Right anterior thoracotomy approach for isolated aortic valve replacement with sutured aortic valve prosthesis | |
DOI: 10.5606/e-cvsi.2016.510 | |
Mustafa Bahadır İnan, Evren Özçınar, Nur Dikmen Yaman, Serkan Durdu, Atilla Aral, Mustafa Şırlak, Ahmet Rüçhan Akar | |
Department of Cardiovascular Surgery, Medical Faculty of Ankara University, Ankara, Turkey | |
Keywords: Aortic valve prosthesis; minimally invasive surgery; right anterior thoracotomy | |
Minimally invasive aortic valve surgery is associated with less bleeding, shorter duration of mechanical ventilation, and reduced intensive
care unit and hospital stays. Herein, we present a 85-year-old male case with minimal invasive sutured aortic valve replacement via right
anterior thoracotomy. We also discuss the advantages of this method. |
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Minimally invasive aortic valve replacement (AVR)
performed through a right anterior thoracotomy
(RAT) or upper hemisternotomy (UHS) is becoming
a favored approach. Advantages of less bleeding and
faster recovery due to the incision technique made the
right anterior thoracotomy a preferable approach. We
present a patient with minimal invasive sutured AVR
via right anterior thoracotomy. |
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CASE PRESANTATION
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A 85-year-old male patient was admitted to our
hospital with complaints of angina and dyspnea on
exertion. His body mass index was 19 kg/m2. Cardiac
examination revealed a regular heart rate and rhythm
with no rubs or heaves. A 3/6 late-peaking systolic
murmur at the right second intercostal border was
radiating to the carotid arteries and encroached
on the second heart sound. Auscultation revealed
normal lung sounds bilaterally and pulmonary
function test results were normal. On preoperative
assessment, there was no contraindication for single
lung ventilation. After physical examination with
suspected of valvular pathology, transthoracic
echocardiography was performed. It showed severe
aortic valve stenosis characterized by an aortic
valve area of 0.8 cm2, a mean aortic valve gradient
of 45 mmHg, and a maximal aortic velocity of
4 m/sec. For further examination, thoracic computed
tomography was performed without contrast
enhancement to evaluate the aortic calcifications,
as well as the relationship among the aortic valve,
sternum, and intercostal spaces. It demonstrated noncalcified ascending aorta with a diameter of 43
mm. The distance of annulus and ascending aorta
to the right anterior thoracotomy incision were
evaluated. Coronary angiography scans were normal
and carotid Duplex ultrasound showed insignificant
stenotic plaques. A written informed consent was
obtained from the patient for surgery. The patient underwent surgery with right anterior thoracotomy incision. After anesthesia induction, he was intubated with a double-lumen endotracheal tube for single lung ventilation and had intraoperative transesophageal echocardiography. On supine position, the external defibrillator pads were placed, and the skin incision and peripheral cannulation was performed. By peripheral cannulation via femoral artery and vein, a right anterior thoracotomy with a 5 cm skin incision from the third intercostal space near the sternal border was performed. The right internal thoracic artery and veins were ligated. A soft tissue retractor was inserted into the incision. Pericardial fat was excised and pericardiotomy was performed 4 cm anterior to the right phrenic nerve. The pericardium was retracted by passing sutures through the chest wall away from the incision. The operative field was insufflated with carbon dioxide. A 23 mm Medtronic Hancock bioprosthetic valve (Medtronic, Minneapolis, MN, USA) was implanted (Figure 1). Cross-clamp and cardiopulmonary bypass times were 83 min and 108 min, respectively. Postoperative course was uneventful. Figure 1: Sutured aortic bioprothesis valve replacement via right anterior thoracotomy approach. |
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In 1996, Cosgrove and Sabik[1] introduced the first
right parasternal approach to reduce the morbidity
from valvular heart operations. Then, techniques
encompassed a wide variety of incisions. Today, the
RAT and UHS are the primarily minimal invasive
AVR approaches. Improved cosmesis, less pain and narcotic use, and rapid recovery have been reported, which offer more comfort to both patients and surgeons. Several studies address ministernotomy, while outcomes of minimally invasive valve replacement via RAT have not been well-defined, yet. Establishing the more comfortable way of operation for aortic valve surgery requires a coordinated effort by the surgeon, anesthesiologist, perfusionist, and nurses. Upper hemisternotomy may be applied by less experienced minimal invasive AVR surgeons. However, stability of the manubrium is the weaker chain of the operation. The sternotomy is re-approximated using steel wires. Right anterior thoracotomy avoids sternotomy, while the integrity of the sternum minimizes the postoperative discomfort with a limited skin incision.[1] Although, the surgical site is smaller and the aortic valve sits deeper within the wound. Exposure is facilitated by minimizing cannulation techniques within the incision, coupled with strategic placement of pericardial sutures.[2] Most studies show that RAT is a safe procedure associated with low mortality and postoperative complications. The in-hospital mortality of 1.5% is lower than the recent mortality rate reported in the Society of Thoracic Surgeons Database.[3] Although cross-clamp and cardiopulmonary bypass times were longer than in the standard approach, the low incidence of postoperative stroke, renal failure, atrial fibrillation, and blood transfusions, as well as the short postoperative recovery, are consistent with other minimally invasive approaches, highlighting the safety of this procedure.[4] In addition, due to the psychological and cosmetic results, it is a preferable method.[5] In conclusion, minimally invasive aortic valve replacement via a right anterior thoracotomy is a safe and effective method.
Declaration of conflicting interests
Funding |
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1) Cosgrove DM, Sabik JF. Minimally invasive approach for
aortic valve operations. Ann Thorac Surg 1996;62:596-7.
2) Malaisrie SC, Barnhart GR, Farivar RS, Mehall J, Hummel
B, Rodriguez E, et al. Current era minimally invasive
aortic valve replacement: techniques and practice. J Thorac
Cardiovasc Surg 2014;147:6-14.
3) Brown JM, O'Brien SM, Wu C, Sikora JA, Griffith BP,
Gammie JS. Isolated aortic valve replacement in North
America comprising 108,687 patients in 10 years: changes
in risks, valve types, and outcomes in the Society of
Thoracic Surgeons National Database. J Thorac Cardiovasc
Surg 2009;137:82-90.
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