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Early and midterm results of upper ministernotomy approach for aortic valve replacement
Journal of the Egyptian Society of Cardio-Thoracic Surgery 25 (2017) 311e315
Contents lists available at ScienceDirect
H O S T E D BY
Journal of the Egyptian Society of Cardio-Thoracic Surgery journal homepage: http://www.journals.elsevier.com/journal-ofthe-egyptian-society-of-cardio-thoracic-surgery/
Early and midterm results of upper ministernotomy approach for aortic valve replacement I. Moursi, K. Al Fakharany* Cardiothoracic Surgery Department, Zagazig University Hospital, Zagazig, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 September 2017 Received in revised form 19 October 2017 Accepted 2 November 2017 Available online 6 November 2017
Background: Aortic valve replacement (AVR) surgery today offers excellent results with low morbidity and mortality. However, the evolution of surgery encourages us to develop minimally invasive techniques. We report in this study our early experience of AVR by Upper Ministernotomy and describe the surgical technique, learning curve, complications and surgical follow-up. Methods: Between March 2009 and March 2013, 50 patients underwent surgery for AVR at Zagazig university hospitals by inverted T Upper Ministernotomy (mean age 48 ± 11.2). The mean Euro-SCORE was 5.7% ± 4.1 and the ejection fraction was 60% ± 12. Six patients had an associated ascending aortic replacement. The cannulation was performed in femorofemoral by the direct or percutaneous approach. Results: Mean aortic clamping time for patients with isolated AVR was 91 ± 29 min and bypass time of 123 ± 56 min. One patient required conversion to sternotomy. The mean duration of mechanical ventilation was 10.3 ± 26.3 h, the average length of stay in intensive care units was 2.6 ± 2.2 days, and the mean hospital stay was 9.3 ± 5.8 days. Hospital mortality was 2 patients (4%). Conclusions: The Upper mini-sternotomy for aortic valve surgery is an approach that offers many benefits. However, it is technically more complicated and requires a learning curve beyond which it can offer a lower complication rate with lower pain, blood loss and transfusion, and rapid return to normal activities. © 2017 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: Ministernotomy Aortic valve Minimally invasive surgery
1. Introduction The development of minimally invasive techniques in cardiac surgery has grown considerably over the past two decades. First, it involved coronary surgery with thoracotomy beating bypass surgery, followed by upper ministernotomy for the aortic valve [1] and mitral surgery with right thoracotomy [2]. The right minithoracotomy was first described in 1999 [3] and has recently developed with several series in the literature [4e9]. The expected benefits of this approach are improved operative results (pain, blood loss, and transfusion), faster recovery (shorter hospital stay, earlier resumption of activities) and an aesthetic benefit. However, the implementation of a new technique requires a learning curve beyond which the technique
* Corresponding author. E-mail addresses: [email protected] (I. Moursi), [email protected] (K. Al Fakharany). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. https://doi.org/10.1016/j.jescts.2017.11.001 1110-578X/© 2017 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
312
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must bring to the patient the same results as conventional surgery while providing a functional and/or cosmetic benefit [15]. We report in this study our early experience of aortic valve replacement (AVR) by ministernotomy, surgical technique and complications. 2. Materials and methods This is a retrospective study to review our results and experiences of AVR by inverted T upper ministernotomy from the first case in March 2009 to March 2013 at Zagazig university hospitals, Zagazig, Egypt. Fifty patients were operated during this period at cardiothoracic surgery department. All patients' data were collected according to the legal Customs and traditions with granted informed consent. Exclusion criteria for the use of this technique were: previous sternotomy (Redo-Surgery), aortic root dilatation, associated cardiac surgery (coronary bypass surgery, atrial fibrillation treatment), octogenarians, and significant comorbidities. The preoperative assessment included the classic assessment of AVR with an arterial and venous Doppler ultrasound for femoral cannulation and aortic calcifications (coronary angiography for patients older than 40 years ± aortic computerized tomography scan). Postoperative renal insufficiency is defined as an increase in serum creatinine of more than 50 mmol/l relative to the baseline value or postoperative dialysis. All patients were subjected to follow up period during the 1st three months postoperative for early and short term results and during 12 months for mid-term results. The data were collected through the visit to our surgery clinic or the treating cardiologist. The post-operative pain was evaluated by a Score of visual analogue scale [16].
