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MMCTS
(May 8, 2009). doi:10.1510/mmcts.2009.003921 Copyright © 2009 European Association for Cardio-thoracic Surgery Comment Commentary on aortic valve replacement through a right-sided anterior minithoracotomy access
a CNR Institute of Clinical Physiology, Fondazione Gabriele Monasterio, ‘G. Pasquinucci’ Heart Hospital, Via Aurelia Sud, 54100 Massa, Italy * Corresponding author: Corresponding author. Tel.: +39-0585-493604; fax: +39-0585-493614. glauber{at}ifc.cnr.it
Key Words: Aortic valve replacement • Minithoracotomy • Minimally invasive
In November 2008 MMCTS published an article describing our approach for an aortic valve surgery in the 2nd intercostal space (Schematic 1) with an emphasis on patient preparation and operative technique [1]. From January 2005 to December 2008, more than 150 consecutive patients with a severe aortic valve disease underwent an aortic valve replacement in our institution.
The preparation technique remains the same. However, we do not place an additional working port anymore, establishing all necessary lines (aortic vent, cardioplegia, cardiotomy vent) and stay sutures via minithoracotomy. The cannulation technique has undergone no changes since we started this approach; currently the market offer is larger and a surgeon can make his choice for available aortic and venous cannulas based on product characteristics and price (MMCTSLink 132, MMCTSLink 177, MMCTSLink 178). The size of aortic cannula usually depends on patients' weight. As for the type of the cannula, it is the surgeon's choice. For patients with weight below 80–90 kg we prefer a 21F cannula, and 23F for those >90 kg, respectively. In the case of an extremely short or retrosternal ascending aorta a femoral artery cannulation is performed. Cardiopulmonary bypass is carried out with a vacuum-assisted venous return with a pressure around –40 mmHg. The choice of venous cannula is based on the same criteria as for the aortic cannula; mainly we employ a range of 22–25Fr, using a 21Fr cannula in a small patient. The prosthesis implantation and aortotomy closure procedure are as in a conventional approach. It is also important to recognize that it is principally the chest incision component that can be improved by minimal access, and that the results like intensive care unit stay, hospital length of stay, and earlier mobilization are all consequences of a short incision, i.e. small surgical access. Postoperative outcomes are based on more ‘delicate’ surgery, with better respect to the integrity and anatomy of the tissues, from technical performance of the surgical team. A lot of components of the procedure are technically equivalent to those in conventional sternotomy. Concomitant procedures: we started performing the treatment of atrial fibrillation with radiofrequency ablation (n=14) and the technical feasibility of the transaortic septal myectomy is another concomitant procedure which seemed absolutely feasible through minithoracotomy (n=6). Implantation of stentless bioprosthesis (n=1) was very difficult (19° Freedom Solo valve), because of working space limits within minithoracotomy. Retrograde administration of cardioplegia (n=4) was performed by placement of the catheter into the coronary sinus under TEE guidance. Complications such as a posterior aortic wall puncture with an aortic cannula type and iliac vein rupture during venous cannula insertion should be also kept in ones mind. We think that confidence with this approach can be better acquired if the initial experience is supported with mitral valve repair or replacement through a right minithoracotomy. In this way the aortic valve replacement through minithoracotomy can be a method of choice because of its feasibility, safety and attractiveness. Further randomized studies are needed to better evaluate the outcomes and compare existing minimally invasive approaches [2, 3, 4].
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