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J Thorac Cardiovasc Surg 2004;127:1026-1032
© 2004 The American Association for Thoracic Surgery

Cardiopulmonary support and physiology

Minimally invasive technology for mitral valve surgery via left thoracotomy: Experience with forty cases

Paul C. Saunders, MDa, Eugene A. Grossi, MDa,*, Ram Sharony, MDa, Charles F. Schwartz, MDa, Greg H. Ribakove, MDa, Alfred T. Culliford, MDa, Julie Delianides, MSNa, F. Gregory Baumann, PhDa, Aubrey C. Galloway, MDa, Stephen B. Colvin, MDa

a Department of Surgery, Division of Cardiothoracic Surgery, New York University School of Medicine, New York, NY, USA

Read at the Twenty-ninth Annual Meeting of The Western Thoracic Surgical Association, Carlsbad, Calif, June 18-21, 2003.

Received for publication June 16, 2003; revisions received August 11, 2003; accepted for publication August 25, 2003.

* Address for reprints: Eugene A. Grossi, MD, NYU Medical Center, Suite 9-V, 530 First Ave, New York, NY 10016, USA
grossi{at}cv.med.nyu.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusion
 Discussion
 References
 
BACKGROUND: Recent evolution of minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery. These same technological advances have also made the left posterior minithoracotomy approach attractive in complex mitral procedures.

METHODS: From 1996 to 2003, 921 isolated mitral valve procedures were performed without sternotomy; 40 (4.3%) of these were performed via left posterior minithoracotomy. In the left posterior minithoracotomy group, ages ranged from 18 to 84 years; 36 patients had had previous cardiac surgery (9 on >=2 occasions). Other factors precluding right thoracotomy included mastectomy/radiation and pectus excavatum.

RESULTS: Arterial perfusion was via femoral artery (n = 26) or descending aorta (n = 14); long femoral venous cannulas with vacuum-assisted drainage were used in 39 procedures. Two patients had direct aortic crossclamping, 18 had hypothermic fibrillation, and 20 had balloon endoaortic occlusion. The mean crossclamp and bypass times were 81.9 and 117.2 minutes, respectively. Hospital mortality was 5.0% (2/40); both deaths occurred in octogenarians. There were no injuries to bypass grafts or conversions to sternotomy. Complications included perioperative stroke (2/40; 5.0%), bleeding (2/40; 5.0%), and respiratory failure (1/40; 2.5%); 28 patients (70%) had no postoperative complications. There was no incidence of perioperative myocardial infarction, renal failure, sepsis, or wound infection. The median length of stay was 7 days.

CONCLUSIONS: Advances in minimally invasive cardiac surgery technology are readily adaptable to a left-sided minithoracotomy approach to the mitral valve. The left posterior minithoracotomy approach is a valuable option in complicated reoperative mitral procedures with acceptable perioperative morbidity and mortality.

Since the advent of minimally invasive cardiac surgery, the right thoracotomy approach has become widely accepted for mitral valve procedures.1-4 The combination of safe cannulation techniques and the excellent exposure attainable from the right chest has made minimally invasive mitral valve surgery an increasingly attractive option. Minimally invasive mitral surgery has been associated with mortality rates of 1.2% to 5.8%, along with less morbidity and a shorter length of stay compared with the conventional sternotomy approach.1,2 Additionally, avoiding traditional sternotomy is often associated with enhanced recovery5,6 and better patient satisfaction.7

For some patients, however, a right thoracotomy approach is relatively contraindicated. Most often this is because of a previous cardiac or thoracic operation, but prior right-sided mastectomy with chest wall radiation may also preclude a right-sided approach. In such cases, minimally invasive nonsternotomy mitral valve procedures are still possible by using a left posterior minithoracotomy (LPMT). The left-sided approach also offers some unique advantages, including a wider angle of vision and a shorter distance for the surgeon to the mitral valve.8

Recent reports have shown the left thoracotomy approach for mitral valve surgery to be safe, although the numbers of patients in these studies have been small.8-11 We examined our recent institutional experience with LPMT mitral surgery and its evolution with minimally invasive technology.


