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ORIGINAL ARTICLE
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 115-119

Minimally invasive thoracotomy approach for double valve replacement for valvular heart diseases


Department of Cardiovascular and Thoracic Surgery, Sher i Kashmir Institute of Medical Science, Srinagar, Jammu and Kashmir, India

Date of Web Publication19-May-2014

Correspondence Address:
Mohd Lateef Wani
Department of Cardiovascular and Thoracic Surgery, Sher i Kashmir Institute of Medical Science, Srinagar 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.132698

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  Abstract 

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 2019 Sep 21];3:115-9. Available from: http://www.ijhas.in/text.asp?2014/3/2/115/132698


  Introduction Top


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 Top


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, [1] 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 Top


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.
Figure 1: Mitral valve being excised

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Figure 2: Replaced mitral valve

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Figure 3: Aortic valve replaced

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Statistical analysis

All data were analyzed using Statistical Package for Social Sciences (SPSS) IBM SPSS statistics software.


  Results Top


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.
Table 1: NYHA class


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Table 2: Preoperative NYHA class with respect to outcome


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Table 3: Ejection fraction in relation with outcome


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Table 4: Postoperative complications


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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 Top


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. [2] 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. [3] 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. [4],[5],[6],[7]

In a study of patients having a right thoracotomy, Casselman et al. [8] 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 [9],[10] which is uncommon, but possible after a partial sternotomy. Grossi et al. [9],[10] 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. [9],[10] Within 4 weeks after a right thoracotomy, approximately one-half of the patients return to work and full activity. [11] Postoperative pain and quality-of-life were evaluated from 1996 to 1997 by the Leipzig group using different scoring systems. [12] This group revealed less pain from the third postoperative day onward after a lateral minithoracotomy (vs. a standard sternotomy. [12] 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. [13] in 2003 compared early postoperative quality-of-life in mini-VS and conventional valve surgery. In a study by Glower et al. [14] 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. [15] 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. [8] 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. [15] 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. [12],[13],[14],[15] 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. [16] 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. [16],[17],[18] 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 Top


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.

 
  References Top

1.Gundry SR, Shattuck OH, Razzouk AJ, del Rio MJ, Sardari FF, Bailey LL. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-4.  Back to cited text no. 1
    
2.Massetti M, Babatasi G, Rossi A, Neri E, Bhoyroo S, Zitouni S, et al. Operation for atrial septal defect through a right anterolateral thoracotomy: Current outcome. Ann Thorac Surg 1996;62:1100-3.  Back to cited text no. 2
    
3.Riess FC, Moshar S, Bader R, Hoffmann B, Löwer C, Bleese N. Correction of congenital heart defects and mitral valve operations using limited anterolateral thoracotomy. Heart Surg Forum 2001;4:34-9.  Back to cited text no. 3
    
4.Hamamoto M, Bando K, Kobayashi J, Satoh T, Sasako Y, Niwaya K, et al. Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement. Ann Thorac Surg 2003;75:28-33.  Back to cited text no. 4
    
5.Remadi JP, Baron O, Tribouilloy C, Roussel JC, Al-Habasch O, Despins P, et al. Bivalvular mechanical mitral-aortic valve replacement in 254 patients: Long-term results: A 22-year follow-up. Ann Thorac Surg 2003;76:487-92.  Back to cited text no. 5
    
6.Gillinov AM, Blackstone EH, Cosgrove DM 3 rd , White J, Kerr P, Marullo A, et al. Mitral valve repair with aortic valve replacement is superior to double valve replacement. J Thorac Cardiovasc Surg 2003;125:1372-87.  Back to cited text no. 6
    
7.McGonigle NC, Jones JM, Sidhu P, Macgowan SW. Concomitant mitral valve surgery with aortic valve replacement: A 21-year experience with a single mechanical prosthesis. J Cardiothorac Surg 2007;2:24.  Back to cited text no. 7
    
8.Casselman FP, Van Slycke S, Wellens F, De Geest R, Degrieck I, Van Praet F, et al. Mitral valve surgery can now routinely be performed endoscopically. Circulation 2003;108 Suppl 1:II48-54.  Back to cited text no. 8
    
9.Grossi EA, Galloway AC, Ribakove GH, Buttenheim PM, Esposito R, Baumann FG, et al. Minimally invasive port access surgery reduces operative morbidity for valve replacement in the elderly. Heart Surg Forum 1999;2:212-5.  Back to cited text no. 9
    
10.Grossi EA, Galloway AC, Ribakove GH, Zakow PK, Derivaux CC, Baumann FG, et al. Impact of minimally invasive valvular heart surgery: A case-control study. Ann Thorac Surg 2001;71:807-10.  Back to cited text no. 10
    
11.Walther T, Falk V, Metz S, Diegeler A, Battellini R, Autschbach R, et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67:1643-7.  Back to cited text no. 11
    
12.Hamano K, Kawamura T, Gohra H, Katoh T, Fujimura Y, Zempo N, et al. Stress caused by minimally invasive cardiac surgery versus conventional cardiac surgery: Incidence of systemic inflammatory response syndrome. World J Surg 2001;25:117-21.  Back to cited text no. 12
    
13.Yamada T, Ochiai R, Takeda J, Shin H, Yozu R. Comparison of early postoperative quality of life in minimally invasive versus conventional valve surgery. J Anesth 2003;17:171-6.  Back to cited text no. 13
    
14.Glower DD, Landolfo KP, Clements F, Debruijn NP, Stafford-Smith M, Smith PK, et al. Mitral valve operation via port access versus median sternotomy. Eur J Cardiothorac Surg 1998;14 Suppl 1:S143-7.  Back to cited text no. 14
    
15.Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations: Early and late results. Ann Surg 2004;240:529-34.  Back to cited text no. 15
    
16.Ryan WH, Dewey TM, Mack MJ, Herbert MA, Prince SL. Mitral valve surgery using the classical 'heartport' technique. J Heart Valve Dis 2005;14:709-14.  Back to cited text no. 16
    
17.Gaudiani VA, Grunkemeier GL, Castro LJ, Fisher AL, Wu Y. Mitral valve operations through standard and smaller incisions. Heart Surg Forum 2004;7:E337-42.  Back to cited text no. 17
    
18.de Vaumas C, Philip I, Daccache G, Depoix JP, Lecharny JB, Enguerand D, et al. Comparison of minithoracotomy and conventional sternotomy approaches for valve surgery. J Cardiothorac Vasc Anesth 2003;17:325-8  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Patients and methods
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Results
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