Minimally Invasive Cardiac Surgery Experiences in a

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ORIGINAL INVESTIGATION
Koşuyolu Heart Journal 2014;17(2):110-113 • DOI: 10.4274/khj.85570
Minimally Invasive Cardiac Surgery Experiences
in a District Branch Hospital
Tanıl Özer, Murat Yücel, İlker Mataracı, Muhammet Onur Hanedan, Ufuk Sayar, İzzet Emir
Ahi Evren Thoracic and Cardiovascular Surgery Training and Research Hospital, Clinic of Cardiovascular Surgery,
Trabzon, Turkey
ABSTRACT
Introduction: With the development of technology and surgical experiences, minimally invasive approaches are
getting more preferable by physicians. Also these smaller incisions provide patients to have higher life quality at
their postoperative periods. In this study we aimed to report our minimally invasive approach experiences.
Patients and Methods: In our clinic 10 patients underwent open heart surgery with minimally invasive
approaches between March 2010 and January 2014. The mean age was 50.5±26 years (range, 22-82 years). Six of
them were females (60%). Four patients have had previous open heart surgery through standard sternotomy. Ministernotomy was performed in 4 patients, 5 patients’ operations were done via right anterior mini-thoracotomy and
one patient was operated via left anterior minithoracotomy.
Results: The mean operation duration was 6.8±1.8 hours (range, 4-10 hours) (time elapsed from anesthesia
induction to wound closure with sterile sponge). Only one patient was extubated in operating theatre. Early
mortality (in postoperative 30 days) was seen in only one patient. One patient was admitted to hospital with
wound complication and re-hospitalized for wound care.
Conclusion: With developments in cardiac surgery field, many disorders are repaired via minimally invasive
techniques providing exposures as good as conventional approaches. In recent years, many clinics reported their
experiences at these applications with excellent results. Minimally invasive cardiac surgery does not have worse
mortality rates than standard techniques. Also, it enables patients to return to their own normal activities, providing
them with less wound complications. With the increasing experiences, minimally invasive cardiac surgery may
be considered in those appropriate patients and particularly in patients who care about their own appearances.
Key Words: Minimally invasive cardiac surgery; open heart surgery
Bir Bölge Dal Hastanesinin Minimal İnvazif Kalp Cerrahisi Deneyimleri
ÖZET
Giriş: Teknolojik ve cerrahi alandaki gelişmelerle, minimal invazif cerrahi yaklaşımlar hekimler için daha fazla
tercih edilebilir hal almışlardır. Aynı zamanda bu küçük kesiler hastaların postoperatif dönemdeki hayat kalitesini
de arttırmıştır. Bu çalışma ile bir bölge dal hastanesi olarak bu alandaki deneyimlerimizi bildirmek istedik.
Hastalar ve Metod: Mart 2010 ile Nisan 2014 arası 10 hasta hastanemizde minimal invazif yaklaşımla opere
edildi. Altısı (%60) bayan olan hastaların yaş ortalaması 50,5±26 yıl (22-82) idi. Dört hastaya ministernotomi, 5
hastaya sağ bir hastaya sol anteriyor minitorakotomi uygulandı.
Bulgular: Ortalama operasyon süresi 6,8±1,8 saat (4-10 saat) (anestezi indüksiyonundan yaranın steril gazlı bez
ile kapatılmasına kadar geçen süre). Sadece bir hasta ameliyathanede ekstübe edildi. Erken mortalite (postoperatif
ilk 30 gün) sadece bir hastada görüldü. Bir hasta yara yeri komplikasyonu nedeniyle yeniden hospitalize edildi.
Sonuç: Kardiyak cerrahi alandaki gelişmeler ile birçok bozukluk konvansiyonel yöntemler kadar iyi görüş
sağlayan minimal invazif tekniklerle ameliyat edilebilmektedir. Son yıllarda birçok klinik bu alanda gayet güzel
sonuçlarını yayınlamışlardır. Sonuçlar da gösteriyor ki, minimal invazif yaklaşım standart tekniklerden daha
kötü sonuçları olmamakla beraber hastaların normal yaşam aktivitelerine dönüşlerini kolaylaştırıp, yara yeri
komplikasyonlarını da azaltmaktadır. Artan deneyimlerle beraber özellikle dış görünümüne önem veren uygun
hastalarda minimal invazif yaklaşımlar akılda bulundurulmalıdır.
