Back to Program
Tomislav Mihaljevic, MD
Introduction
Aortic valve operations have been traditionally performed through the complete median sternotomy with direct cannulation of ascending aorta and the right atrium. An alternative minimally invasive approach was developed to reduce the trauma and allow faster recovery without jeopardizing surgical results for patients. We report our eight year experience with this procedure.
Methods
From January 1995 to December 2003, 1103 patients underwent isolated minimally invasive aortic valve surgery at the Cleveland Clinic Foundation. The operations were performed through a 8-10 cm long skin incision, and partial upper sternotomy extending into the right fourth intercostals space. Normothermic cardiopulmonary bypass was instituted through the cannulation of the distal ascending aorta and the right atrium. Alternatively, the cannulation of the superior vena cava with advancement of the cannula into the inferior vena cava was used. Myocardial protection was accomplished with cold antegrade blood cardioplegia. The aortic valve was exposed through the oblique aortotomy extending into the non-coronary sinus of Valsalva. The surgical procedure for the aortic valve was replacement in 64% of patients, while repair was accomplished in 23% of the patients. Aortic valve replacement was combined with the replacement of the ascending aorta in 13 % of patients.
Results
There were 9 hospital deaths, accounting for hospital mortality of 0.8 %. 7-year survival was 88%. Conversion to complete sternotomy was required in 1.6% of patients. Mean aortic occlusion time was 53 minutes; mean cardiopulmonary bypass time was 67 minutes. The postoperative stroke was observed in 2.7% of patients.
Sixty-seven percent of patients were extubated within six hours from the completion of surgery. The mean time of postoperative ventilatory support was 4 hours. Blood transfusions were used in 9% of patients. Mean hospital postoperative stay was 6 days. The incidence of postoperative wound infection was 0.6%. The comparison with median sternotomy demonstrates a reduction in both postoperative length of stay and direct hospital costs.
Conclusions
Minimally invasive aortic valve surgery represents a safe approach for the treatment of a variety of aortic valve disorders and the disease of the ascending aorta. The comparison with median sternotomy demonstrates a reduction in both postoperative length of stay and direct hospital costs. The minimally invasive approach should be considered for all eligible patients with aortic valve disease.
