Conversion from ministernotomy to full sternotomy in aortic valve replacement

Conversion (C) from ministernotomy (M.S.) to full sternotomy was necessary in 5% of the cases in a series of 100 patients consecutively operated for Aortic Valve Replacement (A.V.R.) Analysis of the demographics and surgical techniques indicate older age, aortic fragility, diffuse coronary disease, chronic renal failure and left vent insertion as contributing factors. Despite increased operative blood losses, extra-corporeal circulation (E.C.C.) times, intensive care unit (I.C.U.) stay and hospital stay, no mortality was observed in the conversion group, as compared to 4.2% mortality in the total ministernotomy (MS) population. Preoperative patients selection, avoidance of technical pitfalls, and knowledge of alternative surgical measures are suggested to further decrease the incidence of conversions.     

"I" ministernotomy for aortic valve replacement.

BACKGROUND: Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement. METHODS: Eighteen patients were operated on by means of an "I" ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an "I" median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto-right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia. RESULTS: Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses. CONCLUSIONS: Our experience demonstrates that the "I" ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.     

Simple de-airing technique for aortic valve replacement with upper ministernotomy

Upper ministernotomy for aortic valve replacement is intimidating for many surgeons, not only for limited surgical exposure but also for the inability to complete de-airing the apex of the heart. Conversion to full sternotomy had been reported for this inability to de-air the apex of the heart in a limited number of cases. We describe a simple de-airing method by introducing a 16 GA catheter into the apex of the left ventricle through the aorta and prosthetic valve.     

Partial versus full sternotomy for aortic valve replacement

Background. Recent trends suggest that smaller incisions reduce postoperative morbidity. This study tests the hypothesis that a partial upper sternotomy improves patient outcome for aortic valve replacement.

Methods. A group of 50 patients who underwent aortic valve surgery through a partial upper sternotomy (group I) were compared to 50 patients who underwent aortic valve replacement through a median sternotomy during the same time period (group II). The mean age (60 ± 2 versus 63 ± 2 years; mean ± SEM) and preoperative ejection fractions (53 ± 2 versus 54 ± 2) were similar. Operations were performed with central cannulation, and antegrade/retrograde blood cardioplegia.

Results. There was one death in each group. No differences were found in aortic occlusion time, mediastinal drainage, transfusion incidence, narcotic requirement, length of stay, or cost. The incidence of pleural and pericardial effusions was increased (18.4% versus 3.9%, p < 0.03), and the need for postoperative inotropic support was higher (38.7% versus 19.6%, p < 0.03) in the partial sternotomy group.

Conclusions. Aortic valve replacement can be performed through a partial sternotomy with results comparable to full sternotomy. The partial sternotomy offers a cosmetic benefit, but does not significantly reduce postoperative pain, length of stay, or cost.     

Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy

BACKGROUND: the theoretical advantages of mini-invasive cardiac surgery are shorter hospitalisation, better surgical results and costs reduction. In November 1997 we started a non-coronary mini-invasive surgery program using a partial upper median sternotomy. This study has been conceived to retrospectively compare two groups of patients who underwent isolate aortic valve replacement using the conventional and the mini-invasive technique. MATERIAL AND METHODS: in Group A 100 patients (mean age 62+/-12 years; 58 male) underwent isolated aortic valve replacement through a partial upper median sternotomy. Group B was composed by the last 100 patients (mean age 63+/-8 years; 56 male) who underwent the same operation through a conventional median sternotomy. For both groups we recorded the ECC and ischaemic times, postoperative intubation time, total postoperative bleeding, intensive care unit length of stay and total hospitalisation time. Major and minor complications were reported. RESULTS: operating times, were significantly longer in Group A (p<0.001). Mechanical ventilation time, ICU and total hospital stay, and total postoperative bleeding showed no significant difference. Adjunctive statistical evidenced the absence of learning curve. Mortality and other complications failed to reveal any significant difference between the two groups. CONCLUSIONS: in our experience, partial upper median sternotomy does not increase surgical risks but failed to demonstrate clear advantages. Apart for an increase in operating times, the surgical results are similar to those of a conventional median sternotomy with only improvement in the aesthetical aspect. In our opinion, this supports the conviction that this approach can be proposed to selected patients, to obtain a better cosmethical result for the same given risk.     

