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Beating Heart Minimally Invasive Mitral Valve Surgery in Patients with Previous Sternotomy: the Operative Technique and Early Outcomes

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Beating Heart Minimally Invasive Mitral Valve Surgery in Patients with Previous Sternotomy: the Operative Technique and Early Outcomes Open Access Cardiac surgery Open Heart: first published as 10.1136/openhrt-2017-000749 on 20 January 2018. Downloaded from Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes Robert B Xu, Mohammad Rahnavardi, Mart Nadal, Fabiano Viana, Robert G Stuklis, Michael Worthington, James Edwards To cite: Xu RB, Rahnavardi M, ABSTRACT Key questions Nadal M, et al. Beating heart Objective Reoperative mitral valve surgery is increasingly minimally invasive mitral valve required and can be associated with significant morbidity surgery in patients with previous What is already known about this subject? and mortality. The beating heart minimally invasive sternotomy: the operative Multiple previous groups have previously presented mitral valve surgery has a proposed benefit in avoiding ► technique and early outcomes. data showing good outcomes with performing the risks of repeat sternotomy, with reducing the need Open Heart 2018;5:e000749. mitral valve surgery on the beating heart, through a for adhesiolysis and cardioplegia reperfusion injury. We doi:10.1136/ right thoracotomy. openhrt-2017-000749 describe our experience with such a technique in patients with previous sternotomy. What does your study adds? Methods A retrospective study was performed and all ► Our case series confirms that this surgical Received 13 November 2017 patients undergoing surgery of mitral valve through a right approach is safe in a single-centre Australian Revised 14 December 2017 limited thoracotomy without application of an aortic cross- Accepted 20 December 2017 setting. In particular, we report a low rate of stroke clamp (beating heart) as a redo cardiac surgery between (4%). January 2006 and January 2015 were included (n=25). Perioperative data as well as the operative technique are How might this impact on clinical practice? presented. ► This would reinforce the feasibility and safety Results Six patients (24%) had two previous sternotomies of this surgical approach, for surgeons that are and one (4%) had three previous sternotomies. Mitral considering undertaking this procedure. valve repair was performed in 11 patients (44%). No http://openheart.bmj.com/ patient required conversion to median sternotomy. Inotropic support beyond 4 hours after operation was Hazards during reoperative surgery include required in seven patients (28%). Ventilation time was sternal re-entry with attendant risks of less than 12 hours in 14 patients (56%) with another six patients (24%) extubated within 24 hours after damage to the right ventricle, aorta, innom- surgery. Postoperative course was complicated with inate vein and patent coronary grafts. Dissec- cerebrovascular accident in two patients (8%). In-hospital tion of adhesions can be time-consuming mortality was 4% (n=1). There was no 30-day mortality and technically challenging, especially if the after discharge. aorta must be exposed for cannulation or on September 27, 2021 by guest. Protected copyright. Conclusions Reoperative mitral valve surgery can be cross-clamping. Adequate exposure of the safely performed through a limited right thoracotomy mitral valve is also a concern with adhesions approach on a beating heart while on full cardiopulmonary potentially limiting the ability to manipulate bypass. The technique can be associated with potentially the heart into a position to facilitate optimum shorter operation, shorter cardiopulmonary bypass and a exposure. In addition, in patients with poor less complicated recovery. ventricular function, as is often seen in long- standing valvular disease or in those with a history of coronary artery disease, myocardial INTRODUCTION protection becomes a concern and cardio- Reoperative cardiac surgery is increas- plegic cardiac arrest will place the patient at ingly being performed as the population risk of ischaemia-reperfusion injury and post- D’Arcy Sutherland 3 Cardiothoracic Surgical Unit, ages. Seven per cent of cardiac surgeries operative low cardiac output. Royal Adelaide Hospital, performed in Australia between 2010 and The beating heart approach to mitral Adelaide, Australia 2011 were redo surgeries.1 Re-entry median valve surgery was first described by Praeger sternotomy is associated with significant and colleagues in 1989.4 Since then, several Correspondence to potential morbidity and mortality, especially groups have reported good outcomes with Dr Robert B Xu; robert. b. xu@ 2 gmail. com if patent coronary artery grafts are present. performing mitral valve surgery on the Xu RB, et al. Open Heart 2018;5:e000749. doi:10.1136/openhrt-2017-000749 1 Open Heart