Asian Cardiovasc Thorac Ann 1998;6:60-61
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Valve Replacement: Surgical Disasters Might Also be Expected
Carlos-A Mestres, MD, PhD,
Norberto Cassinello, MD, PhD,
Manuel Fuentes, MD, PhD
|
Department of Cardiovascular Surgery Hospital "Virgen de la Arrixaca" University of Murcia Murcia, Spain
|
|
For reprint information contact: Carlos-A Mestres, MD, PhD Dept. of Cardiovascular Surgery Hospital Clinic, University of Barcelona Villarroel 170 Barcelona 08036, Spain Tel:34 3 227 5515 Fax:34 3 451 4898
|
 |
ABSTRACT
|
|---|
Minimally invasive cardiac surgery is rapidly gaining popularity. Diminishing surgical trauma by using smaller incisions seems to achieve the goal of a shorter length of hospital stay with reduced cost, better cosmetic results, and overall patient satisfaction. Therefore, a number of advantages can be anticipated, especially in selected patients. However, surgical complications might also be expected. The case of a 54-year-old male suffering intraoperative aortic dissection due to femoral artery cannulation illustrates the fact that we must be very careful when introducing any modification to the usual clinical practice.
|
INTRODUCTION
|
|---|
Cardiac surgery is evolving at a steady and fast pace. Minimally invasive cardiac surgery is currently seen by practising surgeons as an emerging field of interest and one can foresee that in the near future, provided experience is gained and the indications are properly established, minimally invasive cardiac surgery will represent an important part of our practice. Both coronary artery surgery and valve replacements are now performed under minimal access and we are learning how to deal with surgery carried out through small incisions.1–4 Although encouraging experiences are being reported, certain technical problems have been found at the time of surgery. We would like to draw attention to this case of an unexpected and sudden occurrence of intraoperative aortic dissection while attempting minimal access aortic valve replacement using femoral cannulation.
|
CASE REPORT
|
|---|
The patient was a 54-year-old male with a history of surgery for hiatus hernia and duodenal ulcer. He had rheumatic fever as a teenager and was diagnosed with aortic insufficiency at 14 years old. He had a normal active life until he developed dyspnea on effort late in 1996. He had no other symptoms. A diagnosis of aortic insufficiency was conflrmed at a community hospital and he was referred to our institution for further examinations. At admission he was in New York Heart Association functional class II. His electrocardiogram showed left ventricular hypertrophy and overload. Routine biochemical tests were within normal limits. Transthoracic echocardiography showed a thickened aortic valve with severe aortic regurgitation. Cardiac catheterization confirmed this diagnosis. The left ventricular ejection fraction was 50%, coronary arteries were normal as per angiogram, and there was no evidence of peripheral arterial disease. Surgical treatment was indicated.
This patient was considered to be a good candidate for a minimally invasive procedure. The femoral vessels were cannulated with sharp-tipped percutaneous femoral access cannulae (CR Bard, Inc., Tewksbury, MA, USA). Although this cannula is designed to facilitate percutaneous insertion, we decided to make an incision in the left groin and to surgically expose the left common femoral artery. A 5-mm transverse arteriotomy was performed and the cannula was inserted under direct vision without a stylet. Fluoroscopy was not used to control the progression of the tip of the cannula. Unrestricted blood flow was observed and the cannula was connected to the cardiopulmonary bypass tubing. A 7-cm transverse skin incision was made over the 3rd intercostal space followed by a transverse sternotomy. The pericardium was opened and cardiopulmonary bypass was instituted at 32°C. Minor pericardial adhesions were found but the ascending aorta was easily dissected. While on full flow, a sudden drop in aortic pressure together with a massive dilatation of the ascending aorta was noticed. The suspicion of aortic dissection prompted an immediate conversion to a median sternotomy. The patient was cooled to 20°C and the aorta was opened under circulatory arrest. The diagnosis of intraoperative aortic dissection was confirmed. The dissection was repaired with gelatin-resorcin-formol glue, the ascending aorta was replaced with a 30-mm Hemashield (Meadox Medicals Inc., Oakland, NJ, USA) knitted double-velour graft and the aortic valve was replaced with a 27-mm Carpentier-Edwards bovine pericardial xenograft (Baxter Edwards AG, Horw, Switzerland). Aortic cross-clamp time was 40 minutes, circulatory arrest time was 25 minutes, and cardiopulmonary bypass time was 133 minutes. After coming off bypass, massive oozing was noticed from the epicardial surface. The patient eventually died on the operating table from uncontrollable bleeding. Postmortem examination confirmed aortic dissection with an entry point at the level of the left femoral artery.