2.1. Surgical technique 2.1.1. Installation The installation was carried out in supine position with a transverse block Jell pad under the shoulder as usual. The surgical field extended from the suprasternal notch to the second subcostal region, with exposure of the bilateral femoral areas. External defibrillation pads were placed on the posterior and anterolateral left sides of the thorax. The operation was performed under general intravenous anesthesia. When all necessary arterial and venous lines were fixed, the patient was anaesthetized by conventional method. A transesophageal echography (TEE) probe was set up to check the position of the cannulas. 2.1.2. Surgery The patient was prepared with iodine solution, exposing the anterior and right lateral chest wall and both groin areas. An adhesive aseptic strip was fixed to the exposed areas. The skin incision was started 2 fingers breadth below the sternal notch and extended 5e7 cm inferiorly. An oscillating saw was used to perform inverted T-incision into the fourth intercostal space preserving the internal thoracic artery. Entering the third intercostal space resulted in adequate exposure of the aortic valve and right atrial appendage for venous cannulation by double staged venous cannula. If the atrial appendage could not be safely cannulated, percutaneous cannulation of the femoral vein was performed. Then the extracorporeal circulation was established through direct aortic cannulation by Easy Flow aortic cannula (Estech, San Ramon, CA) and percutaneous femoral vein cannulation guided (Seldinger technique) by guide wire and TEE for adequate bicaval insertion of double stage 22-22-Fr and 23e25-Fr venous cannula (Estech, San Ramon, CA). A standard Cardioplegia cannula was placed in the ascending aorta. Cardioplegia was delivered as an antegrade method of crystalloid solution or custodiol into the aortic root and the infusion and venting lines were connected as during usual procedure. After dissection of thymic fat, the pericardium was open with a longitudinal incision along the ascending aorta and a transverse incision along the upper edge of the right atrium. The field was exposed with pericardial suspension sutures passed through the skin by a transcutaneous needle. The body temperature was dropped to 33 C. The aorta was clamped with a flexible Cygnet flexible aortic cross-clamp (Novare Surgical Systems, Inc., Cupertino, CA) and cardioplegia was performed by warm blood or Custodiol with perfusion pressure control. The aorta was open transversely. Valvular resection was performed with conventional instrumentation and technique. The valve was exposed according to the conventional local technique by 3 commissural pull points. A replacement of the ascending aorta was associated in some cases and aortic root enlargement in 3 case by modified Manouguian technique. The instruments used were classical instruments. The deairing of the cardiac cavities was performed conventionally by aspiration in the ascending aorta and in the left atrium under TEE control. The drain was inserted in the right side thoracic cavity where the pleura was opened. The wound was closed in usual manner. 2.2. Data analysis Statistical analysis was done by Statistical Package for the Social Sciences software 19.0 (SPSS). Our data were expressed as mean and standard deviation (S.D.) for continuous variables. The other numerical or categorical data were presented as percentage in a frequency tables.
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3. Results 3.1. Population The mean age of the population was 48 ± 11.2, Euro-SCORE was 5.7 ± 4.1 and the ejection fraction (LVEF) was 60% ± 12. Preoperative and demographic data are shown in Table 1. 3.2. Operative data The operative data are presented in Table 2. The mean clamping time in the case of AVR without associated maneuver was 91.1 ± 29.5 min and the bypass time of 123.6 ± 56 min. A mechanical prosthesis was implanted in 10 patients (20%) and a tissue prosthesis in 40 patients (80%). For calcified rings, a direct continuous suture in 10 cases, and aortic root enlargement in 3 cases (6%) for small annulus (valves 19) were done. The femoral vein cannulation was performed percutaneously in 8 patients (16%), associated ascending aorta replacement was performed in 6 patients (12%). 3.3. Postoperative results The early (3 months) and midterm (one year) postoperative results are shown in Table 3. Hospital mortality was 4% (2 patients). One patient died as a result of hemorrhagic complications on the aortic annulus and one patient died from right ventricular failure by probable dissection of the right coronary artery by the selective cardioplegic cannula. There was no case of wound infection. Conversion to sternotomy was necessary in a patient due to rupture of the aortic annulus. Eleven patients (22%) required transfusion. The mean duration of mechanical ventilation was 10.3 ± 26.3 h, the average length of stay in intensive care units was 2.6 days ± 2.2 and the average hospital stay was 9.3 days ± 5.8. 