|Year : 2014 | Volume
| Issue : 2 | Page : 115-119
Minimally invasive thoracotomy approach for double valve replacement for valvular heart diseases
Ab Gani Ahangar, Farooq Ahmad Dar, Mohd Lateef Wani, Shyam Singh, Shadab Nabi Wani, Hakeem Zubair Ashraf
Department of Cardiovascular and Thoracic Surgery, Sher i Kashmir Institute of Medical Science, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||19-May-2014|
Mohd Lateef Wani
Department of Cardiovascular and Thoracic Surgery, Sher i Kashmir Institute of Medical Science, Srinagar 190 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Double valve replacement (DVR) is usually done through median sternotomy. However, right anterolateral thoracotomy is an alternative approach. Aim: The aim of this study was to analyze the results of right anterolateral thoracotomy for DVR. Patients and Methods: This was a prospective study conducted on during the period from January 2009 to January 2012. This study consists of 56 patients who had a concomitant mitral and aortic valve disease and were subjected to DVR. Patients were studied according to their age and sex, New York Heart Association (NYHA) class, valve pathology, concomitant procedures, urgent/elective, length of incision, surgical exposure, mean bypass time, operating time, hospital stay, and cosmesis. Results: Majority of the patients were in 3 rd and 4 th decade (61%). Postoperative length of stay was 7-12 days, 70% of patients were discharged by the 7 th day. The average size of incision in males was 7.5 cm and in females the size of incision was 7.25 cm with a mean of 7.3 cm in both genders. Rheumatic heart disease was responsible for 89.28% of cardiac valvular lesions, degenerative disease in 7.14% and endocarditis in 3.5%. Postoperatively at 2 months, there was a statistically significant improvement in the NYHA class with 94% of the survivors in class I-II. There was a statistically significant difference in the outcome in patients having higher ejection fraction as compared to those who had low ejection fraction preoperatively. Thirty days mortality was 1.78%. Over the first 24 postoperative hours, only about 30% of patients were pain free, and this proportion increased to about 50% by day 2, 60% by day 3, 70% by day 4, 75% by day 5 and stabilized. Postoperative length of stay was 7-12 days, 70% of patients were discharged by the 7 th day. Conclusion: DVR via thoracotomy appears to be associated with faster recover, early discharge and reduced use of rehabilitation facilities that translate into a shorter hospital stay and cost. In addition to early benefits of thoracotomy approach, late cosmetic results are also better than conventional sternotomy.
Keywords: Aortic valve, cardiac, cosmesis, double valve, hospital stay, minimally invasive, mitral valve, pain, sternotomy, thoracotomy
|How to cite this article:|
Ahangar AG, Dar FA, Wani ML, Singh S, Wani SN, Ashraf HZ. Minimally invasive thoracotomy approach for double valve replacement for valvular heart diseases. Int J Health Allied Sci 2014;3:115-9
|How to cite this URL:|
Ahangar AG, Dar FA, Wani ML, Singh S, Wani SN, Ashraf HZ. Minimally invasive thoracotomy approach for double valve replacement for valvular heart diseases. Int J Health Allied Sci [serial online] 2014 [cited 2020 Mar 30];3:115-9. Available from: http://www.ijhas.in/text.asp?2014/3/2/115/132698
| Introduction|| |
The field of minimally invasive cardiac surgery has grown rapidly in recent years. Although diverse techniques and philosophies have emerged, these techniques share the common goal of decreasing surgical trauma while maintaining surgical efficacy. If successful, this reduction in surgical trauma should decrease pain, reduce morbidity, shorten recovery time, and decrease costs while achieving a superior cosmetic result and improved patient satisfaction. A variety of approaches have been reported, including port-Access techniques, videoscopic techniques, various types of partial sternotomy, and the parasternal approach.
Without the use of state of art instruments, minimally invasive cardiac surgery is very difficult. However, in our setup, some female patients were reluctant to give consent for surgery through sternotomy. This prompted us to do there surgery through right anterolateral thoracotomy.
Our objective was to analyze the results of right anterolateral thoracotomy for double valve replacement (DVR) with reference to: Length of incision, surgical exposure, mean bypass time, operating time, hospital stay, and cosmesis.
| Patients and methods|| |
This prospective study was carried in the Department of cardiovascular and thoracic surgery from 1 st January 2009 to 31 st January 2012. Ethical clearance from local ethical committee and informed consent from patients was taken. Patients having concomitant aortic and mitral valve disease requiring DVR as per the ACC/AHA guidelines,  were included in this study. Patients were studied according to the following parameters: age and sex, New York Heart Association (NYHA) class, valve pathology, concomitant procedures, and urgent/elective. Their follow-up information was obtained prospectively by following patients in the follow-up clinic or through telephonic interview at regular intervals.
