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J Thorac Cardiovasc Surg 1997;114:682-683
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

MINIMALLY INVASIVE REDO AORTIC VALVE REPLACEMENT

Brisbane, Australia

From the Departments of Cardiac Surgery, The Prince Charles Hospital, Brisbane, Australia.

Received for publication Feb. 18, 1997 accepted for publication May. 28, 1997. Address for reprints: Robert Tam, FRACS, Department of Cardiac Surgery, The Prince Charles Hospital, Rode Rd., Chermside, Brisbane, Australia, Q 4032.

A full resternotomy has been the standard approach for reoperation on the aortic valve. This carries a risk of right ventricular injury, which has a significant morbidity and mortality. ¹ Approaches to minimally invasive primary aortic valve replacement have been described. ^2,3 Our approach is to perform primary aortic valve surgery via a minimally invasive upper hemisternotomy without horizontal transection of the sternum. We describe a case of minimally invasive redo aortic valve replacement in which this approach was used.

A 69-year-old man had heart failure as a result of aortic valve xenograft degeneration. He had aortic valve replacement with a bioprosthesis 18 years previously for aortic valve bacterial endocarditis. He had had increasing dyspnea on exertion for 12 months before being admitted to our hospital.

Transesophageal echocardiography showed severe aortic xenograft regurgitation with leaflet prolapse. The ejection fraction was 55%, with an end-diastolic dimension of 66 mm. There was no evidence of prosthetic valve endocarditis. Coronary angiography showed wall disease in the left anterior descending artery.

An upper median hemisternotomy was performed with an oscillating saw. The sternum was divided from the notch to the fourth intercostal space. The sternum was not transected at the distal end (Fig. 1). A small retractor was placed to expose the ascending aorta and the right atrial appendage. Adhesions were freed and excessive thymic fat was excised to improve exposure. A tape was then placed around the aorta, and it was cannulated proximal to the brachiocephalic trunk. Because of the small incision and the previous use of the right atrial appendage for cannulation, repeat cannulation by means of this approach was not possible. The right femoral vein was then exposed and cannulated with a 27F-gauge venous cannula. Cardiopulmonary bypass was established and full flow was achieved by connecting the venous cannula to the roller pump. The patient was cooled to 30° C. The aorta was crossclamped after the heart was drained by continuing venous suction while temporarily ceasing arterial inflow. This prevented left ventricular distention before cardioplegic arrest, because the ventricle could not be vented at this stage.

View larger version (44K): [in this window] [in a new window]   Fig. 1. Sketch demonstrating the upper hemisternotomy before closure. The dotted line indicates the extent of the previous sternotomy.

The patient was extubated 7 hours after the operation and required no inotropic support. The blood loss was 400 ml and he was discharged from the intensive care ward the following day. Postoperative echocardiography showed normal aortic valve function. There were no embolic events. He had minimal wound discomfort and was discharged from the hospital on day 5.

The widely recognized complications of reoperative cardiac surgery are cardiac injury and increased bleeding. The major problem arises from adhesions between the right ventricle and the lower sternum. To avoid this problem, we modified our previous experience of aortic valve surgery by using an upper hemisternotomy. We have found that this approach is a safe alternative to full median sternotomy in primary aortic valve replacement. Some surgeons perform aortic valve surgery using an upper median sternotomy; however, their approach involves transecting the sternum. We have found this unnecessary to achieve adequate access. In addition, our approach does not risk injury to the internal thoracic artery, and the sternum is inherently stable.

In this case the exposure of the aorta was excellent. Owing to scarring of the right atrial appendage, femoral vein cannulation was required. Postoperative blood loss and wound morbidity were minimal. The patient was able to be mobilized and discharged early.

Enthusiasm for minimally invasive direct coronary artery bypass procedures continues to increase. The aim of less invasive procedures is to maintain the effectiveness of the operation, minimize cost, improve patient recovery, and shorten intensive care and hospital stay. These potential benefits encourage our application of minimally invasive aortic valve surgery. With further refinement of techniques, the minimally invasive approach can be applied to other cardiac surgical procedures.

References

1. Dobell ARC, Jain AK. Catastrophic hemorrhage during redo sternotomy. Ann Thorac Surg 1984;37:273-8. [Abstract/Free Full Text]
   
2. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-7. [Abstract/Free Full Text]
   
3. Konertz W, Waldenberger F, Schmautzler M, Ritter J, Liau J. Minimal access valve surgery through superior partial sternotomy: a preliminary study. J Heart Valve Dis 1996;5:638-40.[Medline]
   

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