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ORIGINAL CONTRIBUTIONS |
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Department of Cardiovascular Surgery 1 Department of Anaesthesiology 2 Department of Cardiology Escorts Heart Institute and Research Centre New Delhi, India |
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| For reprint information contact: Yugal K Mishra, PhD Tel: 91 11 682 5000 Fax: 91 11 682 5013 email: dryugal{at}mantramail.com Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025, India. |
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Mitral valve (MV) reoperation is technically demanding and fraught with complications. However, the port-access system obviates most of the complications due to reentry and thus provides a more advantageous procedure. The advantages are a less traumatic operation with less blood loss, less postoperative pain, and faster recovery.
Using ministernotomy and parallel incision, encouraging results with low surgical mortality have been obtained.1–5 The first MV replacements using the port-access system with cardioplegia were performed in dogs.6 This was followed by clinical reports of successful MV operations using this system,7,8 as well as redo MV surgery using the Estech endoclamp.9 We had closed atrial septal defects in 37 patients10 and replaced the MV in 76 patients using the port-access system.11 Encouraged by our initial experience with primary MV replacement, we attempted it in MV reoperation as it would avoid extensive dissection and the resultant bleeding with reentry. In this study, we evaluate the feasibility of the port-access system in redo surgery.
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The right or left femoral artery and vein were surgically exposed through a 3- to 4-cm transverse incision superior to the inguinal skinfold. After systemic heparinization, a 21F Y-shaped arterial return cannula was inserted into the femoral artery, and a 28F venous return cannula was placed in the femoral vein and advanced to the right atrium (RA) and the superior vena cava guided by TEE. A conventional cardiopulmonary bypass (CPB) circuit with a roller pump and membrane oxygenator was incorporated. In addition, a centrifugal pump (Delphin; Sarns Inc., Ann Arbor, MI, USA) was placed in the venous line to enhance venous drainage.
Simultaneously, a 5- to 8-cm anterolateral thoracotomy incision was made in the inframammary groove. The chest was entered via the fourth intercostal space. Once CPB was begun, the lungs were deflated. To expose the roof of the left atrium, the pericardium was opened 3 cm anterior and parallel to the right phrenic nerve and fixed to the chest wall with stay sutures. Temperature was allowed to drift without active cooling or warming until the endoaortic clamp was in place. Before insertion of the clamp, the aorta was screened by TEE for atheromatous debris and thrombi to avoid cerebral embolization with retrograde perfusion. A guidewire was advanced from the descending aorta up to the aortic valve, and the endoaortic clamp was placed 1 cm above the level of the sinotubular junction. The distal lumen of the clamp was situated in the aortic root. The clamp was inflated to occlude the ascending aorta endoluminally, while the heart was vented through the endovascular pulmonary vent. The balloon pressure was continuously measured and maintained between 250 and 340 mm Hg. Additional volume was inflated in case of a fall in pressure below 250 mm Hg. A warm-blood cardioplegic solution was delivered antegradely through the distal lumen of the clamp while maintaining aortic root pressure between 50 and 70 mm Hg. In 16 cases, retrograde cardioplegia was also used as an adjunct with antegrade cardioplegia through a coronary sinus catheter placed transjugularly after anesthesia induction but prior to the commencement of surgery.
The endoaortic clamp was used in 24 initial cases, but we have switched to the Chitwood transthoracic sliding-rod aortic clamp (Scanlan International, Minneapolis, MN, USA), which was used in 8 cases. This clamp was passed through the second intercostal space at the anterior axillary line through a 3-mm port. Antegrade cardioplegia was delivered via a cardioplegia catheter (DLP, Inc., Grand Rapids, MI, USA), which was also used for aortic root suction during deairing.
After the establishment of cardiac arrest, the left atrium was opened and the MV was exposed by a specially designed atrial retractor inserted through another 3-mm port at the fourth or fifth intercostal space parasternally. MV repair or replacement was then performed under direct vision with the help of specially designed instruments. A Starr-Edwards MV prosthesis (Baxter Healthcare, Irvine, CA, USA) was used for replacement. On completion, a left atrial vent was positioned across the MV and the left atrial incision was closed.