4. Discussion Minimal invasive surgery is now widespread for mitral surgery but this approach is newer and less widespread for aortic valve surgery. Most of the teams performing this procedure through right minithoracotomy perform a preoperative scan to locate the intercostal space that will provide the best exposure and to verify the position of the aorta with respect to the medial portion of the sternum [5,6]. We did not perform a systematic scan and our approach was mimicking the standard sternotomy without need for sophisticated investigation. It gave adequate space for the surgical field with preservation of both internal mammary arteries even in the cases of replacement of the ascending aorta. Some teams put on an aorto-femoral bypass [6,8,9] however the ordinary arterial cannula takes up space in the operating field which is already reduced but the use of direct aortic cannulation by Easy Flow aortic cannula (Estech, San Ramon, CA) which is flexible gives space in the operative field and avoids the complication of arterial femoral cannulation. The use of TEE reduces the risk of false route of the venous cannula. At the beginning of our experience, we used blood cardioplegia every 20 min with selective perfusion in the coronary ostia. However, cardioplegia perfusion in right coronary ostium could prove tedious and was responsible for right coronary artery dissection in a patient. We then changed cardioplegia to cold crystalloid
Table 1 Preoperative and Demographic patient's data. Patient's data
NO.50
Age Sex (male) BMI COPD HTA Diabetes Peripheral arterial disease NYHA LVEF (%) AS AI AD Euro-SCORE (%)
48 ± 11.2 31 (62%) 28 ± 5.4 3 (6%) 31 (62%) 9 (18%) 2 (4%) 3-4 9 (18%) 60 ± 12 46 (92%) 2 (4%) 2 (4%) 5.7 ± 4.1
Data are presented in number (%) or mean ± standard deviation or median (minemax) BMI: Body Mass Index; COPD: Chronic obstructive pulmonary disease; HTA: high blood pressure; NYHA: New York Heart Association classification; LVEF: Left ventricular ejection fraction; AS: aortic stenosis; AI: aortic insufficiency; AD: aortic disease.
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Table 2 Operative data. Data
Pt No.
Variables
AVR with OR without other maneuver
50
AVR ISOLATED
36
Aortic clamp time Bypass time (min) Aortic clamp time Bypass time (min)
VALVE TYPE Mechanical valve Stented tissue valve OTHERS Conversion to full sternotomy Replacement of ascending aorta Manouguian Technique
20 30
40% 60%
1 6 3
2% 12% 6%
98.8 ± 33.1 131 ± 53.6 91,1 ± 29.5 123,6 ± 56
AVR: Aortic valve replacement.
Table 3 Postoperative data. Data
NO.50
Bleeding (reopening) Cerebral Stroke Renal insufficiency Wound infection Blood transfusion Permanent pacemaker Mechanical ventilation time (hours) ICU Stay (days) Hospitalization (days) Hospital mortality
1 (2%) 1 (2%) 3 (6%) 0 11 (22%) 0 10.3 ± 26.3 2.6 ± 2.2 9.3 ± 5.8 2 (4%)
ICU: Intensive Care Unit. Postoperative renal insufficiency is defined as an increase in serum creatinine of more than 50 mmol/l relative to the baseline value or postoperative dialysis.
(Custodiol) no longer requiring selective injection in coronary ostia. This cardioplegia was controlled by injection pressure and under moderate hypothermia (32e33 C). Most teams use Custodiol cardioplegia in a single injection in the ascending aorta [6,8,10]. Glauber et al. [10] use warm cardioplegia in coronary ostia or a retrograde cannula placed under TEE control only in cases of significant aortic insufficiency. The aorta was clamped with a flexible Cygnet flexible aortic cross-clamp (Novare Surgical Systems, Inc., Cupertino, Calif., USA). Most teams use a flexible aortic clamp [6,8e10], as it can be kept away of the surgical field. Several studies comparing classical sternotomy with minimally invasive procedures have shown a reduction in postoperative complications. Glauber retrospectively compared a series of 192 patients operated by minithoracotomy to a series of 336 patients operated by classical sternotomy [10]. There results showed a lower incidence of postoperative atrial fibrillation by minithoracotomy, as well as less blood transfusion, shorter ventilation duration and shorter duration of stay, with no difference in mortality but the bypass and clamping times were higher by thoracotomy group. Ruttmann et al. [11] also compared a series of 87 patients operated by minithoracotomy to a series of 228 patients operated by classical sternotomy. They did not show any benefit in terms of surgical follow-up by minithoracotomy but with complications related to the femoral cannulation. Sharony et al. [12] showed a lower duration of stay and a more frequent return home in the group operated by minimally invasive (minithoracotomy and ministernotomy) versus complete sternotomy. Sansone et al. [8] compared in a retrospective study a series of 50 patients operated by minithoracotomy to a series of 50 patients operated by sternotomy. They showed longer clamping times and bypass time by minithoracotomy but lower bleeding with less transfusion and less scar infection. Lamelas et al. [13] showed a lower rate of complications in the minimally invasive manner with a lower rate of renal insufficiency, a decrease in the duration of ventilation and a decrease in the risk of scar infection in a series comparing the minimal invasive technique, for the aortic and mitral valves, to the classical sternotomy. This technique can therefore be expected to have a benefit in terms of transfusion rate, scar infection, pain, rehabilitation time and cosmetics. A prospective, randomized study is needed to confirm definitively these best results of minimal invasive technique. However, the implantation of the valve remains technically more difficult due to less exposure and reduced operating field. This technique requires specific expertise with a learning curve. In addition, clamping and bypass times are higher than in conventional surgery [4,10]. The development of sutureless prostheses is likely to facilitate the use of this approach initially by technically easier implantation and shorter clamping times and bypass [14]. This technique could then be considered as an alternative to TAVI in high-risk patients.
