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J Thorac Cardiovasc Surg 1998;115:255
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

Minimally invasive aortic valve surgery: Pocket AVR

To the Editor:

We read with interest the article by Benetti and associates on minimally inasive aortic valve replacement in the April 1997 issue of this Journal (1997;113:806-7). We are also doing various minimally invasive cardiac operations. We performed our first mitral valve replacement with a Heartport device (Heartport, Inc., Redwood City, Calif.) with the Stanford group ¹ in early 1996.

We started our project on minimally invasive aortic surgery in November 1996 by doing a feasibility study on cadavers. We found that we could view the aortic valve clearly from the small right thoracotomy via the second intercostal space. Since December 1996, we have used a similar approach to perform 13 minimally invasive aortic valve operations. We have termed our surgical approach "pocket aortic valve replacement" (pocket AVR) because the skin incision resembles the opening to the pocket on the right side of a shirt.

The patient is placed supine on the operating table with about a 30-degree left lateral decubitus tilt. Both arms are at his or her sides, and an external defibrillator is in place. A double-lumen endotracheal tube is inserted. A small transverse skin incision of about 7 cm is made over the right second intercostal space, depending on the build of the patient and position of the aortic root on the posteroanterior chest x-ray film. The third costal cartilage is either divided or excised. The right internal thoracic artery is preserved during the entry into the thoracic cavity.

A Finochietto sternal retractor is placed transversely to open the intercostal space. The pericardium is incised anterior to the right phrenic nerve. To improve the exposure of the aorta, the lower edge of the pericardium is retracted to the right by passing the sutures through large-bore cannulas that are introduced through the third and fifth intercostal spaces along the midaxillary line. This maneuver pulls the aorta slightly toward the right side. The upper edge of the pericardium is stitched to the skin. A DLP descending arch cannula (DLP Inc., Grand Rapids, Mich.) is used to cannulate the ascending aorta. A size 28 curved Polystan wire–reinforced venous cannula (Polystan A/S, Walgerholm, Varlose, Denmark) is introduced through a 11.5 mm Thoracoport device (United States Surgical Corporation, Norwalk, Conn.) via a lateral stab incision through the fifth or sixth intercostal space and inserted via the right atrial appendage. This incision will later be used for the chest tube. To further improve the view of the aortic root, a slight traction can be applied inferiorly on the venous cannula.

After cardiopulmonary bypass is established, a left ventricular vent is inserted via the right superior pulmonary vein. The aorta is then crossclamped and a transverse aortotomy is made. The cardioplegic solution is delivered into either the aortic root or the coronary ostia, with or without retrograde cardioplegia. The aortic valve is replaced or repaired in the usual manner.

The average skin incision was 7.3 cm (7.5 to 10.5 cm). All patients had aorta–right atrial cannulation except for the first patient, who had femoral artery–right atrial cannulation. Twelve of the 13 patients had aortic valve replacement, with the other having aortic repair and closure of a ventricular septal defect. The mean operative time was 2 hours 56 minutes (1 hour 55 minutes to 3 hours 45 minutes), and the mean cardiopulmonary bypass and crossclamp times were 101 minutes (83 to 119 minutes) and 69.5 minutes (57 to 85 minutes), respectively.

The outcome of the operations was encouraging. All the patients were weaned from cardiopulmonary bypass without any inotropic support. The mean extubation time was 5.3 hours (up to 11 hours), with three patients being extubated on the operating table. The mean blood loss was 490 ml (140 to 900 ml), and only two patients required blood transfusion to correct a low hematocrit value. The mean intensive care unit stay and ward stay were 27 hours (15 to 45 hours) and 5.5 days (4 to 7 days), respectively. According to a pain scale of 0 to 10 (0 for no pain; 10 for very severe pain), the mean pain score was 3.6 (0 to 7). The postoperative transesophageal and transthoracic echocardiograms showed a good surgical result. All the patients were satisfied with the surgical approach. The follow-up times range from 4 weeks to 5 months. All patients are doing well and in New York Heart Association functional class I.

We believe that the "pocket incision" is a good approach for aortic valve replacement. We use only standard surgical instruments and aorta–right atrial cannulation. The right internal thoracic artery is preserved during the operation. When compared with our patients with midline sternotomy, patients undergoing minimally invasive valve surgery had shorter intensive care unit and hospital stays, which can result in cost savings. The incision also offers a good cosmetic result, with excellent patient satisfaction.

We have extended our "pocket incision" approach for the closure of atrial septal defects. To date we have used this approach to close atrial septal defects in seven patients, with no problems.

Department of Cardiothoracic Surgery
National Heart Institute145 Jalan Tun Razak
50400 Kuala Lumpur, Malaysia References

1. Pompili MF, Yakub A, Siegel LC, Stevens JH, Awang Y, et al. Port-access mitral replacement: initial clinical experience. Circulation 1996;94(Suppl):I533.
   

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