In the 2 patients undergoing TV and MV surgery, the venous drainage cannula was withdrawn into the inferior vena cava following MV surgery, and the RA was opened while the pump sucker was sucking out blood returning from the superior vena cava. The TV was exposed with the in situ atrial retractor and then repaired by the Reeds annuloplasty technique. Once completed, the RA was repaired and the venous cannula was moved to the RA.
Deairing was performed by inflating the lungs and simultaneously reducing venous drainage with the patient placed in the Trendelenburg position. Aortic deairing was done by suctioning through the distal lumen of the endoaortic clamp or the cardioplegia catheter (whichever was in place). The clamp was deflated, while the catheter was left in place for further venting. Defibrillation, if required, was performed using the external defibrillation pads. A temporary pacing wire was placed in the right ventricular epicardium prior to the release of the endoaortic clamp. Once deairing was complete, the endoaortic clamp or the cardioplegia catheter at the aortic root was removed. After achieving hemodynamic stability, the patient was weaned off CPB. Heparin reversal by protamine in a 1:1 ratio was done slowly after removal of the femoral venous cannula and completed after removal of the arterial cannula. The chest wound was closed after a pleural tube was inserted separately through a stab incision.
In 10 cases, exposure of the MV was facilitated with an endoscope attached to a voice-controlled robotic arm (AESOP 3000; Computer Motion, Goleta, CA, USA) that allows stabilization and voice-activated camera positioning. One-lung ventilation was achieved by a double-lumen endobronchial tube.
The patients were followed up at 3 and 5 months and then annually, with serial echocardiography whenever possible. Preoperative, operative, and postoperative data were prospectively collected. Results are expressed in mean ± standard deviation.
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RESULTS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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One patient developed pneumothorax with prolonged air leak, which closed without intervention. Another developed lymphorrhea from the groin wound, which subsided on its own. There was no reexploration for bleeding or neurological complications.
Patients were followed up for a mean of 18.4 ± 9.2 months. One patient had anticoagulation-related bleeding, which required transfusion of fresh frozen plasma to control the elevated prothrombin time. There were no paravalvular leaks. The New York Heart Association functional class improved by 1.4 ± 0.1. There was no mortality during the follow-up period.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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We believe that a 5- to 8-cm incision on the thorax along with a 3- to 4-cm incision in the groin is less invasive than a single 10- to 12-cm incision on the sternum. Adhesions were not dense in 8 patients, hence we were able to dissect the aorta easily to apply the transthoracic aortic clamp instead of the endoaortic clamp. We prefer the latter when there is less adhesion because it is cost effective, more secure, and is applied under direct or video-assisted vision.
We adopted alternative strategies to achieve the potential benefits of minimally invasive redo MV surgery. The strategies were right anterolateral minithoracotomy, strict avoidance of graft manipulation in cases with previous coronary artery bypass to reduce the risk of graft atheroembolism, and modifications in CPB and myocardial protection. The modifications were femoral arterial and venous cannulation for CPB, centrifugal-pump-assisted venous return, endoaortic balloon occlusion or direct transthoracic aortic clamping, and the use of specially designed instruments.
The negligible operative morbidity, zero mortality, and excellent early echocardiographic results prove the safety and efficacy of this approach, which were similar to those of conventional first-time MV surgery. We adopted this technique after gaining adequate experience from atrial septal defect closure and primary MV and TV surgery, hence there was practically no learning curve, which may have contributed to the good results. Also, this technique barely requires more operating time. The extra CPB time was the result of additional maneuvers to enhance exposure, while the extra ischemic time was mainly due to additional precautions taken for deairing under TEE guidance.
The right anterolateral minithoracotomy offers excellent exposure and minimizes the need for dissection and hence the risk of injury to the cardiac chambers and great vessels. Avoiding resternotomy reduces the patient’s discomfort, hastens recovery, and shortens intensive care unit and hospital stay. Moreover, there is a significant decrease in blood requirement. Hence, we recommend the port-access system as a standard approach for redo MV surgery.
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Acknowledgments |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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