Should Minimally Invasive Aortic Valve Replacement be Restricted to Primary Interventions?

Abstract

Background: The role of minimally invasive aortic valve replacement in cardiac reoperations has not yet been defined. The purpose of this study is to report our experience with this technique. Methods: Nineteen consecutive patients underwent aortic valve replacement via J-sternotomy as a reoperative cardiac procedure between 1999 and 2005. The mean age was 73.6 ± 11.4 years. Previous cardiac operations included 12 (63.2 %) coronary artery bypass graftings, 6 (31.5 %) aortic valve replacements and 1 (5.2 %) mitral valve replacement. Mean follow-up was 23.6 ± 19.7 months. The medical records were retrospectively analyzed. Results: All procedures were successful. Mean aortic cross-clamping time and cardiopulmonary bypass time were 87.4 ± 32.7 and 133.1 ± 54.4 minutes, respectively. Cannulation sites were: ascending aorta (52.6 %), femoral artery (47.4 %), femoral vein (94.8 %) and right atrium (5.2 %). Myocardial protection was obtained by selective coronary osteal cold crystalloid cardioplegia and systemic cooling (mean 26.2 ± 4 °C). Average intubation time was 1.5 ± 1.4 days. Mean intensive care unit stay and postoperative hospital stay was 2.9 ± 2.6 and 12.9 ± 5.7 days, respectively. Median chest tube output was 550 ml. There were 4 revisions for bleeding. There were 2 late deaths and one non-incision related hospital death (5 %). This patient, who was already being treated for chronic dialysis, died on day 22 due to a cerebrovascular accident. Conclusions: Minimally invasive aortic valve replacement is feasible as a reoperative procedure. Its major advantage is avoidance of cardiac reexposure with potential damage to coronary grafts. We think this technique deserves more widespread application.

Key words

aortic disease - heart valve surgery - coronary bypass surgery - myocardial protection

References

• 1 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
• 2 Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study.  Ann Thorac Surg. 2002;  73 460-466
• 3 Cosgrove D MIII, Sabik J. Minimally invasive approach to aortic valve operations.  Ann Thorac Surg. 1996;  62 596-597
• 4 Svensson L G. Minimal-access “J” or “j” sternotomy for valvular, aortic and coronary operations or re-operations.  Ann Thorac Surg. 1997;  64 1501-1503
• 5 Moreno-Cabral R J. Mini-T sternotomy for cardiac operations.  J Thorac Cardiovasc Surg. 1997;  113 810-811
• 6 Aris A. Reversed C sternotomy for aortic valve replacement.  Ann Thorac Surg. 1999;  67 1806-1807
• 7 Von Segesser L K, Westaby S, Pomar J, Loisance D, Groscurth P, Turnia M. Less invasive aortic valve surgery: rationale and technique.  Eur J Cardiothorac Surg. 1999;  15 781-785
• 8 Bakir I, Casselman F, Wellens F. et al . Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients.  Ann Thorac Surg. 2006;  81 1599-1604
• 9 Tam R K, Garlick R B, Almeida A A. Minimally invasive redo aortic valve replacement.  J Thorac Cardiovasc Surg. 1997;  114 682-683
• 10 Shanmugam G. Aortic valve replacement following previous coronary surgery.  Eur J Cardiothorac Surg. 2005;  28 731-735
• 11 Hoff S J, Merrill W H, Stewart J R, Bender Jr H W. Safety of remote aortic valve replacement after prior coronary artery bypass grafting.  Ann Thorac Surg. 1996;  61 1689-1692
• 12 Sundt T M, Murphy S F, Barzilai B. et al . Previous coronary artery bypass grafting is not a risk factor for aortic valve replacement.  Ann Thorac Surg. 1997;  64 651-658
• 13 Byrne J G, Aranki S F, Couper G S, Adams D H, Allred E N, Cohn L H. Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy.  J Thorac Cardiovasc Surg. 1999;  118 991-997
• 14 Byrne J G, Karavas A N, Adams D H. et al . Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery.  Eur J Cardiothorac Surg. 2000;  18 282-286
• 15 Casselman F P, Van Slycke S, Wellens F. et al . Mitral valve surgery can now routinely be performed endoscopically.  Circulation. 2003;  108 II‐48-II-54
• 16 Cohn L H, Adams D H, Couper G S. et al . Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.  Ann Surg. 1997;  226 421-428
• 17 Cooley D A. Minimally invasive valve surgery versus the conventional approach.  Ann Thorac Surg. 1998;  66 1101-1105
• 18 Aris A, Cámara M L, Montiel J, Delgado L J, Galán J, Litvan H. Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study.  Ann Thorac Surg. 1999;  67 1583-1588
• 19 Szwerc M F, Benckart D H, Wiechmann R J. et al . Partial versus full sternotomy for aortic valve replacement.  Ann Thorac Surg. 1999;  68 2209-2214
• 20 Liu J, Sidiropoulos A, Konertz W. Minimally invasive aortic valve replacement (AVR) compared to standard AVR.  Eur J Cardiothorac Surg. 1999;  16 S80-S83
• 21 Doll N, Borger M A, Hain J. et al . Minimal access aortic valve replacement: effects on morbidity and resource utilization.  Ann Thorac Surg. 2002;  74 S1318-S1322
• 22 Sun L, Zheng J, Chang Q. et al . Aortic root replacement by ministernotomy: technique and potential benefit.  Ann Thorac Surg. 2000;  70 1958-1961