Anahtar Kelimeler: Minimal invazif kalp cerrahisi; açık kalp cerrahisi
Correspondence
Tanıl Özer
E-mail: drtanilozer@gmail.com
Submitted: 06.06.2014
Accepted: 24.06.2014
@Copyright 2014 by Koşuyolu Heart
Journal - Available on-line at
www.kosuyolukalpdergisi.com
INTRODUCTION
Most of cardiac surgical procedures are
still performed through standard incisions.
These incisions enabling operators achieve
better exposures and therefore feel more
confident themselves. However, patients’
satisfactory is not as much as ours. With
the development of technology and surgical
experiences, minimally invasive approaches
are getting more preferable by physicians.
Also these smaller incisions provide patients
to have higher life quality at the postoperative
periods(1,2). In this study we aim to report our
minimally invasive approach experiences.
Özer T, Yücel M, Mataracı İ, Hanedan OM, Sayar U, Emir İ.
PATIENDS and METHODS
In our clinic 10 patients has underwent open heart surgery
with minimally invasive approaches between March 2010 and
January 2014. Median age was 50.5±26 years (22-82 years). Six
of them were female (60%). Four patients have had previous
open heart surgery through standard sternotomy. Ministernotomy
was performed for 4 patients who were performed aortic valve
replacement (AVR), 5 patients’ operations were done via right
anterior minithoracotomy and one patient underwent coronary
artery bypass grafting (CABG) via left anterior minithoracotomy
(Table 1). One patient who had underwent mitral valve
replacement (MVR), AVR and tricuspid valve ring annuloplasty
6 years ago was operated urgently after the diagnosis of prosthesis
valve dysfunction. This patient also supported by extracorporeal
membrane oxygenation (ECMO) at the postoperative period.
Surgical Techniques
In upper ministernotomy group; a nearly 6-8 cm length
midline skin incision was made starting from suprasternal notch.
Sternum was divided down to the fourth intercostal space and
angled right with an oscillating saw (J shape). A Finochietto
sternal retractor was used to separate the sternal edges. The
remnant thymus gland and/or fatty tissues were excised to
improve the exposure. The pericardium was opened sufficiently
and suspended to exposure the aorta and left ventricular
outflow tract. The arterial cannulation was made to distal part
of the ascending aorta with conventional technique. The venous
cannulation was performed from femoral vein percutaneously.
The cross clamping and cardioplegia applications were done via
conventional technique. Aortic valve’s exposure was as good as
standard full sternotomy. A 36 Fr drainage tube was placed to the
mediastinal cavity lying undersurface of the sternum (Figure 1).
Koşuyolu Heart Journal 2014;17(2):110-113
In anterior minithoracotomy group; left anterior
minithoracotomy was made to patient operated for CABG and
right anterior minithoracotomy was made to the others. The
submammarian groove was used for the anterolateral incision
(Figure 2). CABG was performed at the beating heart. Internal
mamarian artery was prepared through thoracotomy and
anastomosed to anterior descending coronary artery by using
Genzyme retractor. Right femoral artery for arterial cannulation,
right femoral and jugular veins for venous cannulation were
used to the patients whose operations were performed under
cardiopulmonary bypass (CPB). Pericardium was opened
nearly 2 cm anterior of phrenic nerve to save from retraction’s
injury and traction sutures placed to exposure the caval veins,
ascending aorta, pulmonary veins and the left atrium. Chitwood
cross clamp was placed with Chitwood technique. Antegrade
cardioplegia was administered with aortic root needle.
All operations were performed using the same anesthesia
protocol, moderate hypothermic CPB (30 °C to 32 °C) and
isothermic blood cardioplegia.
Statistics Analysis
No statistical tests were used. Data was expressed as mean
± standard deviation.