   Methods
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 Methods
Results
 Discussion
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 Discussion
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Patient clinical characteristics
From 1996 to 2003, 921 mitral valve procedures were performed without sternotomy; 40 (4.3%) of these were performed via LPMT. Patient clinical characteristics are summarized in Table 1. The mean age within the LPMT group was 56.5 years (range, 18-84 years). Thirty-six patients had undergone previous cardiac operations, 7 had undergone 2 prior operations, and 2 patients had undergone 3 or more prior operations; the mean time from the last operation was 44.2 months. Data on prior cardiac operations are included in Table 2. Twenty-one patients had undergone a previous right thoracotomy. Other factors that precluded right thoracotomy included mastectomy/radiation (n = 3) and pectus excavatum (n = 1). Mitral valve pathology in this group included mitral insufficiency in 25 patients (62.5%), mitral stenosis in 2 patients (5%), and prosthetic valve dysfunction in 5 patients (12.5%). Endocarditis was present in 7 patients (17.5%).


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  		TABLE 1. Patient clinical characteristics (n = 40)

 

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  		TABLE 2. Previous cardiac procedures

 
Surgical approach
Mitral valve procedures were performed with the patient in right lateral decubitus position and with single-lung ventilation techniques. Transesophageal echocardiography (TEE) was performed routinely in all cases. A left posterolateral minithoracotomy incision (approximately 6-8 cm) was made in the fourth, fifth, or sixth intercostal space, and the lung was retracted inferiorly to expose the heart. Figure 1 shows the incision and typical exposure of the descending aorta for direct cannulation. The pericardium was opened posterior to the phrenic nerve and retracted with retention sutures, and the left atrium was opened along the base of the left atrial appendage. Intra-atrial retractors were positioned by using a self-retaining retractor, providing exposure of the mitral valve (Figure 2). Standard mitral repair and replacement techniques were used, and the operative field was flooded with CO2. After the mitral procedure, the left atrium was closed in 2 layers with 3-0 Prolene sutures (Ethicon, Inc, Somerville, NJ). Deairing was achieved through a transvalvular vent placed through the atriotomy and optionally via a needle placed in the left ventricular apex. Valvular function, myocardial performance, and intracardiac deairing were monitored with TEE.



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  		Figure 1. Left posterior minithoracotomy with direct descending aortic cannulation.

 


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  		Figure 2. Surgeon's view of the left atrial exposure. Note that the mitral valve orientation is upside down, with the posterior annulus anterior, as compared with the orientation seen with the sternotomy and right thoracotomy approaches.

 
Perfusion technique
Either femoral or direct descending aortic arterial cannulation was used; vacuum-assisted venous drainage was used routinely. When both femoral arterial and venous cannulation were used, a short (approximately 3 cm) transverse left groin incision allowed exposure of the left femoral artery and vein. In these patients, a Heartport arterial cannula (CardioVations; Ethicon) was used, and a 22F long venous cannula (CardioVations) was placed through an anterior pursestring in the femoral vein by using the Seldinger technique. TEE guidance was used to verify arterial and venous guidewires and position the endoclamp and distal tip of the venous cannula.12 In those patients in whom central aortic cannulation was used, the descending aorta was cannulated directly, and a long venous cannula was percutaneously placed through the left femoral vein.

Myocardial protection
Myocardial protection strategies included either aortic occlusion with retrograde cardioplegia or perfused cold fibrillation (22°C-25°C). When endoaortic balloon clamp technology was used, cardioplegia was delivered either retrograde via a transjugular coronary sinus catheter or antegrade via the endoclamp catheter.

