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Minimally Invasive Aortic Valve Replacement Via Right Mini Symbiosis www.symbiosisonline.org www.symbiosisonlinepublishing.com Research article American Journal of Cardiovascular and Thoracic Surgery Open Access Minimally Invasive Aortic Valve Replacement via Right Mini- thoracotomy versus Conventional Full Median Sternotomy: Tertiary Center Experience Mohamed Alassal1*, Mohamed Saffan1, Basem Mofreh1, Samer AbdEl-Shafi2, Moataz Rezk1, Ehab Fawzy1, Mohammed Obida1, Mahmoud Elemam1 and Yosry Shaheen1 1Cardiothoracic Surgery Department, Benha University, faculty of medicine, Egypt 2Cardiothoracic Surgery Department, Military Medical Academy, Cairo, Egypt Received: 20 December, 2017; Accepted: 15 January, 2018; Published: 22 January, 2018 *Corresponding author: Mohamed Alassal, Cardiothoracic Surgery Department, Benha University, faculty of medicine, Egypt. E-mail: dmo- [email protected] Introduction Abstract Full median sternotomy has been well established as a Introduction: Minimally invasive approach to Aortic Valve Replacement (AVR) is increasingly accepted as a valid alternative standard approach for all types of open heart surgery for many to full sternotomy approach, as to reduce operative trauma with work is to evaluate the feasibility of minimally invasive aortic valve years. Although well established, the full sternotomy incision has the final aim to improve post-operative outcomes. The aim of this been frequently criticized for its length, post-operative pain and surgical access to achieve better cosmetic results, less postoperative possible Developments complications in minimally like wound invasive infection aortic and surgery instability began [1]. in discomfortsurgery through and fastera right recovery mini-thoracotomy, while maintaining and hence the to sameminimize level the of the mid-1990s with the pioneering work of Cohn, Cosgrove, Navia Methods: In this study a 150 patients with Aortic Valve Disease safety and favorable results as with conventional surgery. and others. Technological advancements in instrumentation, assisted vision, and CPB support have followed closely and have (AVD) requiring aortic valve surgery were none randomly selected. expedited this evolutionary process. Within a few short years The study was performed at Benha University Hospital & the Armed MIAVS have gone from simple modifications of conventional Forces Hospitals. Seventy five patients underwent aortic valve surgerynd or 3rd techniques to near totally endoscopic operations [2-5]. by traditional median sternotomy with central cannulation (group B), procedures, cardiac operations have become increasingly more Endpointsthe other seventy were overall five patients postoperative by right mini-thoracotomycomplications, major on 2adverse Because of the continuous trend towards less invasive right intercostal space with peripheral femoral cannulation (group A). cardiac related complications, use of blood products and need for cardiac operations require higher surgical abilities to accomplish transfusions, bypass time and cross clamp time, ventilation time and thesophisticated same quality and compared complex. with Minimally the traditional invasive procedures techniques with in lengthResults: of hospital-stay. reduction in need for blood and blood products transfusions, as well as Cardio-PulmonaryMinimally invasive Bypass aortic (CPB) valve or full surgery sternotomy has evolved [6]. into a Minimally invasive AVR was associated with a significant centers, providing greater patient satisfaction and lower postoperative cardiac and non-cardiac complications. Post-operative well tolerated, efficient surgical treatment option in experienced pain was significantly reduced in the mini-invasive group, a trend to aortic valve replacement arise from the concept that patient lower mean ventilation times, ICU stay and hospital-stay in the mini- complication rates. Potential advantages of minimally invasive invasiveConclusion: group was Minimally also detected. invasive aortic valve surgery has evolved morbidity and potential mortality could be reduced without centers, providing greater patient satisfaction and lower complication and include improved cosmetic results, safer access in the into a well tolerated, efficient surgical treatment option in experienced compromising the excellent results of the conventional procedure Replacement (MIAVR) arise from the concept that patient morbidity rates. Potential advantages of Minimally Invasive Aortic Valve and potential mortality could be reduced without compromising the case of re-operation, less post-operative bleeding, fewer blood transfusions, lower intensive care unit and in-hospital stays, as operativeexcellent resultsbleeding, of theless conventional blood transfusions, procedure lower and intensive