Minimally Invasive Aortic and Mitral Valve Operation

Stephen B. Colvin, Eugene .A. Grossi, Greg Ribakove, and Aubrey C. Galloway

A hhough minimally invasive approaches for indi- vidual aortic and mitral valve surgery are common-

place, 1-3 these techniques are also quite appropr ia te for those patients with bivalvular (aortic and mitral) dis- ease. Through a small anterior thoracotomy incision, the surgeon gains access to operate on both tile aortic and nfitral valves. This incision obviates tile need for a s ternotomy and its at tendant complications. 4 This ar- ticle describes the s tandard NYU approach for mini- lnally invasive aortic and mitral valve disease.

T e a m A p p r o a c h

As fully described in another article in this issue (p 176), tile nfinimally invasive approach for valvular heart surgery requires a team approach for int raopera- tive patient care. Although the minimally invasive double-valve operation does not rely on " e n d o c l a m p " technology, 5 tile anesthesiolo~st should be facile with placement of a coronary sinus catheter. Transesopha- geal echocardiography (TEE) is a mainstay of the procedure for both catheter placement and monitoring and requires excellent eehoeardiographic skills, either from an echocardiolo~st or from cardiac anesthesia personnel trained in this discipline. 6 Tile benefits of the

lninimaHy invasiveapproach to the patient are predi- cated on this critical mass of required skills.

O p e r a t i n g R o o m S e t u p

Tile patient is positioned on tile table in the s tandard fashion in a supine position without the necessity to move tile chest in either direction. After endotracheal intubation with a single-lumen tube, a TEE probe is placed, and tile aorta is visualized and evaluated. Care is taken to note tlle presence of aortic atheromatous disease or concomitant anomalies such as an atrial septal defect or a persistent left superior vena cava. Such information may change tile intraoperative strategy.

Next, the anesthesiolo~st places a coronary sinus eardiople~a catheter through a percutaneous right internal jugular introducer. Although this is not abso- lutely necessary, it facilitates the operation by obviating the need for handheld cardiople~a eannulas. After this catheter is placed under TEE guidance, a br ief fluoro- scopic exam with a coronary sinus an~ogram is per- formed. This confirms appropr ia te placement of the catheter in the coronary sinus and verifies that the catheter has not been advanced into a small t r ibutary coronary vein.

SURGICAL TECHNIQUE

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1 Mter the patient is prepped and draped, a small groin incision is made, and the femoral vein is identi- fied and prepared with vessel loops and snares. Typi- cally, it is not necessary to use the femora! artery for retrograde arterial perfusion, because tile ascending aorta is immediately accessible and ~ l be directly cannulated. A skin incision on tile right anterior chest over tlle third interspace is performed, and an intercos- tal incision is made.

2 12 Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 5, No 3 (August), 2000: pp 212-220

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2 A soft tissue retractor is placed, and tile chest is spread open with a small Finochetto retractor. The intercostal incision is extended posteriorly, allowing the surgeon to spread apart interspace without fracturing the rib. The fat overlying the anterior mediastinum is mobilized, and an incision is made into the pericardium, exposing the root of the aorta and the junction of the superior vena cava and right atrial appendage. The pericardial incision is continued inferiorly. Opening the retractor will provide excellent exposure. Sutures are placed laterally in the pericardium to help marsupialize the pericardial contents, b r i n i n g the pulmonary veins up fully into the operative field. If exposure is limited initially, the third rib can be disconnected from the cartilage, which will greatly facilitate exposure.

Tile patient is now fully heparinized, 4-0 monofilament pursestring sutures are placed in the ascending aorta, and an arterial cannula is placed. The aortic cannulation site is chosen to allow sufficient room proximally on tile aorta for crossclamp application and creation of an aortotomy. A long venous cannula is placed under guidance of transesophageal echocardiography (TEE) in the femoral vein. First, a guide wire is advanced into the superior vena cava; then tile venous cannula is advanced over this wire. A closed bypass system with venous vacuum is used to provide total drainage of tile atrium. Occasionally, the surgeon may opt to place a second small venous cannula in the right atrial appendage to facilitate venous drainage. (Ao, aorta; RAA, right atrial appendage; SVC, superior vena cava.)

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3 Cardiople~e arrest and exposure of the valves. With lmmp flow temporarily diminished, a standard erosselamp is direetly applied to the ascending aorta just below the aterial eannulation site. Retrograde eardiople~a is delivered to provide cardiac arrest. With cardiac arrest achieved, the patient is typically cooled to 25~ (Ao, aorta.)

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4 A transverse aortotomy is performed in the ascending aorta to expose tile diseased aortic valve. The incis ion is often curved down to tile aortic root to enhance exposure. The aortic valve is resceted at this point. The aortic prosthesis is not inserted at this t ime, because this wonhl hinder access to the mitral valve.

2 1 6 COLVaN ET AL

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5 Attention is now turned to the initral valve. Pulling on the lateral sutures placed in the pericardium brings the right superior puhnonary vein into view. An incision is made just anterior to the vein and posterior to tlie atrial septum. This incision is continued caudally, just anterior to both pulmonary veins. (RAA, right atrial appendage.)

