sternum. This causes more disruption to thesternum and risks injuring the internal thoracic artery. The sternum ispotentially unstable despite wiring. Konertz and colleagues 2 have described a paramediansternotomy.
Using an upper hemisternotomy and a modified Guiraudon verticaltransatrial septal approach, 3we describe an approach to mitral valve surgery in which standard equipment isused.
Technique. External defibrillator padsare placed on the left side of the chest wall and posteriorly. An incision ismade below the sternal notch to the fourth intercostal space. The upper part ofthe sternum is divided to the fourth intercostal space. The sternum is nottransected. A small sternal retractor is used. Traction on pericardial suturesexposes the ascending aorta and right atrium.
Partial cardiopulmonary bypass is established after aortic and superiorvena cava cannulation. The right atrium collapses and the inferior vena cava iscannulated posterolaterally in the right atrium. The ascending aorta isencircled with a tape and crossclamped. Antegrade cardioplegia is administered.The superior and inferior venae cavae are snared (Fig. 1). An incision is made starting from themedial aspect of the right atrial appendage and extending cephalad onto the domeof the left atrium. A caudal extension of the right atrial incision toward theinferior vena cava is not necessary. The left atrial incision is extended behindthe aorta. The sinoatrial nodal artery is avoided, if possible, by incisingparallel to it (Fig. 2). A vertical septal incision is madeextending to the foramen ovale.
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The left atrium is closed starting from the dome to the interatrialseptum, with care taken to avoid the sinoatrial artery. Starting caudally, asecond suture closes the interatrial septum and the right atrium. With the useof transesophageal echocardiographic monitoring, air is evacuated through theaortic root.
Results. Ten patients had surgery withthis approach. Four patients had mitral valve repair, five had valvereplacement, and one had combined mitral and aortic valve replacement. Themedian age was 56 years (range 45 to 77 years). The median aortic crossclamptime was 59 minutes (range 39 to 155 minutes), with a bypass time of 81 minutes(range 61 to 194 minutes). Patients were extubated at a median of 7 hours (range2 to 14 hours). Stay in the intensive care unit was a median of 2 days (range 1to 5 days), with a hospital stay of 6 days median (range 4 to 21 days).
One patient died, a 54-year-old woman who 20 years previously had amitral valvotomy via a left thoracotomy. She had recurrent mitral stenosis withsevere pulmonary hypertension. A thrombus was removed from the left atrium. Atthe end of the procedure she was noted to have severe right ventriculardysfunction, probably resulting from embolism to the right coronary artery. Afull sternotomy was performed and a right ventricular assist device wasinserted. Despite this she was unable to be weaned from bypass.
One patient had a delayed pericardial effusion that was drainedpercutaneously. Four patients had junctional rhythm in the postoperative period,but this did not persist. Two patients had atrial fibrillation. No strokes orwound infections occurred.
Comment. Our experience in minimallyinvasive mitral valve surgery demonstrates that it can be performed safely andeffectively. The reduced trauma has potential benefits of less pain, shorterrecovery time, and shorter hospital stay. Concern regarding the incidence ofjunctional arrhythmia has been raised. 4This can be minimized by avoiding division of the sinoatrial artery. The sinusnode artery does not seem necessary to sustain normal sinus node function, 5 as seen in cardiac transplantation.
Hemisternotomy without transection of the sternum gives excellent accessto the mitral valve, allowing the full range of mitral valve surgery with thebenefits of a smaller incision. The sternum is inherently stable. Our approachis easily converted to full sternotomy if the need arises, without the sternumbeing in multiple segments. Patients are pleased with the small wound and maywell drive the application of this technique.
Footnotes
J Thorac Cardiovasc Surg 1998;115:246-7
References
This article has been cited by other articles:
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  T. Gudbjartsson, S. Aranki, and L. H. Cohn Mechanical/Bioprosthetic Mitral Valve Replacement Card. Surg. Adult, January 1, 2003; 2(2003): 951 - 986. [Full Text]
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 R. Tam Kien Wing, C. Smith, G. Wright-Smith, A. A Almeida, and M. Davidson Minimally Invasive Excision of Left Atrial Appendage Hemangioma via Hemisternotomy Asian Cardiovasc Thorac Ann, December 1, 1998; 6(4): 316 - 317. [Abstract] [Full Text] [PDF]
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