Data collection
All data were prospectively collected by trained nurse clinicians and entered into an institutional database. The database conforms to the definitions used by the New York State Cardiac Surgery Reporting System, an audited data-collection instrument used to record and analyze all cardiac operations performed in New York. Follow-up survival was ascertained from the Social Security Death Index.

Data were retrospectively analyzed with SPSS statistical software (version 11; SPSS, Inc, Chicago, Ill). Results are expressed as the mean ± SD unless otherwise indicated.


   Results
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Discussion
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A summary of operative techniques is found in Table 3. Half of the operations (20/40) were performed through the sixth intercostal space; there were no conversions to sternotomy. Femoral arterial cannulation was used in 65% (26/40) of patients, and descending aortic cannulation was used in the remainder. Femoral venous cannulation was used in all 40 patients. In the first operation performed (without vacuum assistance), femoral venous drainage was augmented with an additional pulmonary artery cannula. Endoaortic balloon occlusion was used in 50% (20/40), and retrograde cardioplegia was given via transjugular coronary sinus catheter in 9 of these (45%). Two early patients had direct aortic clamping. Cold perfusion and fibrillation were used in 18 patients. The mean bypass time was 117.2 ± 35 minutes, and the mean crossclamp time (when used; n = 22) was 81.9 ± 22 minutes.


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  		TABLE 3. Operative techniques (n = 40)

 
In the 15 operations performed since 2001, descending aortic cannulation was used in 87% (13/15), and similarly 87% (13/15) were performed with hypothermic fibrillation. All 15 of these operations used CO2 in the operative field, and the mean bypass time among this group was 27 minutes shorter than before 2001 (102.1 ± 27.5 minutes vs 129.8 ± 35.6 minutes; P = .006).

Hospital mortality occurred in 2 patients (5%), both octogenarians. One death occurred after an intraoperative posterior ventricular wall rupture in a patient who had undergone previous aortic valve replacement and coronary artery bypass grafting; the other death was associated with a perioperative stroke. Among the 36 patients undergoing reoperative operations, the mortality was 2.8% (1/36). With 95% follow-up, there has been 1 additional postoperative death, which took place 1 year after surgery. Postoperative morbidity is listed in Table 4. Postoperative stroke occurred in 7.5% (3/40); 2 strokes occurred perioperatively, and 1 occurred 1 week after surgery. Two patients underwent reoperation for bleeding. There were no reported instances of exposure injuries to cardiac structures or previous bypass grafts, aortic dissections, or deep chest wound infections. In 28 (70%) of 40 patients, there were no major complications. The median hospital length of stay was 7.0 days.


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  		TABLE 4. Postoperative morbidity and mortality (n = 40)

 

   Discussion
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 Discussion
Conclusion
 Discussion
References
 
This experience represents a large contemporary series of mitral valve operations with a left thoracotomy approach. The left-sided approach has existed for cardiac procedures since 1910, when Alexis Carrel13 proposed it for a coronary artery bypass from the thoracic aorta. Some of the earliest mitral valve interventions were also performed with this approach; in the 1960s, mitral valvuloplasties were commonly approached from the left side.14,15 However, as median sternotomy became the standard approach for cardiac operations, the left thoracotomy fell out of favor.16

The 1990s saw an explosion of minimally invasive techniques in cardiac operations, fueled by new technology and driven by the desire for shorter hospital stays and improved patient satisfaction. Minimally invasive approaches for both coronary artery bypass and valve surgery became widely performed at many centers around the world,7,17,18 and, by using port access technology, mitral valve surgery via right thoracotomy has gained popularity.4,19,20 At our institution and others, the approach of choice to the mitral valve is the right anterior minithoracotomy approach.21

The potential of minimally invasive approaches for reoperative mitral valve surgery has been explored as well.22,23 Avoidance of reoperative sternotomy has allowed for shorter hospital stays, earlier return to work, and fewer transfusions, with morbidity and mortality similar to those of sternotomy.24 The left thoracotomy approach has been advocated for reoperative coronary artery bypass graft by a number of centers.25-27 Grosner and colleagues28 and Lajos and associates29 have reported a large series of 90 left thoracotomy coronary artery bypass graft patients followed up over 10 years; they cite the advantages of safer exposure in the setting of patent bypass grafts with similar morbidity and mortality.

