1. Right Antrolateral Minithoracotomy Versus Median Sternotomy in Mitral Valve Surgery
T Salah, MD., M Saber, MBBCh., T ElTaweil, MD. and N Rasmy,MD.
Department of Cardiothoracic Surgery, Cairo University, Egypt.
ABSTRACT
Introduction
Results
Median sternotomy has been a standard approach for open heart surgeries :
Definitive view of the surgical field.
Excellent short- and long-term results.
Advantages of Minimally invasive cardiac surgery:
Less invasive.
Better comfort .
More desirable cosmetic results.
More rapid and complete rehabilitation.
Equivalent safety, efficacy and outcome to conventional Procedures.
Although MI approaches have been integrated into many areas of cardiac surgery, MI mitral valve surgery has been particularly influenced by MI techniques.
Carpentier/ Loulmet Classification of degrees of surgical invasiveness
Preoperative results:
There was no significant difference between both groups as regards perioperative demographic data of the patients, NYHA functional class of the patients or Mitral Valve pathology .
Surgical techniques
Group A
Objectives: To determine the potential benefits of minimally invasive Mitral valve surgery via right antrolateral minithoracotomy versus median sternotomy.
Methods: In that study, forty patients with isolated mitral valve disease requiring mitral valve surgery were included. The patients were divided into two groups:
Group "A": Included twenty patients who underwent mitral valve surgery through right antrolateral minithoracotomy.
Group "B": Included twenty patients who underwent mitral valve surgery through standard median sternotomy.
Results: The length of incision was smaller in minithoracotomy group compared with sternotomy group by 11.5 cm. The postoperative mechanical ventilation time was less in minithoracotomy group versus sternotomy group by 2.5 hours. The amount of blood drainage in the first 24 hours was less in minithoracotomy group than sternotomy group by 324 ml. The blood units transfused to minithoracotomy group patients was less than sternotomy group patients by 1.6 U and the number of patients who received blood transfusion in minithoracotomy group versus sternotomy group was (11 VS 18 patients). The mean hospital stay was less in minithoracotomy group versus sternotomy group (6.75 ± 0.7 days VS 11.4 ± 4.69 days). Wound satisfaction was much better in minithoracotomy group versus sternotomy group (95% Vs 15%). Time from skin incision to full cannulation was increased in minithoracotomy group than sternotomy group by 13 min while cross-clamp time and total bypass time was of no statistical significance.
Conclusion: Mitral valve surgery through antrolateral minithoracotomy is a good alternative to conventional surgical access. Excellent cosmetic results and avoidance of the sternal complications are major advantages, also it is intended to minimize harm to patients by reducing blood loss, reducing amount of blood transfusion, reducing the danger of infection by minimizing wound dimensions, thereby shortening the patient's hospital stay and decreasing costs.
Intraoperative Results:
Group "A"
Group "B"
P value
Sig.
Cannulation time (min)
39.7 ± 2.8
26.7 ± 3.2
< 0.01 HS
Cross clamp time (min)
49.8 ± 7.3
51.5 ± 5.9
> 0.05 NS
Total bypass time (min)
64.15 ± 7.16
64.1 ± 6.46
Total operative time (min)
149.5 ± 13.9
153.2 ± 16.08
Draping of the Patient
Femoral artery and vein cannulation.
Level I
Mini-incision(10-12 cm)
Direct vision
Level II
Micro-incision (4-6 cm)
Video-assisted
Level III
Micro or port incision (1-2 cm)
Video-directed
Level IV
Port incision with robotic instrument
Surgical Technique: Group “A”
Postoperative Results:
Aim of study:
That study was designed to determine the potential benefits of minimally invasive mitral valve surgery via right antrolateral minithoracotomy versus median sternotomy.
Group "A"
Group "B"
P value
Sig.
MV (hours)
4 ± 1.3
6.45 ± 2.8
< 0.01 HS
Blood loss (ml)
241.5 ±
565 ± 344.3
Blood transfusion (unit)
1 ± 1.1
2.6 ± 1.6
ICU stay (Hours)
34.8 ± 12.25
43.2 ± 16.7
> 0.05 NS
Figure 2. Label in 24pt Arial.
Patients and methods
Video assisted
Chitwood clamp & endoscopic camera
The study was done in the period between June 2015 and July 2016, at Cardiothoracic Surgery Department, Kasr EL-Aini Hospital, Cairo University, and Zayied specialized hospital.
Forty patients with isolated mitral valve disease requiring mitral valve surgery were divided into two groups:
Group "A": Included twenty patients who underwent mitral valve surgery through right antrolateral minithoracotomy. (MIMVS)
Group "B": Included twenty patients who underwent mitral valve surgery through standard median sternotomy.
Preoperative parameters:
Full history taking & Clinical examination.
Routine laboratory investigations, Chest x-ray, Echocardiography and Coronary angiography(> 40 years).
During the preoperative counseling visit ,the visual analogue scale for pain assessment in the post-operative period was instructed to the patients.
Group B
Table 1. Label in 24pt Arial.
Total Hospital stay in both groups
Pain Score in both Groups
Group "A"
Group "B"
P value
Sig.
Mean
± SD (days)
6.75
± 0.7
11.4
± 4.69
< 0.01 HS
Group "A"
Group "B"
P value
Sig.
1st day
6.3 ± 0.7
5.45 ± 0.88
< 0.05
2nd day
4.4 ± 0.75
3.4 ± 0.75
Pre-discharge
2.7 ± 1.34
2 ±
0.97
> 0.05 NS
CONTACT
Thoracotomy incision wound.
Conventional Median sternotomy.
Operative parameters:
Cannulation time, Aortic Cross Clamp Time, total Bypass Time, and total operative time.
Length of skin incision at closure of the wound.
Postoperative parameters:
A. Intensive Care Unit Evaluation:
1-Post-Operative mechanical Ventilation time.
2-Post-Operative Blood Loss, Blood Transfusion .
3-Total Intensive Care Unit Stay.
4-Post-Operative Pain Score.
B. Hospital stay Evaluation:
1-Pain score and wound satisfaction.
2-Total hospital stay.
Length of skin incision
Group "A"
Group "B"
P Value
Sig.
Mean + SD (cm)
8.15
± 1.13
19.65
± 2.7
< 0.01 HS
Operative procedure:
Anaesthetic Technique:
Routine anaesthetic technique for open heart surgery .
Double lumen endotracheal tubes were used in group "A" patients, and single lumen endotracheal tubes were used for patients in group "B".
External adhesive DC pads were placed at the back and Lt Side of the chest in patients of the minithoracotomy group.
TEE probe was inserted into the patients of both groups whenever available.
Wound Satisfaction in both groups (P value was < 0.01)
Contact
Prof. Dr. Tarek Salah.
Professor of Cardiothoracic Surgery.
 Faculty of Medicine-Cairo University.
Consultant of pediatric cardiac surgery.
Member of EACTS.
Conclusion
Our experience with MIMVS as well as the literature showed encouraging results regarding the feasibility, safety and the efficacy of MIMVS but larger sample size studies and long term follow-up are needed for better recommendations about MIMVS.