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There were no recorded late complications or late deaths in our patients during the follow up. Finally our results of minimal invasive upper ministernotomy had benefits related to patients (cosmosis, rapid return to full activity, and reduced complications) and healthcare provider (reduced complication, reduced length of stay and patient overall satisfaction). Further clinical experience and data are necessary. 5. Conclusions The Upper Ministernotomy for aortic valve surgery is an approach that offers many benefits. However, it is technically more complicated and requires a learning curve beyond which it can offer a lower complication rate with fewer pain, blood loss and transfusion, and rapid return to normal activities. References [1] Brown ML, McKellar SH, Sundt TM, Schaff HV. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg 2009;137:670e9. [2] Chitwood Jr WR, Wixon CL, Elbeery JR, Moran JF, Chapman WH, Lust RM. Video-assisted minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg 1997;114:773e80. [3] Benetti F, Rizzardi JL, Concetti C, Bergese M, Zappetti A. Minimally aortic Valve surgery avoiding sternotomy. Eur J Cardiothorac Surg 1999;16:S84e5. [4] Sansone F, Zingarelli E, Punta G, et al. Aortic valve replacement using a stentless Bioprosthesis through right minithoracotomy: an initial experience. Heart Lung Circ 2011;20:543e6. [5] Glauber M, Miceli A, Bevilacqua S, Farneti PA. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early outcomes and midterm follow-up. J Thorac Cardiovasc Surg 2011;142:1577e9. [6] Plass A, Scheffel H, Alkadhi H, et al. Aortic valve replacement through a minimally invasive approach: preoperative planning, surgical technique, and outcome. Ann Thorac Surg 2009;88:1851e6. [7] Murzi M, Cerillo AG, Bevilacqua S, Gilmanov D, Farneti P, Glauber M. Traversing the learning curve in minimally invasive heart valve surgery: a Cumulative analysis of an individual surgeon's experience with a right Minithoracotomy approach for aortic valve replacement. Eur J Cardiothorac Surg 2012;41:1242e6. [8] Sansone F, Punta G, Parisi F, et al. Right minithoracotomy versus full sternotomy for the aortic valve replacement: preliminary results. Heart Lung Circ 2012;21:169e73. [9] Glower DD, Lee T, Desai B. Aortic valve replacement through right minithoracotomy in 306 consecutive patients. Innovations (Phila) 2010;5:326e30. [10] Glauber M, Miceli A, Gilmanov D, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg 2013 May;145(5):1222e6. https://doi.org/10.1016/j.jtcvs.2012.03.064. Epub 2012 Apr 18. [11] Ruttmann E, Gilhofer TS, Ulmer H, et al. Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy. Heart Valve Dis 2010;19: 606e14. [12] Sharony R, Grossi EA, Saunders PC, et al. Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement. J Heart Valve Dis 2004;13:887e93. [13] Lamelas J, Sarria A, Santana O, Pineda AM, Lamas GA. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg 2011;91:79e84. [14] Folliguet TA, Laborde F, Zannis K, Ghorayeb G, Haverich A, Shrestha M. Sutureless Perceval aortic valve replacement: results of two European centers. Ann Thorac Surg 2012;93:1483e8. ski Przemysław, Zembala Michał, et al. Minimally invasive aortic valve replacement e pros and cons of keyhole aortic [15] Kaczmarczyk Marcin, Szałan surgery. Kardiochir i Torakochir Pol 2015;12(2):103e10. [16] Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain 1994;56:217e26.
