Minimally invasive triple valve surgery through partial upper sternotomy: Early results are promising

Objectives: Partial upper sternotomy (PUS) has become an established less invasive approach mainly for single and double valve surgery. More complex procedures including triple valve surgery (TVS) are associated with considerable perioperative risk and classically performed through a full sternotomy. We report herein our institutional results of TVS performed through PUS.

Methods: The medical records of 19 consecutive patients who underwent primary elective (95%) or urgent (5%) TVS between 2005 and 2011 were reviewed. Patients mean age was 69 ± 13 years, 73% were in New York Heart Association Class III or IV, 63% had pulmonary hypertension and 74% had recent cardiac decompensation. Insufficiency was more common than stenosis for both, the aortic (63%) and mitral (89%) valve. Tricuspid valve disease was functional regurgitation in all patients.

Results: Aortic valve procedures consisted of 13 (68%) replacements and 6 (32%) repairs. The mitral valve could be repaired in 85% of patients while tricuspid valve repair was feasible in all patients. The PUS was taken down to either the 4^th (11 patients; 58%) or 5^th (8 patients; 42%) left intercostal space as appropriate. Additionally, the ascending aorta was either reduced in diameter in 6 (38%) or replaced in 3 (16%) patients. No conversion to full sternotomy was necessary. Aortic cross-clamp, cardiopulmonary bypass, and operative times averaged 148 ± 23 min., 194 ± 26 min. and 352 ± 82 min., respectively. Ventilation time was 30 ± 16 hours and ICU stay averaged 3 ± 2 days. Myocardial infarction was not observed. Chest tube drainage was 330 ± 190 ml, and 2 patients (10%) needed reexploration for bleeding or tamponade. A single permanent neurologic deficit was observed due to HIT Syndrome after initial unremarkable neurologic recovery. Wound dehiscence was observed in one patient that required high doses of vasopressors and was mechanically reanimated early postoperatively. Thirty-day mortality was 5% due to fulminant mesenteric infarction in the same patient with wound dehiscence.

Conclusion: PUS provides adequate exposure to all heart valves, with mortality, but also wound dehiscence and postoperative bleeding reported herein that are at the lower level as compared to other series of triple valve surgery via full sternotomy. Despite the limited number of patients in this preliminary report we feel comfortable with this approach and will further extend its application to complex surgery in the future.