Open Heart: first published as 10.1136/openhrt-2017-000749 on 20 January 2018. Downloaded from beating heart, through a right thoracotomy.5–10 The removal was confirmed with transoesophageal echocardi- proposed benefit of this approach is reduction in the ography. A pleural drain was then placed. The patient was risks of redo sternotomy, release of adhesions and cardio- then weaned off CPB and decannulated. An intercostal plegia reperfusion injury. catheter for local anaesthetic infusion was inserted and We describe our experience with redo surgery for mitral the wounds were closed in a routine fashion. valve intervention performed through a right anterolat- eral thoracotomy incision done on a beating heart. RESULTS The most common prior cardiac surgery was coronary artery bypass grafting (n=12, 48%, table 1). Three patients METHODS (12%) had prior mitral valve replacement. Six patients A retrospective study was performed and all patients (24%) had two previous sternotomies and one (4%) undergoing surgery of mitral valve through a right ante- had three previous sternotomies. Mitral valve repair was rolateral thoracotomy without application of an aortic performed in 11 patients (44%, table 2). Annuloplasty cross-clamp (beating heart) as a redo cardiac surgery rings were used in all patients that had mitral valve repair. between January 2006 and January 2015, in our institute, Concomitant atrial fibrillation surgery was performed in were included (n=25). Patients with previous sternotomy three (12%) patients. that merely required mitral valve intervention with no No patient required conversion to median sternotomy. contraindication for a right thoracotomy were considered Weaning from CPB was successful in all patients without for this approach. Exclusion criteria included patients requiring intra-aortic balloon pump, with or without who had previously undergone a right-sided thoracotomy inotropic support. Inotropic support beyond 4 hours and more than mild aortic regurgitation. Preoperative after operation was required in seven patients (28%). patient factors, perioperative outcomes, as well as compli- Ventilation time was less than 12 hours in 14 patients cation rates were identified through retrospective data- (56%) with another six patients (24%) extubated within base and case note review. Data were reported as mean 24 hours after surgery. Postoperative course was compli- and SD, median and IQR or frequency, as appropriate. cated with stroke in one patient (4%, table 3) and the Given the retrospective nature of the study, no specific patient made near complete recovery with minimal local ethics committee approval was required. deficit. Early (in-hospital) mortality was 4% (n=1). There was no mortality within the first month after discharge. Operative technique All patients were intubated with a single lumen endotra- cheal tube. They were placed in a semi-supine position DISCUSSION with the right chest slightly raised. External defibrillation Reoperative mitral valve surgery is increasingly required http://openheart.bmj.com/ pads were placed in all cases. Normothermic cardiopul- and carries a high burden of associated potential monary bypass (CPB) was established via femoral artery morbidity and mortality.8 Alternatives for repeat mitral using a EOPA Arterial Cannula (Medtronic, Minnesota, surgery include redo median sternotomy and cardio- USA) and femoral vein using a Multi-Stage Femoral plegic arrest, or hypothermic ventricular fibrillatory Cannula (Medtronic) with vacuum assist. A limited right arrest. The technique used in the current series is similar anterolateral thoracotomy was then performed through to what has been described before by other groups.4–10 A the fourth or fifth intercostal space. A PeriVue soft tissue number of advantages are described: it avoids the need retractor (Edwards Lifescience, Irvine, California, USA), for a repeat sternotomy and its associated risk of injury to a rib spreader (Geister Medizintechnik, Tuttlingen, cardiac structures, potential catastrophic cardiac injury on September 27, 2021 by guest. Protected copyright. Germany) and malleable copper blade retractors were and sternal wound infection11; by limiting the degree used to aid exposure. A 10 mm thoracoscopic camera of adhesiolysis required, through entry via a preserved was placed through a separate port placed in the third right pleural space and avoiding the need for dissection intercostal space. The pleural space was insufflated with around the aorta for cross-clamping, there is a potential carbon dioxide at a rate of 5 L/min to reduce intracar- reduction in the operative and CPB times as well as the diac air. The aorta was not particularly dissected free, risk of perioperative bleeding.12 If the right pleura has cannulated or clamped and no cardioplegia was used. not previously been entered, there are rarely any signifi- The interatrial
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