Initial Experience of Minimally Invasive Concomitant Aortic and Mitral Valve Replacement/Repair at a Tertiary Care Cardiac Centre of a Developing Country

Abstract

IntroductionMinimally invasive double valve replacement (DVR) surgery through a small transverse anterior thoracotomy is an alternate technique to sternotomy for concomitant aortic and mitral valve (AVR, MVR) surgery. The aim of this study was to evaluate the in-hospital and early outcomes of direct vision minimal invasive double valve surgery (DVMI-DVR) at a tertiary care cardiac center of a developing country.MethodsThis study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan from January 2018 to September 2018. Nineteen consecutive patients undergoing DVMI-DVR for aortic and mitral disease without any prior cardiac surgery were included in this study. For all procedures, access was obtained through small transverse anterior thoracotomy incision with wedge resection (Chaudhry’s Wedge) of sternum opposite to the third and fourth costosternal joints. Patients were observed during their hospital stay and the following variables were observed the length of hospital stay (LOHS), ventilator support, intensive care unit (ICU) stay, pain score, and mortality. The pain score was assessed using the visual analog scale (VAS).ResultsThe male/female ratio was 11:8 with a mean age of 35 ± 12 years with mean EuroSCORE of 6.6 ± 3.5%. The mean total bypass time was 129.8 ± 23.83 min (range: 98-181 minutes). The mean mechanical ventilation time was 3.16 ± 1.12 hours (range: 2-6 hours). The mean intensive care unit (ICU) stay was 41.84 ± 8.36 hours. The mean post-operative LOHS was 5.63 ± 1.12 days (range: 4-8 days). We had zero frequency of wound infection and surgical mortality. The mean pain score was 4.32 (on a predefined pain scale of one to nine with a high value indicating severe pain).ConclusionMinimally invasive DVR surgery is a safe and reproducible technique with comparable outcomes such as postoperative pain score (4.32 ± 2.05), ventilation time (3.16 ± 1.12 hours), ICU stay (41.84 ± 8.36 hours), and hospital stay (5.63 ± 1.12 days). In terms of mortality, operative times, ICU stay, and hospital stay, the minimally invasive DVR is at least comparable to those achieved with median sternotomy. Further prospective randomized studies are needed to validate our findings.

Outcomes in minimally invasive double valve surgery

“…Miura et al 26 did not find any significant difference between the groups (72 vs. 24 h; p = .23, respectively). Most non‐comparative studies using MIS report varying ICU stays of between 24 and 72 h, providing similar results to the MIS groups in the comparative studies 12,29,31,32 . One MIS study reported an ICU stay of 8.6 ± 3.2 h, 33 which was significantly lower than any other double valve MIS or MS ICU stay reported.…”

“…Five non‐comparative double valve MIS studies reported this outcome, four of which found no sternal wound infection (SWI) post operatively 12,17,29,33 and one reported 1 case (1.3%) 18 . The three comparative studies which reported this outcome found no significant difference between the groups (MIS vs. MS: 0% vs. 0.04%, 26 1.2% vs. 0% 24 and 1.1% vs. 3.3% 25 ).…”

“…[9][10][11] As research and technology advances, newer techniques and methods have been introduced that result in more optimal patient outcomes. 12 There is an increasing body of evidence supporting the use of MIS, which was first performed in 1952 by Dr John Gibbon, 13 including reduced procedural blood loss, postoperative pain, and length of hospital and intensive care unit (ICU) stay. 1,3,14 In 1997, this was further supported by Cohn et al who found in addition to the advantages stated by Navia in 1996, there was also a financial benefit.…”

“…Most studies found were carried out in single centers. Some studies are carried out in parts of the world where the majority of the double valve pathologies are caused by rheumatic heart disease, 12,34 however the prevalence of this disease in the US and Europe is low 50 . The studies used varying MIS techniques, and some had different inclusion and exclusion criteria, again making it difficult to apply to the results to other centers.…”

An Overview of First 100 Cardiac Surgery Cases at a Newly Developed Satellite Center in Sukkur, Pakistan

“…ONCAB and valvular procedures were performed through median sternotomy with target activated clotting time above 480 seconds and myocardial protection using St. Thomas cardioplegia delivered antegrade (graft plegia was preferred by few surgeons) or retrograde with topical cooling. Minimally invasive atrial septal defect (ASD) closure was performed using the same technique as described in our previous publication on double valve replacement with central cannulation [9].…”