Contents lists available at ScienceDirect
H O S T E D BY
Journal of the Egyptian Society of Cardio-Thoracic Surgery journal homepage: http://www.journals.elsevier.com/journal-ofthe-egyptian-society-of-cardio-thoracic-surgery/
Early and midterm results of upper ministernotomy approach for aortic valve replacement I. Moursi, K. Al Fakharany* Cardiothoracic Surgery Department, Zagazig University Hospital, Zagazig, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 September 2017 Received in revised form 19 October 2017 Accepted 2 November 2017 Available online 6 November 2017
Background: Aortic valve replacement (AVR) surgery today offers excellent results with low morbidity and mortality. However, the evolution of surgery encourages us to develop minimally invasive techniques. We report in this study our early experience of AVR by Upper Ministernotomy and describe the surgical technique, learning curve, complications and surgical follow-up. Methods: Between March 2009 and March 2013, 50 patients underwent surgery for AVR at Zagazig university hospitals by inverted T Upper Ministernotomy (mean age 48 ± 11.2). The mean Euro-SCORE was 5.7% ± 4.1 and the ejection fraction was 60% ± 12. Six patients had an associated ascending aortic replacement. The cannulation was performed in femorofemoral by the direct or percutaneous approach. Results: Mean aortic clamping time for patients with isolated AVR was 91 ± 29 min and bypass time of 123 ± 56 min. One patient required conversion to sternotomy. The mean duration of mechanical ventilation was 10.3 ± 26.3 h, the average length of stay in intensive care units was 2.6 ± 2.2 days, and the mean hospital stay was 9.3 ± 5.8 days. Hospital mortality was 2 patients (4%). Conclusions: The Upper mini-sternotomy for aortic valve surgery is an approach that offers many benefits. However, it is technically more complicated and requires a learning curve beyond which it can offer a lower complication rate with lower pain, blood loss and transfusion, and rapid return to normal activities. © 2017 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: Ministernotomy Aortic valve Minimally invasive surgery
1. Introduction The development of minimally invasive techniques in cardiac surgery has grown considerably over the past two decades. First, it involved coronary surgery with thoracotomy beating bypass surgery, followed by upper ministernotomy for the aortic valve [1] and mitral surgery with right thoracotomy [2]. The right minithoracotomy was first described in 1999 [3] and has recently developed with several series in the literature [4e9]. The expected benefits of this approach are improved operative results (pain, blood loss, and transfusion), faster recovery (shorter hospital stay, earlier resumption of activities) and an aesthetic benefit. However, the implementation of a new technique requires a learning curve beyond which the technique
* Corresponding author. E-mail addresses: [email protected] (I. Moursi), [email protected] (K. Al Fakharany). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. https://doi.org/10.1016/j.jescts.2017.11.001 1110-578X/© 2017 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
312
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must bring to the patient the same results as conventional surgery while providing a functional and/or cosmetic benefit [15]. We report in this study our early experience of aortic valve replacement (AVR) by ministernotomy, surgical technique and complications. 2. Materials and methods This is a retrospective study to review our results and experiences of AVR by inverted T upper ministernotomy from the first case in March 2009 to March 2013 at Zagazig university hospitals, Zagazig, Egypt. Fifty patients were operated during this period at cardiothoracic surgery department. All patients' data were collected according to the legal Customs and traditions with granted informed consent. Exclusion criteria for the use of this technique were: previous sternotomy (Redo-Surgery), aortic root dilatation, associated cardiac surgery (coronary bypass surgery, atrial fibrillation treatment), octogenarians, and significant comorbidities. The preoperative assessment included the classic assessment of AVR with an arterial and venous Doppler ultrasound for femoral cannulation and aortic calcifications (coronary angiography for patients older than 40 years ± aortic computerized tomography scan). Postoperative renal insufficiency is defined as an increase in serum creatinine of more than 50 mmol/l relative to the baseline value or postoperative dialysis. All patients were subjected to follow up period during the 1st three months postoperative for early and short term results and during 12 months for mid-term results. The data were collected through the visit to our surgery clinic or the treating cardiologist. The post-operative pain was evaluated by a Score of visual analogue scale [16].