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6 An intra-atrial blade retractor is placed into the left atrium under direct visualization. A separate stab wound is made on tile anterior chest wall, and the handle is introduced to the blade. Typically, because bivalvular disease is most commonly rheumatic, the operation will consist of bivalvular replacement. The nfitral valve is removed, and sutures are placed for the new valve. Care is taken at 4 to 5 o'clock on tile mitral annulus, because deep sutures could puncture the coronary sinus catheter balloon.

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7 After tile mitral valve has been replaced, the inferior portion of tile atrial incision is closed ~ith two running layers of 3-0 Prolcne suture (Ethicon, Inc., Somerville, NJ). A venting catheter is placed through tile atrial closure lille, across the prosthetic valve, and into the left ventricle. This catheter is connected to one of tile pump suction catheters and left clamped. The superior portion of the atriotomy incision line is closed with 3-0 Prolene, and a snare is placed around tile venting catheter.

MINIMALLY IN$~$SIVE AORTIC AND MITRAL VALVE OPEtLXTION 219

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8 Tbe aortic annular sutures are placed, and the aortic prosthesis is sewn in place. The aortotomy is closed with standard techniques. Typically the lateral inferior portion of the incision is closed with interrupted figure eight sutures, whereas the anterior part of the incision is closed ~dth two running layers of Prolene. The most anterior corner of the suture line is left loose; this will be used to vent the root during tile de-airing process.

With tile heart still decompressed, a temporary epicardial pacing wire is placed on the surface of the right ventricle and connected to an electrical fibrillator. With blood volume gradient placed in the heart , tlle venting catheter is placed on gentle suction, and tile crosselamp is released. TEE is used to monitor the left atr ium and ventricle for tile presence of air. With the heart under electrically induced fibrillation, more blood volume gradient is placed into the atr ium and ventricle and vented through the catheter. The lungs are nmnually inflated to clear any t rapped air from the puhnonary venous bed. The patient is moved back and forth to help dislodge any air tlmt may be t rapped inside the ventricle. After all air is cleared, as verified by TEE, the crossclalnp is reapplied. The electrical fibrillator is stopped, and the heart is cardioverted. The heart is allowed to beat against the crossclamp wlfile the aortic root is vented through the loose corner of the aortotomy closure line.

When tlfis has been completed, the main pump flow is temporari ly dinfinished, and the crossclamp is completely removed. The aortotomy sntures are secured. The venting catheter is then withdrawn through the suture line, and the atriotomy is oversewn. The patient is ventilated and warmed to luore than 35~ and cardiopuhuonary bypass is discontinued. The long venous cannula is removed, and the femoral vein is repaired primari ly with 5-0 Prolenc. IIeparinization is reversed with protamine, and the arterial cannula is removed from the aorta. The purscstrings are tied shnt and oversewn with monofilament suture.

A chest tube is placed through a separate stab incision. A soft silastic sump catheter is laid over the aortic root and the right atr ium and exteriorized separately. Paracostal incisions arc used to approximate the intercostal incision. The chest wall muscle and soft tissues are closed with rnlming

sutures.

2 2 0 COLVIN ET AL

P O S T O P E R A T I V E M A N A G E M E N T

Patients are not extubated in tile, operating room, but rather are extubated within the first few hours in the recovery room after reversal of tile neuromuscular blockade. Patients are typically discharged on the third or fourth postoperative day. Oral anticoagulation is started on the first postoperative night. Regulation of oral anticoagulation may not be achievable during the short postoperative stay, and so is adjusted on an outpatient basis.

The minimally invasive approach for combined aor- tic and nfitral valve surgery provides excellent access to the valves. This approach is associated with diminished patient discomfort. Postdischarge, patient activity and return to function is superior to that associated with the standard sternotomy approach.

R E F E R E N C E S

1. Colvin SB, Galloway AC, Ribakove G, et ah Port-access mitral vah'e surgery: Summary of results. J Card Surg 13(4):286-289, 1998

2. Benetti F, Rizzardi JL, Concerti C, et ah Minimally aortic valve surgery avoiding sternotomy. Eur J Cardiothorae Surg 16 Suppl 2:$84-85, 1999

3. Christiansen S, Stypmann J, Tjan TD, et ah Minimally-invasive versus conventional aortic valve replacement--Perioperative course and mid- term resuhs. Enr J Cardiothorae Surg 16(6):617-652, 1999

4. Grossi EA, Zakow PK, Ribakove G, et ah Comparison of post-operatlve pain, stress response, and quality of llfe in port access versus standard sternotomy coronary bypass patients. Eur J Cardiothorae Surg 16 Suppl 2:$39-42, 1999

5. Schwartz DS, Ribakove GtI, Grossi EA, et ah Minimally invasive mitral valve replacement: Port-access technique, feasibility, and myocardial functional preservation. J Thorac Cardiovase Surg 113(6):1022-1030; discussion 1030-1031, 1997

6. Applebaum RM, Cutler WM, Bhardwaj N, et ah Utility of transesopha- geal echoeardiogTaphy during port-access minimally invasive cardiac surgery. Am J Cardio182(2): 183-188, 1998

From the Division of Cardiothoracie Surger), New York University School of Medicine, New Sbrk, NY.

Address reprint requests to Stephen B. Colvin, hiD, 530 First Ave, Ste SK-9V, New York, NY 10016.

Copyright �9 2000 by W.B. Saunders Company 1522-2942;00/0503-0008$10.00[0 doi:10.1053/otct.2000.16222