RESULTS
Mean operation duration was 6.8±1.8 hours (4-10 hours)
(from anesthesia induction to wound closure with sterile sponge)
Table 1. Demographic data of patients
Patient
Age/Gender
BMI
Type of
Pathology
Re-Operation
1
24/M
21.2
AR
-
2
72/M
21.6
AS
-
3
72/F
43.3
AS
-
4
82/M
29.4
AS
+
1
22/F
21.4
M PVD, TR
+
2
23/M
21.8
ASD
+
3
23/F
21.5
ASD
-
4
43/F
19.3
MR, AR
-
5
71/F
26.0
MR,TR
+
6
73/F
30.5
CAD
-
50.5
25.6
Mini Sternotomy
Mini Thoracotomy
Total
Mean
10
AR: Aortic regurgitation, AS: Aortic stenosis, ASD: Atrial septal defect, CAD:
Coronary artery disease, F: Female, M: Male, M PVD: Mitral prosthesis valve
dysfunction, MR: Mitral regurgitation, TR: Tricuspid regurgitation
Figure 1. Postoperative view of Ministernotomy
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Koşuyolu Heart Journal 2014;17(2):110-113
Minimally Invasive Open Heart Surgery
(Table 1). Only one patient was extubated in operating theatre.
Early mortality (in postoperative 30 days) was seen on only one
patient who had undergone CABG 16 years ago and aortic and
innominate vein injuries were occurred peroperatively. This
patient could not wean from CPB. One patients hospitalization
extended by the cause of atrial fibrillation (AF). One patient who
was performed ECMO at the postoperative period hospitalized
for about one month. She was discharged from hospital in a
healthy status. One patient was admitted to hospital with wound
complication and re-hospitalized for wound care.
DISCUSSION
With developments in cardiac surgery field, many disorders are
repaired via minimally invasive techniques providing exposures as
good as conventional approaches(1). In recent years, many clinics
reported their experiences at these applications with excellent
results. From ASD repairment to CABG and/or three valve
repairments, many cardiac surgical procedures can be performed
via minimally invasive approaches(3-6). As shown in the Table 2,
our cases which include four redo surgeries had the nearly same
complexity scale as the world.
While exerting effort to minimize the incisions, we know
that the importance of providing outcomes at least as good as
conventional approaches. In the literature there are so many
reports showing good results about minimally invasive cardiac
surgery. Moreover, some reports have included complex
cases(4,6,7). In addition to these good results, one of the most
focused issue was patient satisfactory. Cosmetic reasonsespecially for young women - gain importance to prefer these
smaller incisions(1,3). Komai et al. described a lower small
midline skin incision with minimal sternotomy approach to 78
pediatric patients who had undergone minimally invasive open
heart surgery procedure with comparable cosmetic results(8).
Less traumatic wounds provide patients more comfortable
postoperative periods. Pain levels and daily life activities
are the most important indicators for having physical and
psychological well-being(5,7).
CONCLUSION
Minimally invasive cardiac surgery does not have worse
mortality rates than standard techniques. However, it enables
patients to return to their own normal activities, providing them
with less wound complications. By increasing experiences,
minimally invasive cardiac surgery may be considered in those
Figure 2. Postoperative view of minithoracotomy
Table 2. Operative and postoperative data of patients
Patient
Procedure
CCT (min)
CPBT(min)
OT (hour)
ICU (day)
Hospital (day)
Drainage (ml)
1
AVR
127
169
4
1
5
250
2
AVR
87
139
8
2
11
150
3
AVR
136
203
6
2
7
300
4
AVR
120
240
10
-
-
-
1
MVR, T Expl
118
360
8
17
31
500
2
ASD Repair
60
132
6
1
6
150
3
ASD Repair
48
110
5
1
6
250
4
AVR, MVR
170
203
8
2
7
400
5
M and T Repair
97
131
7
5
7
500
6
CABG
BH
BH
6
1
6
250
114.4
33.3
197.1
76.7
6.8
1.8
3.56
5.2
9.6
8.2
305
133
Mini Sternotomy
Mini Thoracotomy
Mean
Standard Deviation
AVR: Aortic valve replacement, ASD: Atrial septal defect, CABG: Coronary artery bypass grafting, CCT: Cross clamp time, CPBT: Cardiopulmonary bypass time, ICU:
Intensive Care Unit, OT: Operation time, MVR: Mitral valve replacement, T Expl: Tricuspid exploration
Özer T, Yücel M, Mataracı İ, Hanedan OM, Sayar U, Emir İ.
appropriate patients and particularly in patients who care about
their own appearances.
CONFLICT of INTEREST
The authors reported no conflict of interest related to this
article.
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Koşuyolu Heart Journal 2014;17(2):110-113
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