Using left thoracotomy approaches, Hughes and colleagues11 reported a case of combined transmyocardial revascularization and mitral valve replacement, and Pratt and colleagues9 described a mitral replacement in a patient who had previously undergone esophagogastrectomy with a substernal gastric conduit. Combined coronary artery bypass graft and mitral procedures using a left-sided approach have been reported.30 Van Nooten and colleagues10 reported 10 cases of reoperative mitral valve procedures that used a left thoracotomy, peripheral cannulation, and an endoclamp. Repossini and colleagues8 reported on 11 patients who underwent mitral valve operations with left thoracotomy, all via femoral cannulation with direct aortic crossclamping. However, this series contained only 1 patient undergoing reoperation, which, in our experience, makes anatomic dissection of the aorta for direct clamping more adventurous.

In our series of 40 patients, the minimally invasive technique has evolved since its initial use in 1996. In the early experience, all cannulation was performed via the femoral vessels, most cases were performed with endoaortic balloon clamps, and transjugular coronary sinus catheters were frequently used for the administration of retrograde cardioplegia. In our more recent experience, most cases have been performed more simply by using hypothermic fibrillation and direct aortic cannulation. With central aortic cannulation, the issues of obstructive peripheral vascular disease, small femoral arterial size (particularly in women), and possible groin complications have been avoided.31 With the routine use of vacuum-assisted drainage, long venous cannulation achieves excellent drainage while minimizing the risk of gaseous microemboli.32 Performing operations under hypothermic fibrillation avoids the use of the balloon endoclamp,33 which can be more difficult to correct in the right lateral decubitus position without direct access to the ascending aorta. However, the presence of moderate aortic insufficiency remains an indication for the endoclamp technique. Self-retaining intra-atrial retractors, which are routinely used for all minimally invasive mitral procedures, allow for optimal exposure through a small incision.

The evolution of this technique has been driven by increased experience with less-invasive strategies and greater comfort with the technology used. In its current form, the left thoracotomy approach is simpler and more adaptable to each individual patient than in its early phases. As a result, the mean cardiopulmonary bypass time has decreased by approximately 30 minutes since 2001.

This series of patients included 36 patients undergoing reoperative mitral valve operations, 9 of whom had undergone multiple previous procedures. Our experience has shown this approach to be safe and reproducible, with acceptable morbidity and mortality in this high-risk subset of patients, and, significantly, there were no exposure injuries to cardiac structures or bypass grafts. Because the number of reoperative valve procedures continues to increase, safe approaches for reoperative valve operations are increasingly important.

As minimally invasive cardiac surgery begins to involve more endoscopic and robotic technology, the left thoracotomy approach may also have specific advantages of its own. By allowing access to the descending aorta for placement of proximal anastomoses, a left-sided approach may facilitate combined mitral and coronary procedures by using endoscopic or robotic techniques.34

There are some disadvantages inherent in a left thoracotomy, however, most notably the poor access to the ascending aorta for direct crossclamping, especially in the reoperative setting. Also, the orientation of the mitral valve from this exposure is such that it is inverted compared with that achieved from the right side.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusion
Discussion
 References
 
Advances in minimally invasive cardiac surgery technology are readily adaptable to a left-sided minithoracotomy approach to the mitral valve. LPMT is a valuable option in complicated reoperative mitral valve procedures, with acceptable perioperative morbidity and mortality.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Conclusion
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References
 
Dr James Fann (Stanford, Calif). Dr Saunders, New York University has been one of the leaders in minimally invasive cardiac surgery and has indeed advanced our knowledge of mitral valve surgery by employing innovative techniques. I want to congratulate you and your colleagues on the presentation and the use of limited left thoracotomy approach for again bringing to our attention the use of this unique approach.