Limited upper sternotomy for minimally invasive aortic valve replacement

The practice of minimally invasive valve surgery remains controversial. From May 1998, we began minimal invasive aortic valve replacement through the limited upper sternotomy. This technique is simple and provides and easy approach for the aortic valve. From May 1998 to Jan 2000, we performed 15 cases of aortic valve replacement with the limited upper sternotomy approach. All patients received valve replacement with prosthetic valve. We also described a simple and easy air evacuation system to avoid air embolism, a serious problem with a limited operative field. Mean aortic cross clamping time was 79 min, mean cardiopulmonary bypass time was 106 min, and mean operation time was 207 min. It did not take too much time compared with the conventional approach. Mean extubation time was 62 min and mean bleeding 12 hours after the operation was 96 ml. No patient required blood transfusions. All patients but one walked the very next day after the operation. We believe this new method brings not only cosmetic benefits, but also results in excellent post-operative course.     

Valve replacement via upper partial sternotomy for quadricuspid aortic valve

A 52-year-old man was referred to our clinic because of chronic heart failure. A Levine 3/6 diastolic heart murmur was audible at the apex. Chest radiography showed an enlarged left ventricle. Transthoracic echocardiography showed moderately severe aortic regurgitation. Left ventricular end-diastolic/systolic diameter and ejection fraction were 75/59 mm and 41 %, respectively. Preoperative transesophageal 3-dimensional echocardiography revealed a quadricuspid aortic valve whose cusps were of almost equal size. Aortic valve replacement was performed via upper partial sternotomy.     

Comparison of limited and full sternotomy in aortic valve replacement

Objective: The practice of minimally invasive valve surgery remains controversial. The aim of this study was to evaluate the technical feasibility and postoperative course of aortic valve replacement through limited upper sternotomy compared to conventional full sternotomy. Methods: From May 1998 to August 2000, we performed 24 cases of isolated aortic valve replacements through the limited upper sternotomy approach (group M). During the same period, 18 patients received isolated aortic valve replacements through the conventional full sternotomy approach (group C). Operation duration, postoperative course and laboratory data were compared between the two groups. Results: All patients received a valve replacement with a prosthetic valve. There was no significant difference between the two groups in mean aortic cross-clamping time, mean cardiopulmonary bypass time or mean operation duration (skin to skin). No patient required blood transfusion. Patients in the group M were extubated earlier, with less postoperative blood loss and discharged earlier after the operation than those in group C. On the first postoperative day, the peak level of lactic acid dehydrogenease was significantly lower in the group M than those in group C. Conclusion: Limited upper sternotomy for aortic valve replacement resulted in shorter operation duration and minimized operative risks for the patients. We believe this method brings not only cosmetic benefits but also improved postoperative course.     

Reversed “C” ministernotomy for aortic valve replacement

The technique of aortic valve replacement through a reversed “C” sternotomy incision is described. The sternal incision extends between the second and the fifth intercostal space and provides excellent exposure of the ascending aorta, the aortic root, and the right atrial appendage. The procedure can be performed with standard cannulation for cardiopulmonary bypass and conventional surgical instruments.     

Alternative to sternotomy: aortic valve replacement through right thoracotomy

Many minimally invasive alternatives to aortic valve replacement through full sternotomy have been described. We report an approach through a right thoracotomy that has been planified in 2 patients with contraindication to standard thoracotomy. Exposure was excellent, and valve replacement could be performed safely.     

Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study

Background. Minimally invasive aortic valve replacement reduces surgical trauma and, supposedly, postoperative pain, blood loss, and length of stay. A prospective, randomized study was designed to prove these theoretical advantages.

Methods. Forty patients undergoing isolated, elective aortic valve replacement were randomized into two equal groups. Patients in group M underwent aortic valve replacement through a ministernotomy (reversed or reversed ). In group S, a median sternotomy was used. The anesthetic and surgical protocol was identical for both groups. Pain was evaluated on a daily basis. Pulmonary function tests were performed preoperatively and before hospital discharge in all patients.