include improved care unit well as the absence of sternal wound infection [7]. cosmetic results, safer access in the case of re-operation, less post- The key to successful thoracic surgical procedures is adequate and in-hospital stays, as well as the absence of sternal wound infection. and proper exposure. A well chosen thoracic incision provides effortless and excellent exposure for almost any procedure. However, an ill chosen or an improperly placed or performed Symbiosis Group * Corresponding author email: [email protected] Minimally Invasive Aortic Valve Replacement via Right Mini-thoracotomy versus Copyright: Conventional Full Median Sternotomy: Tertiary Center Experience © 2018 Alassal M, et al. Materials and Methods incision often leads to a difficult and frustrating procedure [8]. Patient Selection There is a learning curve associated with any cardiac surgical In this retrospective study, a 150 patients with Aortic Valve “learningprocedure, curve”, despite surgeons what experiencedneed to consider surgeons this the now standard consider of Disease (AVD) requiring aortic valve surgery were none randomly routine and simple. In order to overcome the conceptual is acquired, the minimal access approach may be the procedure care in isolated AVR surgery and make it reality. Once proficiency selected. The study was performed in the period from January 2014 through June 2016 at Benha University Hospital &the Armed of choice for AVR [9]. Forces Hospitals (El Maadi, El Galaa and kobryElkobba). Seventy five patients underwent aortic valve surgery by traditional The right mini-thoracotomy approach for aortic valve 3rdmedian right sternotomy intercostal spacewith centralwith peripheral cannulation femoral (group cannulation B), the replacement was first described by Rao and Kumar and was other seventy five patients by right mini-thoracotomy on 2nd or reproduced by Galloway and others. undergo computed tomography scan without contrast (group A). enhancementAll patients to scheduledevaluate the for anatomic right mini-thoracotomy relationship among should the • In group “A”, age ranged from 21-71 years with a mean of 49.1 ± 16. (I)intercostal at the level spaces, of main ascending pulmonary aorta, artery, and aortic the ascendingvalve. Patients aorta are is • While in group “B” age ranged from 24-73 years with a mean rightwardsuitable for (more this approach than one onlyhalf locatedif the following on the right criteria in respect are met: to of 47.6 ±13. the right sternal border); (II) the distance from the ascending • In group “A”, there was 45 males (60%) and 30 females (angle between the angle midline and the inclination of ascending (40%), while in group “B” there was 48 males (66.6%) and 27 aorta to the sternum does not exceed 10 cm (III) the α angle females (33.3%). aorta) should be > 45 (Figure 1A and 1B) [10]. Figure 1: SurgicalCT Technique angiography (A&B) showing the suitability of the patient for the minimally invasive approach Anesthesia is provided according to the standard protocol a transverse 3-4 cm incision along the inguinal fold over the used for conventional aortic valve surgery with the only pulsating femoral artery projection is made to expose the vessels. Purse string sutures with prolene 5/0 taken over the artery and vein. When heparin is administered, femoral artery and vein exception for a double lumen endotracheal tube for intubation. for monitoring the heart and valve functions throughout the cannulation are performed utilizing a Seldinger technique. We Transesophageal echocardiography was used in all patients perform arterial cannulation first; the cannula should never be forced and should advance easily. The cannula is then secured operation. Two defibrillator pads are placed across the chest wall over the vessel with a tourniquet and connected to the CPB to guarantee effective electric conduction. The patient is placed in arterial line (Figure 4). a supine position (Figure 2). After initiation of the CPB, venous drainage is achieved with The procedure is carried out through a 5-6 cm skin incision vacuum assistance of approximately -40 mmHg. Currently, several beginning at the right sternal border extending to the right muscle is opened by cautery followed by the intercostals muscle options are available for aortic cross-clamping. An external antero-lateral portionnd of rdthe chest wall. After that the pectoralis or 3 Cosgrove flexible or a Chitwood clamp can be used (Figure 5). delivered through the aortic root, a transverse aortotomy is made entering into the 2 ICS. We use a soft tissue retractor and After cross-clamping of the aorta and cardioplegia solution rib retractor to obtain further exposure (Figure 3). approximately 1.5 cm above the take off the right coronary artery, When both femoral arterial and
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