2.1. Surgical technique 2.1.1. Installation The installation was carried out in supine position with a transverse block Jell pad under the shoulder as usual. The surgical field extended from the suprasternal notch to the second subcostal region, with exposure of the bilateral femoral areas. External defibrillation pads were placed on the posterior and anterolateral left sides of the thorax. The operation was performed under general intravenous anesthesia. When all necessary arterial and venous lines were fixed, the patient was anaesthetized by conventional method. A transesophageal echography (TEE) probe was set up to check the position of the cannulas. 2.1.2. Surgery The patient was prepared with iodine solution, exposing the anterior and right lateral chest wall and both groin areas. An adhesive aseptic strip was fixed to the exposed areas. The skin incision was started 2 fingers breadth below the sternal notch and extended 5e7 cm inferiorly. An oscillating saw was used to perform inverted T-incision into the fourth intercostal space preserving the internal thoracic artery. Entering the third intercostal space resulted in adequate exposure of the aortic valve and right atrial appendage for venous cannulation by double staged venous cannula. If the atrial appendage could not be safely cannulated, percutaneous cannulation of the femoral vein was performed. Then the extracorporeal circulation was established through direct aortic cannulation by Easy Flow aortic cannula (Estech, San Ramon, CA) and percutaneous femoral vein cannulation guided (Seldinger technique) by guide wire and TEE for adequate bicaval insertion of double stage 22-22-Fr and 23e25-Fr venous cannula (Estech, San Ramon, CA). A standard Cardioplegia cannula was placed in the ascending aorta. Cardioplegia was delivered as an antegrade method of crystalloid solution or custodiol into the aortic root and the infusion and venting lines were connected as during usual procedure. After dissection of thymic fat, the pericardium was open with a longitudinal incision along the ascending aorta and a transverse incision along the upper edge of the right atrium. The field was exposed with pericardial suspension sutures passed through the skin by a transcutaneous needle. The body temperature was dropped to 33 C. The aorta was clamped with a flexible Cygnet flexible aortic cross-clamp (Novare Surgical Systems, Inc., Cupertino, CA) and cardioplegia was performed by warm blood or Custodiol with perfusion pressure control. The aorta was open transversely. Valvular resection was performed with conventional instrumentation and technique. The valve was exposed according to the conventional local technique by 3 commissural pull points. A replacement of the ascending aorta was associated in some cases and aortic root enlargement in 3 case by modified Manouguian technique. The instruments used were classical instruments. The deairing of the cardiac cavities was performed conventionally by aspiration in the ascending aorta and in the left atrium under TEE control. The drain was inserted in the right side thoracic cavity where the pleura was opened. The wound was closed in usual manner. 2.2. Data analysis Statistical analysis was done by Statistical Package for the Social Sciences software 19.0 (SPSS). Our data were expressed as mean and standard deviation (S.D.) for continuous variables. The other numerical or categorical data were presented as percentage in a frequency tables.
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3. Results 3.1. Population The mean age of the population was 48 ± 11.2, Euro-SCORE was 5.7 ± 4.1 and the ejection fraction (LVEF) was 60% ± 12. Preoperative and demographic data are shown in Table 1. 3.2. Operative data The operative data are presented in Table 2. The mean clamping time in the case of AVR without associated maneuver was 91.1 ± 29.5 min and the bypass time of 123.6 ± 56 min. A mechanical prosthesis was implanted in 10 patients (20%) and a tissue prosthesis in 40 patients (80%). For calcified rings, a direct continuous suture in 10 cases, and aortic root enlargement in 3 cases (6%) for small annulus (valves 19) were done. The femoral vein cannulation was performed percutaneously in 8 patients (16%), associated ascending aorta replacement was performed in 6 patients (12%). 3.3. Postoperative results The early (3 months) and midterm (one year) postoperative results are shown in Table 3. Hospital mortality was 4% (2 patients). One patient died as a result of hemorrhagic complications on the aortic annulus and one patient died from right ventricular failure by probable dissection of the right coronary artery by the selective cardioplegic cannula. There was no case of wound infection. Conversion to sternotomy was necessary in a patient due to rupture of the aortic annulus. Eleven patients (22%) required transfusion. The mean duration of mechanical ventilation was 10.3 ± 26.3 h, the average length of stay in intensive care units was 2.6 days ± 2.2 and the average hospital stay was 9.3 days ± 5.8. 