|
DISCUSSION
|
|---|
There is no doubt that minimally invasive cardiac surgery will modify our patterns of practice in the near future. The early experience reported by a number of authors shows extremely encouraging data in the attempt to diminish surgical trauma and morbidity, to improve patient satisfaction, and to reduce costs. Both minimally invasive coronary bypass surgery5 and valvular procedures3,4 are nowadays becoming more popular worldwide. It seems that one of the major issues is patient selection, especially in the current early days of the learning curve. Regarding valve replacement or repair, procedures performed through a right mediastinotomy, transverse sternotomy, or limited superior sternotomy are gaining popularity. However, we must keep in mind that although surgeons are accumulating experience there are no large series proving that minimally invasive cardiac surgery provides better overall results than conventional surgery, in spite of the overall feeling supported by personal impressions.6
In our case, we had an intraoperative complication that we consider most likely related to a modification of the normal surgical strategy. The intraoperative aortic dissection was related to femoral artery cannulation using a sharp-tipped cannula designed for percutaneous insertion. As this happened early in our minimally invasive experience, it led us to an immediate modification of our approach and following the experience of others we now try to avoid cannulation of the femoral artery. It is our impression that femoral artery cannulation is avoided by most surgeons performing minimally invasive cardiac surgery. For those working on port-access surgery that includes femoro-femoral cardiopulmonary bypass and endoaortic clamping, intraoperative aortic dissection might represent a major threat.7,8
The lesson learned from this surgical disaster and from other unreported complications from different surgeons is that femoral artery cannulation should be eliminated unless strictly necessary and that we must avoid the use of sharp-tipped cannulae. On the other hand, for many years femoral artery cannulation has been used for a number of procedures such as complex reoperations and surgery for aortic arch dissection, using soft-tipped cannulae, without major vascular complications. Why did we changed our femoral artery cannulation strategy and material? Why do we perform cannulation of the ascending aorta rather than attempt the femoral approach? Even though the incidence of intraoperative aortic dissection using the conventional sternotomy approach and arch cannulation has been reported to be very low, such a complication may endanger a minimally invasive surgical program and this should be considered as a serious warning.
In an attempt to minimize the chances of intraoperative aortic dissection it is probably not wise to cannulate the femoral arteries but if this is required, to use a short flexible-tipped cannula rather than a very long cannula, as has been the rule. In the event of any difficulty in progression of the cannula (without fluoroscopic control) we recommend that the cannula be removed immediately. Careful selection of material and patients is probably the best approach to avoid undesirable complications.
|
REFERENCES
|
|---|
-
Calafiore AM, Angelini GD, Bergsland J, Salerno TA. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg
1996;62:1545–8.[Abstract/Free Full Text]
-
Robinson MC, Gross DR, Zemen W, Stedje-Larsen E. Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy. J Cardiac Surg
1995;10:529–36.[Medline]
-
Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg
1996;62:596–7.[Abstract/Free Full Text]
-
Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg
1996;62:1542–4.[Abstract/Free Full Text]
-
Lytle BW. Minimally invasive cardiac surgery. J Thorac Cardiovasc Surg
1996;111:554–5.
-
Arom KV, Emery RW. Minimally invasive direct coronary artery bypass graft surgery: experience during the learning curve. Asian Cardiovasc Thorac Ann
1997;5:15–9.
-
Stevens JH, Burdon TA, Peters WS, et al. Port-access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg
1996;111:567–73.[Abstract/Free Full Text]
-
Pompili MF, Stevens JH, Burdon TA, et al. Port-access mitral valve replacement in dogs. J Thorac Cardiovasc Surg
1996;112:1268–74.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
S. Tokunaga, S. Morita, S. Sumiyoshi, and R. Tominaga
Management for intraoperative acute aortic dissection during minimally invasive aortic valve replacement
Interactive CardioVascular and Thoracic Surgery,
December 1, 2005;
4(6):
595 - 596.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
