Mitral valve surgery using video-assisted right minithoracotomy and deep hypothermic perfusion in patients with previous cardiac operations

Abstract

BackgroundRedo-sternotomy for mitral valve (MV) surgery may be complex and attendant complications can be avoided using anterolateral right thoracotomy, deep hypothermia (20°C, nasopharyngeal) with low flow cardiopulmonary perfusion. Video-assisted minithoracotomy technique is a further improvement.MethodsWe performed 20 consecutive MV operations in patients with previous cardiac surgery using video-assisted right minithoracotomy, femoro-femoral bypass, deep hypothermia, low flow cardiopulmonary bypass without aortic cross-clamping. The mean follow-up was 30 ± 17.8 mo. Data is presented as the mean ± standard deviation of the mean.ResultsThere were 11 males and 9 females (age, 62.3 ± 12.1; ejection fraction 50.1 ± 11.2). Operations included MV replacement (n = 11), MV repair (n = 5), and MV re-replacement (n = 4). There were no hospital deaths, and the mean hospital stay was 8 ± 2.9 days. There were no postoperative strokes or need for mechanical circulatory support. The mean cardiopulmonary bypass time was 152 ± 28 minutes. Two patients (10%) required inotropic support beyond 24 hrs. All patients were free from inotropic support at 48 hours. The mean number of transfused red cell units was 2.8 ± 0.8 (range, 2 to 4). One patient died in another institution six months postoperatively following surgery for acute type III aortic dissection. At 30 ± 17.8 months follow-up all patients were found to be in NYHA Class I or II.ConclusionsMinimally invasive video-assisted MV surgery using deep hypothermia, low-flow cardiopulmonary bypass without aortic clamping can result in excellent clinical outcomes in patients with previous cardiac surgery via a median sternotomy. This technique offers reproducible results, good myocardial protection (as evidenced by the low rate of inotropic support that patients needed postoperatively), and low rates of complications.

Robotic‐assisted cardiac surgery without lung isolation utilizing single‐lumen endotracheal tube intubation

“…Currently, DL endotracheal intubation with lung isolation is the standard for robotic cardiac surgery in high volume robotic cardiac centers 1‐3,10,11,15‐19 . This approach has been applied in video‐assisted cardiothoracic surgery to ensure lung exclusion 20‐26 . However, proper placement of DL endotracheal tubes or bronchial blockers for lung isolation is a complex procedure, requires experienced anesthesiologists and carries potential hazards even in experienced hands 12‐15 .…”

“…Therefore, we may speculate that the potential risks of DL intubation may be minimized with the application of SL intubation and without lung isolation. The feasibility of minimal invasive cardiac operations without lung isolation has been previously used by Kiziltan et al 21 and Kim et al 22 previously. The authors reported no perioperative event that was related to the intubation technique.…”

“…Nevertheless, right‐sided unilateral pulmonary edema developed in several patients. With the goal of providing better outcomes, the studies and alternative techniques in minimally invasive cardiac surgery were reviewed 1‐26 . The literature on robotic cardiac surgery presented no recommendations about the use of SL endotracheal tubes without lung isolation.…”

“…The literature on robotic cardiac surgery presented no recommendations about the use of SL endotracheal tubes without lung isolation. However, some authors used SL endotracheal intubation without lung isolation in minimally invasive cardiac operations 20‐22 . Ito 20 noted that although lung isolation is important but not essential for minimally invasive cardiac surgery.…”

Minimal access in cardiac surgery

“…[ 1 - 6 ] Minimally invasive port-access surgery has proved its safety and feasibility worldwide. [ 6 , 7 ] Finally, robotically-assisted totally endoscopic surgery has been widely used during the last two decades. [ 8 - 20 ] Minimally invasive cardiac surgery provides reduced surgical trauma, less complication, better rehabilitation period, as well as a higher patient comfort and cosmesis.…”