4. Discussion Minimal invasive surgery is now widespread for mitral surgery but this approach is newer and less widespread for aortic valve surgery. Most of the teams performing this procedure through right minithoracotomy perform a preoperative scan to locate the intercostal space that will provide the best exposure and to verify the position of the aorta with respect to the medial portion of the sternum [5,6]. We did not perform a systematic scan and our approach was mimicking the standard sternotomy without need for sophisticated investigation. It gave adequate space for the surgical field with preservation of both internal mammary arteries even in the cases of replacement of the ascending aorta. Some teams put on an aorto-femoral bypass [6,8,9] however the ordinary arterial cannula takes up space in the operating field which is already reduced but the use of direct aortic cannulation by Easy Flow aortic cannula (Estech, San Ramon, CA) which is flexible gives space in the operative field and avoids the complication of arterial femoral cannulation. The use of TEE reduces the risk of false route of the venous cannula. At the beginning of our experience, we used blood cardioplegia every 20 min with selective perfusion in the coronary ostia. However, cardioplegia perfusion in right coronary ostium could prove tedious and was responsible for right coronary artery dissection in a patient. We then changed cardioplegia to cold crystalloid
Table 1 Preoperative and Demographic patient's data. Patient's data
NO.50
Age Sex (male) BMI COPD HTA Diabetes Peripheral arterial disease NYHA LVEF (%) AS AI AD Euro-SCORE (%)
48 ± 11.2 31 (62%) 28 ± 5.4 3 (6%) 31 (62%) 9 (18%) 2 (4%) 3-4 9 (18%) 60 ± 12 46 (92%) 2 (4%) 2 (4%) 5.7 ± 4.1
Data are presented in number (%) or mean ± standard deviation or median (minemax) BMI: Body Mass Index; COPD: Chronic obstructive pulmonary disease; HTA: high blood pressure; NYHA: New York Heart Association classification; LVEF: Left ventricular ejection fraction; AS: aortic stenosis; AI: aortic insufficiency; AD: aortic disease.
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Table 2 Operative data. Data
Pt No.
Variables
AVR with OR without other maneuver
50
AVR ISOLATED
36
Aortic clamp time Bypass time (min) Aortic clamp time Bypass time (min)
VALVE TYPE Mechanical valve Stented tissue valve OTHERS Conversion to full sternotomy Replacement of ascending aorta Manouguian Technique
20 30
40% 60%
1 6 3
2% 12% 6%
98.8 ± 33.1 131 ± 53.6 91,1 ± 29.5 123,6 ± 56
AVR: Aortic valve replacement.
Table 3 Postoperative data. Data
NO.50
Bleeding (reopening) Cerebral Stroke Renal insufficiency Wound infection Blood transfusion Permanent pacemaker Mechanical ventilation time (hours) ICU Stay (days) Hospitalization (days) Hospital mortality
1 (2%) 1 (2%) 3 (6%) 0 11 (22%) 0 10.3 ± 26.3 2.6 ± 2.2 9.3 ± 5.8 2 (4%)
ICU: Intensive Care Unit. Postoperative renal insufficiency is defined as an increase in serum creatinine of more than 50 mmol/l relative to the baseline value or postoperative dialysis.
(Custodiol) no longer requiring selective injection in coronary ostia. This cardioplegia was controlled by injection pressure and under moderate hypothermia (32e33 C). Most teams use Custodiol cardioplegia in a single injection in the ascending aorta [6,8,10]. Glauber et al. [10] use warm cardioplegia in coronary ostia or a retrograde cannula placed under TEE control only in cases of significant aortic insufficiency. The aorta was clamped with a flexible Cygnet flexible aortic cross-clamp (Novare Surgical Systems, Inc., Cupertino, Calif., USA). Most teams use a flexible aortic clamp [6,8e10], as it can be kept away of the surgical field. Several studies comparing classical sternotomy with minimally invasive procedures have shown a reduction in postoperative complications. Glauber retrospectively compared a series of 192 patients operated by minithoracotomy to a series of 336 patients operated by classical sternotomy [10]. There results showed a lower incidence of postoperative atrial fibrillation by minithoracotomy, as well as less blood transfusion, shorter ventilation duration and shorter duration of stay, with no difference in mortality but the bypass and clamping times were higher by thoracotomy group. Ruttmann et al. [11] also compared a series of 87 patients operated by minithoracotomy to a series of 228 patients operated by classical sternotomy. They did not show any benefit in terms of surgical follow-up by minithoracotomy but with complications related to the femoral cannulation. Sharony et al. [12] showed a lower duration of stay and a more frequent return home in the group operated by minimally invasive (minithoracotomy and ministernotomy) versus complete sternotomy. Sansone et al. [8] compared in a retrospective study a series of 50 patients operated by minithoracotomy to a series of 50 patients operated by sternotomy. They showed longer clamping times and bypass time by minithoracotomy but lower bleeding with less transfusion and less scar infection. Lamelas et al. [13] showed a lower rate of complications in the minimally invasive manner with a lower rate of renal insufficiency, a decrease in the duration of ventilation and a decrease in the risk of scar infection in a series comparing the minimal invasive technique, for the aortic and mitral valves, to the classical sternotomy. This technique can therefore be expected to have a benefit in terms of transfusion rate, scar infection, pain, rehabilitation time and cosmetics. A prospective, randomized study is needed to confirm definitively these best results of minimal invasive technique. However, the implantation of the valve remains technically more difficult due to less exposure and reduced operating field. This technique requires specific expertise with a learning curve. In addition, clamping and bypass times are higher than in conventional surgery [4,10]. The development of sutureless prostheses is likely to facilitate the use of this approach initially by technically easier implantation and shorter clamping times and bypass [14]. This technique could then be considered as an alternative to TAVI in high-risk patients.