The patients were followed-up to 31 st January 2012. All the patients had undergone complete preoperative evaluation and the patient above 40 years age also underwent coronary angiography.
The study consists of 56 patients who had a concomitant mitral and aortic valve disease and were subjected to DVR. The patients in whom only repair of either valve or single valve replacement was done were excluded from the study.
| Operative procedure|| |
Patients were put in standard right anterolateral thoracotomy position for thoracotomy approach to DVR. A 7-8 cm incision was created in the right sub-mammary fold starting 3-5 cm from the lateral border of the sternum. The breast tissue was gently mobilized and the right chest cavity was entered through the third or fourth intercostal space. A chest retractor was placed and opened gradually so as not to break any ribs. The right lung was compressed with a wet lap to expose the pericardial sac. The pericardial sac was entered through an incision 2-3 cm anterior and parallel to the phrenic nerve extending from the diaphragm to the aortic reflection. The routine procedure for DVR was done as usual.
All the operations were performed with the patient supported by standard cardiopulmonary bypass through central cannulation, with moderate hemodilution and moderate hypothermia (28°C). Cold blood cardioplegia was used as the method of myocardial preservation. Mitral valve was implanted first followed by aortic valve using running 2.0 polypropylene sutures. All the patients had DVR with a mechanical prosthesis and the majority of the valves were of bileaflet type. Sizing of prosthesis was done by standard company sizer. Most of the times St. Jude bileaflet prosthesis was used [Figure 1], [Figure 2], [Figure 3].
Patients were electively ventilated over several hours. Oral anticoagulation was started on 2 nd postoperative day with acenocoumarol to maintain an INR of 2.5-3.0. Intravenous antibiotics, a combination of ceftriaxone/sulbactum and amikacin were administered during the hospital stay.
The follow-up information was collected via telephonic interview and in the follow-up clinic. Three patients were lost to follow-up.
All data were analyzed using Statistical Package for Social Sciences (SPSS) IBM SPSS statistics software.
| Results|| |
Majority of the patients were in 3 rd and 4 th decade (61%). Mean age was 32.5 ± 10.2 standard deviation. Breathlessness (94%) and palpitations (92%) were the most common symptoms followed by easy fatigability (44%) and chest pain (35%). The mean duration of symptoms was 6.1 ± 2.9 years, with a minimum of 1 month and a maximum of 78 months. The average size of incision in males was 7.5 cm and in females the size of incision was 7.25 cm with a mean of 7.3 cm in both genders. Rheumatic heart disease was responsible for 89.28% of cardiac valvular lesions, degenerative disease in 7.14% and endocarditis in 3.5%. Preoperatively, 96% of the patients were in NYHA III-IV. Postoperatively at 2 months, there was a statistically significant improvement in the NYHA class with 94% of the survivors in class I-II [Table 1] and [Table 2]. There was a statistically significant difference in the outcome in patients having higher ejection fraction when compared to those who had low ejection fraction preoperatively [Table 3]. The immediate postoperative complications are listed in [Table 4]. One patient died within 1 month of surgery yielding 30 days mortality of 1.78%. The cause of death was low cardiac output. There was one death at 2 months, due to acute renal failure. There were three late deaths. One patient died of congestive heart failure, one died of prosthetic valve endocarditis, and one died of massive intracranial thrombosis. Whereas as one patient was lost to follow-up and are considered to have died.
Over the first 24 postoperative hours, only about 30% of patients were pain free, and this proportion increased to about 50% by day 2, 60% by day 3, 70% by day 4, 75% by day 5 and stabilized. Postoperative length of stay was 7-12 days, 70% of patients were discharged by the 7 th day.
| Discussion|| |
Midline sternotomy is the incision generally used for heart surgery. Articles that describe alternative approaches appear regularly that are surgically less traumatic and eliminate the risk of sternal instability, in addition to improving cosmetic results.  There is no doubt that midline sternotomy is the most common, convenient, and safe approach, and that it provides better exposure for the cardiac surgeon. Several authors have reported their experience with alternative approaches to sternotomy (less invasive, better cosmetic result, etc.) for the surgical treatment of certain congenital heart diseases.  All agree that the cosmetic results of the surgical approach are important, especially in girls and women. In this context, right anterior thoracotomy is particularly attractive for two reasons: It uses a space below the breast for the incision (better cosmetic result), and it provides "easy" access to the right atrium, thus facilitating surgery in conditions that are approached this way.