Given the fact that only 4.3% of the nonsternotomy cases are performed in this fashion, one can consider this as probably a distant second when it comes to a nonsternotomy approach to the mitral valve. My questions mainly deal with the technical aspects of this procedure. The mitral valve is rotated from the conventional right-sided approach, as you mentioned, and I wonder if this angle of approach is more difficult: that is, is there any trick when it comes to exposing the mitral valve from the left side?

Dr Saunders. Thank you very much for your comments. You are correct; this is definitely a distant second to the right anterior thoracotomy approach, but it has a very specific indication. While it is not our approach of choice, it is a valuable option in certain difficult patient situations.

While we find the exposure to be very good, the valve is obviously upside down as compared to the right-sided approach. With respect to exposure, we find that silk retraction sutures and self-retaining retractors are all that we need to obtain good visualization.

Dr Fann. In 50% of the cases the sixth intercostal space was used, and in 25% of the cases either the fourth or fifth intercostal space was used as the approach. Is there a good way of determining which intercostal space is the best approach for a left thoracotomy?

Dr Saunders. There are no specific maneuvers we use to determine the intercostal space to use; mostly this depends on individual surgeon preference and the patient's particular body habitus.

Dr Fann. Two patients had direct aortic crossclamping. Why was this technique limited to 2 patients, as opposed to being utilized in more of the patients in this particular group?

Dr Saunders. Those 2 were actually 2 of the first 3 that underwent this procedure. Exposure of the aorta is very difficult from this approach, especially in reoperative cases. Although some authors that have written about this approach routinely use direct aortic crossclamping, we feel that this is difficult as a standard technique.

Dr Fann. There were no femoral arterial complications reported in this series, and this complication has been infrequent in previous series from New York University. Why has the preference been to use the descending aorta for cannulation?

Dr Saunders. As our experience with right thoracotomy mitral valve surgery has evolved, we have moved away from routine use of endoballoon catheters toward direct ascending aortic cannulation and crossclamping. This serves to make the case simpler and more efficient and may decrease the bypass time and total case time. It also limits the number of complications associated with endoballoons, in terms of aortic dissection or balloon migration.

Dr Fann. In this patient population, the frequency of atherosclerosis is typically not very high, but given your institutional experience with evaluating the ascending aorta prior to cannulation, do you examine the descending thoracic aorta with TEE for any intraluminal disease prior to cannulation?

Dr Saunders. We do, using a combination of TEE prior to aortic cannulation and direct palpation of the aorta by the operating surgeon.

Dr Fann. And in the fibrillatory arrest subset, do you think that the deairing is a problem, or is a transvalvular vent and flooding the field with CO2 adequate?

Dr Saunders. We find the deairing we can achieve from this approach to be adequate, but in addition to the transvalvular vent, we occasionally access the left ventricle directly, using a needle, for additional deairing. We also use the combination of typical maneuvers in changing the position of the table to augment deairing. Again, at the conclusion of the case, TEE is used to assess intracardiac air.

Dr Fann. And finally, in the 2 patients with the perioperative strokes, were those cases performed with descending aortic cannulation and fibrillatory arrest, and what was the method of deairing in those 2 patients?

Dr Saunders. Those 2 patients were actually early in our experience, and both had femoral arterial cannulation and endoaortic balloon clamping. There were no strokes in the later group, although we have to say that in our larger overall series of minimally invasive cases, we have never found a correlation between use of the endoballoon catheter and strokes.


   Footnotes
 
Supported in part by the Foundation for Research in Cardiac Surgery and Cardiovascular Biology.


   References
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 Abstract
 Methods
 Results
 Discussion
 Conclusion
 Discussion
 References
 

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