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J Thorac Cardiovasc Surg 1997;113:806-807
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT

Buenos Aires, Argentina

From Fundation Benetti, Buenos Aires, Argentina.

Received for publication Oct. 8, 1996 accepted for publication Nov. 27, 1996. Address for reprints: Federico J. Benetti, MD, M.T. de Alvear 2323, Buenos Aires, Argentina.

Several reports have been published recently detailing less invasive techniques for cardiothoracic surgical procedures designed to limit surgical trauma while decreasing costs. ¹ After our initial successful experience with minimally invasive video-assisted coronary surgery ^2-4 and minimally invasive video-assisted mitral valve replacement, ⁵ which followed the first report of video-assisted mitral valvuloplasty by Carpentier and associates, ⁶ we performed two cases of minimally invasive aortic valve replacement with a new technique.

Clinical summaries

patient 1.
A 63-year-old male patient was admitted in July 1996 with severe calcific aortic stenosis, chronic obstructive pulmonary artery disease, and New York Heart Association class IV symptoms. The patient was placed on the operative table in the 30-degree left lateral decubitus position with the right arm elevated above the head. A 6 cm incision was made in the third intercostal space (Fig. 1), and a specially adapted wound spreader (Access Platform, CardioThoracic System, Inc., Portola Valley, Calif.) was secured in place and gently opened to avoid rib fractures.The pericardium was opened on the lateral side exposing the aortic root, the right atrium, and the right superior pulmonary vein (RSPV). To improve the exposure, we supplied several stay sutures at the edges of the pericardial opening and fixed them to the skin. The right femoral artery and the right atrium were cannulated. A vent was inserted in the RSPV. After cardiopulmonary bypass (CPB) was established, the aorta was crossclamped and crystalloid cardioplegic solution was infused in the aortic root. A transverse aortotomy was performed and three stitches were placed in the commissures and pulled upward to expose the anulus. A 21 mm mechanical prosthesis was implanted with single Cardioflon sutures (Peters Laboratories, France). The aortotomy was then closed with a polypropylene running suture, and the air was evacuated through the aortic root and the RSPV vent. Perfusion time was 85 minutes and crossclamp time was 70 minutes. The patient was extubated 24 hours after the operation and discharged on postoperative day 6. The postoperative course was uneventful.

View larger version (19K): [in this window] [in a new window]   Fig. 1. The site of the incision in the right third intercostal space.

Discussion.
To the present day only a few reports of minimally invasive valve operations have been published. ^5-8 The method described with a small anterolateral thoracotomy in the third intercostal space and the use of a specially adapted wound spreader permits an optimal exposure of the aortic root, the aortic valve, the right atrium, and the RSPV, thus allowing appropriate access to all sites of cannulation. The use of the femoral artery as an alternative site of cannulation depends both on the anatomic characteristics of each patient (i.e., the presence of aortic calcification) and on the surgeon's preference.

Undoubtedly, the rapid and effective development of the instruments has played a major part in the growth of minimally invasive procedures in cardiac surgery. In fact, in this report the two described cases of minimally invasive aortic surgery were possible because of the technical evolution of the specific instruments: the particular shape of the wound spreader's arms creates a visual tunnel through the intercostal space by retracting the third rib while pushing it downward, at the same time retracting the fourth rib and pulling it upward. This access produces an operative view adequate to safely perform aortic valve surgery. Therefore removal of ribs or cartilage fragments is not necessary, which results in a less traumatic and less painful approach. Minimally invasive valve surgery, ^5-8 although still in its pioneering era, can open new horizons for cardiac surgery. In fact, along with the widespread and well-defined application of video-assisted technique in thoracic surgery, minimally invasive coronary and valvular procedures ^1-8 are the reenergizing forefront of the future evolution of cardiac surgery and could offer concrete benefits to patients with cardiac disease.

References

1. Lytle BW. Minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 1996;111:554-5.
   
2. Benetti FJ, Ballester C. Use of thoracoscopy and a minimal thoracotomy in mammary-coronary bypass to left anterior descending artery without extracorporeal circulation: experience in 2 cases. J Cardiovasc Surg 1995;36:159-61.[Medline]
   
3. Benetti FJ, Ballester C, Sani G, Boonstra PW, Grandjean JG. Video-assisted coronary bypass surgery. J Card Surg 1995;10:598-602.
   
4. Benetti FJ, Mariani MA, Sani G, Boonstra PW, Grandjean JG, Giomarelli PP, et al. Video-assisted minimally invasive coronary operations without cardiopulmonary bypass: a multicenter study. J Thorac Cardiovasc Surg 1996;112:1478-84.[Abstract/Free Full Text]
   
5. Benetti FJ, Rizzardi JL, Pire L, Polanco A. Mitral valve replacement under video-assist through a small thoracotomy. Ann Thorac Surg. In press.
   
6. Carpentier A, Louimet D, Carpentier A, et al. First heart operation (mitral valvuloplasty) under videosurgery through a minithoracotomy. CR Acad Sci Paris 1996;319:219-23.
   
7. Lin PJ, Chang CH, Chu JJ, et al. Video-assisted mitral valve operations. Ann Thorac Surg 1996;61:1781-7.[Abstract/Free Full Text]
   
8. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-7.[Abstract/Free Full Text]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Federico J. Benetti Massimo A. Mariani Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Benetti, F. J. Articles by Benetti, I. Search for Related Content PubMed PubMed Citation Articles by Benetti, F. J. Articles by Benetti, I.