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There were no recorded late complications or late deaths in our patients during the follow up. Finally our results of minimal invasive upper ministernotomy had benefits related to patients (cosmosis, rapid return to full activity, and reduced complications) and healthcare provider (reduced complication, reduced length of stay and patient overall satisfaction). Further clinical experience and data are necessary. 5. Conclusions The Upper Ministernotomy for aortic valve surgery is an approach that offers many benefits. However, it is technically more complicated and requires a learning curve beyond which it can offer a lower complication rate with fewer pain, blood loss and transfusion, and rapid return to normal activities. References [1] Brown ML, McKellar SH, Sundt TM, Schaff HV. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg 2009;137:670e9. [2] Chitwood Jr WR, Wixon CL, Elbeery JR, Moran JF, Chapman WH, Lust RM. Video-assisted minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg 1997;114:773e80. [3] Benetti F, Rizzardi JL, Concetti C, Bergese M, Zappetti A. Minimally aortic Valve surgery avoiding sternotomy. Eur J Cardiothorac Surg 1999;16:S84e5. [4] Sansone F, Zingarelli E, Punta G, et al. Aortic valve replacement using a stentless Bioprosthesis through right minithoracotomy: an initial experience. Heart Lung Circ 2011;20:543e6. [5] Glauber M, Miceli A, Bevilacqua S, Farneti PA. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early outcomes and midterm follow-up. J Thorac Cardiovasc Surg 2011;142:1577e9. [6] Plass A, Scheffel H, Alkadhi H, et al. Aortic valve replacement through a minimally invasive approach: preoperative planning, surgical technique, and outcome. Ann Thorac Surg 2009;88:1851e6. [7] Murzi M, Cerillo AG, Bevilacqua S, Gilmanov D, Farneti P, Glauber M. Traversing the learning curve in minimally invasive heart valve surgery: a Cumulative analysis of an individual surgeon's experience with a right Minithoracotomy approach for aortic valve replacement. Eur J Cardiothorac Surg 2012;41:1242e6. [8] Sansone F, Punta G, Parisi F, et al. Right minithoracotomy versus full sternotomy for the aortic valve replacement: preliminary results. Heart Lung Circ 2012;21:169e73. [9] Glower DD, Lee T, Desai B. Aortic valve replacement through right minithoracotomy in 306 consecutive patients. Innovations (Phila) 2010;5:326e30. [10] Glauber M, Miceli A, Gilmanov D, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg 2013 May;145(5):1222e6. https://doi.org/10.1016/j.jtcvs.2012.03.064. Epub 2012 Apr 18. [11] Ruttmann E, Gilhofer TS, Ulmer H, et al. Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy. Heart Valve Dis 2010;19: 606e14. [12] Sharony R, Grossi EA, Saunders PC, et al. Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement. J Heart Valve Dis 2004;13:887e93. [13] Lamelas J, Sarria A, Santana O, Pineda AM, Lamas GA. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg 2011;91:79e84. [14] Folliguet TA, Laborde F, Zannis K, Ghorayeb G, Haverich A, Shrestha M. Sutureless Perceval aortic valve replacement: results of two European centers. Ann Thorac Surg 2012;93:1483e8. ski Przemysław, Zembala Michał, et al. Minimally invasive aortic valve replacement e pros and cons of keyhole aortic [15] Kaczmarczyk Marcin, Szałan surgery. Kardiochir i Torakochir Pol 2015;12(2):103e10. [16] Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain 1994;56:217e26.