Valvular Disease: The Case for Conventional Treatment

Infrequent Procedures

As cardiac surgeons, we are committed to performing surgery with the least possible morbidity in our patients. It can be assumed that everybody will agree with that statement. The question arises as to whether morbidity and mortality are lowest when performing minimally invasive cardiac surgery. Four years ago, we held a round-table discussion in this convention with 7 chairmen of cardiac surgical centers participating. In the conclusion, Prof. Leitz from Bremen stated that minimally invasive surgery is still experimental [1]. Of course, time has changed and progress has been made; but minimally invasive surgery is still only performed by few surgeons, and the overall incidence as compared to conventional procedures is rather low [2].

Why is this? The reasons for adhering to conventional surgery are manifold: First, conventional surgery is applicable to every patient, and all surgeons are trained in these procedures. Exposure is excellent, and there are many ways to improve access where necessary. Cannulation is easily performed via the sternotomy approach, and modifications are always possible according to anatomical variations. Femoral cannulation is rarely required. Another very important point is the feasibility of enlarging the procedure, which will be discussed later. Taken together, and everybody knows this, conventional surgery is simple, safe, and quick [3].

When speaking of minimally invasive valvular surgery, we should consider its aims [4]. In coronary bypass surgery, the primary intention is to avoid extracorporeal circulation - certainly a tremendous advantage. However, valvular surgery would be impossible without a heart-lung machine! Therefore, our main goal is to reduce trauma. Usually, the secret lies in minimizing the incision. The problem is that many surgical techniques lead to maximization of technical difficulty while minimizing the access [5]. This cannot or should not be the solution for the problem. Further arguments often held in the US involve recovery time and costs. Our system is different, as our patients are not discharged home one week after surgery. With the increasing problems in our health care system, however, these arguments may play a role in the future.

Another question is whether patients really want to have minimally invasive surgery. A paper form the Bad Nauheim Group stated that “78 % of patients preferred to have a full sternotomy” [6]. Of course, we all know that a decision in favor of one type of operation or another is a matter of “talking with the patients”, that is, how to emphasize advantages and disadvantages of a procedure. Still, we should assume that there is a certain percentage or patients who prefer to have conservative or standard surgery.

References

• 1 Leitz K H. Rundtischgespräch mit dem Thema: Minimal-invasive Herzchirurgie - verändert sich der Standard?.  Thorac Cardiovasc Surge. 1998;  46 311-320
• 2 Kalmár P, Irrgang E. Cardiac surgery in Germany during 2000.  Thorac Cardiovasc Surge. 2001;  48 XXXIII-XXXVIII
• 3 Scheld H H, Deng M C, Schmid C, Hammel D. Koronarchirurgie - Münsteraner Konzept.  Z Herz Thorax-Gefäßchirur. 1995;  9 1-8
• 4 Scheld H H, Schmid C. Cardiac surgery without the use of cardiopulmonary bypass: the challenges. Curr Op.  Anaesthesiol. 1998;  11 5-8
• 5 Baldwin J C. Editorial (con) re minimally invasive post-access mitral valve surgery.  J Thoracic Cardiovasc Surg. 1998;  115 563-564
• 6 Ehrlich W, Skwara W, Klövekorn W -P, Roth M, Bauer E P. Do patients want minimally invasive aortic valve replacement?.  Eur J Cardiothorac Surg. 2000;  17 714-717
• 7 Estrera A L, Reardon M J. Current approaches to minimally invasive aortic valve surgery.  Curr Opin Cardiol. 2000;  15 91-95
• 8 Christiansen S, Stypmann J, Tjan T DT. et al . Minimally-invasive versus conventional aortic valve replacement - perioperative course and mid-term results.  Eur J Cardiothorac Surg. 1999;  16 647-652
• 9 Schroeyers P, Wellens F, De Geest R. et al . Minimally invasive video-assisted mitral valve surgery: our lessions after a 4-year experience.  Ann Thorac Surg. 2001;  72 S1050-S1054
• 10 Autschbach R, Onnasch J F, Falk V. et al . The Leipzig experience with robotic valve surgery.  J Card Surg. 2000;  15 82-87

1 During the 31^st Annual Meeting of the German Society of Thoracic and Cardiovascular Surgery, a panel discussion was held. This paper reflects the presentation and consecutive discussion of the “pro-conventional surgery” standpoint.