Results. There were two deaths in each group. Cross-clamp time was longer in group M: 70 ± 19 minutes versus 51 ± 13 minutes in group S (p = 0.005). There were no statistically significant differences between groups M and S in pump time (95 ± 20 minutes versus 83 ± 19 minutes), extubation time (9.9 hours in both groups), chest drainage (479 ± 274 mL/ 24 hours versus 355 ± 159 mL/ 24 hours), transfusion requirements (27% in both groups), pain evaluation (1.34 ± 1.3 versus 2.15 ± 1.5), length of stay (6.2 ± 2.3 days versus 6.3 ± 2.5 days), and cosmetic appraisal. Forced vital capacity decreased 26% from preoperative reference values in group M and 33% in group S (p = not significant). Forced expiratory volume in 1 second decreased 22% and 35%, respectively (p = not significant).

Conclusions. This study has failed to prove the theoretical advantages of minimally invasive aortic valve replacement. With this technique, cross-clamp time is longer than with a median sternotomy.     

Minimally invasive sternotomy for aortic valve replacement followed by a minilaparotomy for abdominal aneurysm repair

Abdominal aortic aneurysms (AAAs) are commonly associated with severe coronary artery disease, but the incidence of associated aortic valve disease and AAAs in the general population is not known. The standard approach for surgical repair of AAAs is a laparotomy, and for aortic valve repair, a full sternotomy; results of both approaches are well documented. However, when AAAs and aortic valve disease occur concomitantly and both are symptomatic, they should be repaired during a combined procedure, with the aortic valve repair performed first. We describe the case of a 75-year-old patient with a symptomatic infrarenal AAA and severe aortic valve stenosis. To avoid an extensive surgical incision and shorten the recovery period, we performed a combined procedure in which we replaced the aortic valve through a ministernotomy and repaired the AAA through a minilaparotomy. The postoperative period was uneventful, and the patient was discharged home 6 days after surgery.     

Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy

OBJECTIVE: We developed techniques for partial upper hemisternotomy for reoperative aortic valve replacement and compared the results with those of reoperative aortic valve replacement by way of conventional full resternotomy. METHODS: We retrospectively analyzed data from 19 patients who underwent conventional full sternotomy and 20 patients who underwent partial hemisternotomy for isolated elective reoperative aortic valve replacements performed between November 1996 and September 1998. Univariable and multivariable analyses were used to document the differences between the groups. RESULTS: The 2 groups were similar with respect to age, sex, New York Heart Association functional class, valve pathologic characteristics, and numbers and types of previous operations. There were neither any operative deaths nor any postoperative valve-related morbidities in either group. There was 1 injury to a cardiac structure, which occurred in the conventional full sternotomy group. Univariable analysis documented that patients in the conventional full sternotomy group were significantly more likely to have at least 1000 mL blood loss during the first 24 hours after the operation (odds ratio 8.1, P =.02), were more likely to require transfusion of more than 5 units of packed red blood cell (odds ratio 3.6, P =.08), and were more likely to have a total operative duration longer than 5 hours (odds ratio 3.6, P =.08). In the multivariable analysis conventional full resternotomy remained a risk factor for greater blood loss (odds ratio 5.7, P =.06), greater transfusion requirement (odds ratio 2.4, P =.25), and longer total operative duration (odds ratio 7.7, P =.03). CONCLUSIONS: Partial upper hemisternotomy for reoperative aortic valve replacement avoids unnecessary lower mediastinal dissection, thereby reducing blood loss, transfusion needs, and total operative duration. These beneficial effects, which are accomplished without compromising the efficacy of the valve operation, make the partial upper hemisternotomy an excellent alternative to conventional full resternotomy for reoperative aortic valve replacement.     

Partial median "I" sternotomy: minimally invasive alternate approach for aortic valve replacement

Minimally invasive aortic valve replacement using the inversed L-like partial upper sternotomy has evolved during the last 10 years. It is performed with excellent results with regard to sternal stability and cosmesis. However, the lateral incision may result in sternal overriding, instability, or fracture. We present an alternate minimally invasive approach to aortic valve replacement. We performed a partial median "I" sternotomy in 30 consecutive patients: After a 6- to 8-cm skin incision, the sternum was incised from the jugulum downward to the corpus, ending at the level of the fourth or fifth intercostal space. No lateral incision of the sternum was performed. The access to the heart and aorta was excellent. During the postoperative course and during follow-up, clinical examination revealed sternal stability and normal wound healing in all patients. These results show that the partial median I sternotomy can be performed safely and provides excellent clinical and cosmetic results.