The overall hospital mortality in our study was 10%, which compares favorably with other studies were sternotomies were performed. ,,,
In a study of patients having a right thoracotomy, Casselman et al.  have reported that approximately 99% of patients thought that their scar was esthetically pleasing.
The incidence of wound infections and septic complications is lower with a thoracotomy than with a median sternotomy. This virtually eliminates mediastinitis , which is uncommon, but possible after a partial sternotomy. Grossi et al. , in their study have reported incidence of 0.9% for mini-thoracotomy and 5.7% for sternotomy cases (P < 0.05). This had increased to 1.8% and 7.7%, respectively, in elderly patients (P < 0.03).
Compared with a complete sternotomy, thoracotomy incisions are associated with less pain, discomfort, and postoperative analgesics. , Within 4 weeks after a right thoracotomy, approximately one-half of the patients return to work and full activity.  Postoperative pain and quality-of-life were evaluated from 1996 to 1997 by the Leipzig group using different scoring systems.  This group revealed less pain from the third postoperative day onward after a lateral minithoracotomy (vs. a standard sternotomy.  Better stability of the bony thorax leads to earlier mobilization and return to daily activities. Thus, patient-related factors are a significant advantage of minimally-invasive valve surgery (mini-VS). In concordance with their findings, Yamada et al.  in 2003 compared early postoperative quality-of-life in mini-VS and conventional valve surgery. In a study by Glower et al.  they found that postoperative pain resolved more quickly with a minimally-invasive approach; patients returned to normal activity 5 weeks earlier than after a median sternotomy (2-4 weeks vs. 1-9 week, P < 0.01). Mihaljevic et al.  noted patients undergoing minimally-invasive aortic surgery had shorter length of stay and with more frequent discharge home without additional stationary rehabilitation services. Casselman et al.  have reported that 94% of their patients reported no or mild postoperative pain, 99.3% reported an esthetically pleasing scar, 93% would choose the same procedure again if they needed additional surgery, and 46% returned to work within 3 weeks. Perhaps the most insightful evidence comes from studies reporting that patients undergoing surgery via a minimally-invasive approach as their second procedure all thought that their recovery was faster/less painful than their original sternotomy.  The use of small incisions, which necessitates, for example, rib retractors, results in less pain, given less stretching of the muscle fibers, compared with sternotomy retractors.
Minimally-invasive approaches appear to be associated with faster recovery, earlier discharge, and reduced use of rehabilitation facilities. ,,, Does a rapid recovery translate into a shorter hospital stay/reduced costs? Although cost data for mini-VS have not been thoroughly evaluated, length of hospital stay is a known surrogate for resource use and hospital costs. Asher et al.  found that patients who underwent an upper hemisternotomy had significantly less perceived pain, shorter hospital stay, and a greater proportion of home discharges than those who had conventional full sternotomies.
Many studies reported a shorter hospital stay with a minimally-invasive approach. ,, Moreover, these patients had fewer requirements for rehabilitation, a significant advantage in health care savings: 91% were discharged home compared with 67% with the conventional approach.
| Conclusion|| |
Concomitant Mitral Aortic valve disease of rheumatic etiology is still prevalent in our country. Rheumatic heart disease was responsible in 90.66% of the patients, whereas degenerative cause was responsible in only 6.66% of patients in our study. The average size of incision made was 7.25 cm in females and 7.5 cm in males with excellent surgical exposure and cosmesis for DVR. Mean cross-clamp time was 88 min and total mean bypass time was 130 min. The average hospital stay was 7-12 days with an overall hospital mortality of 8.0% in our study. DVR through thoracotomy does not increase the mortality and morbidity, when compared to conventional sternotomy and has cosmetic and blood product use advantage over the conventional surgery. DVR via thoracotomy appears to be associated with faster recover, early discharge and reduced use of rehabilitation facilities that translate into a shorter hospital stay and cost. In addition to early benefits of thoracotomy approach, late cosmetic results are also better than conventional sternotomy.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]