Mario Viganò, Davide Ricci, Andrea M. D'Armini, Carlo Pellegrini, Alessia Alloni, Barbara Cattadori, Patrizio Spreafico, Laura Riva; Foundation Policlinico San Matteo - University of Pavia, Pavia, Italy
Objective: Redo mitral valve procedures performed through median sternotomy carries a substantial mortality and morbidity. Potential postoperative complications like phrenic nerve paralysis, surgical bleeding, mediastinitis and sternal dehiscence are reported to be more frequent after sternal re-entry. To avoid the abovementioned complication of sternal re-entry and adequate mitral exposure in a fibrous mediastinum, antero-lateral thoracotomy has been suggested by some authors.Methods: From October 1997 to June 2006, 605 mitral valve operations have been performed in our center using port- access video-assisted mini-thoracotomy. Among these, 225 (37.2 %) were performed on patients who had undergone a previous cardiac surgery procedure. 168 patients had only one previous cardiac surgery; 41 had two previous operations; 12 had three previous cardiac surgeries and 4 had four or more previous operations. The patients can be roughly devided into four categories: group I (previous surgery on the mitral valve) 65.3%, group II (previous surgery on the aortic valve or ascending aorta) 24.2%, group III (previous coronary surgery including aortic and mitral valve) 30.6%.
Results: The population of patient was very heterogeneous and no exclusion criterias were applied. The mean CPB time was 118±48 minutes and the endo-clamp time 73±31 minutes. In 110 patients (48.9%) the aortic cannulation was performed using the endo-direct cannula, inserted through a small anterior port in the first intercostals space, in the rest of the cases (115 pts. 51.1%) a femoral artery approach was used. In only two cases (0.9%) we had to convert to a median sternotomy because of an aortic dissection and a LV free wall rupture. Aortic dissection occurred in only one case (0.4%) during the cannulation of the aorta from the femoral artery. The median ICU stay was 24 hours with a median intubation time of 12 hours and the median blood lost from chest drains was 450cc. A surgical revision was performed in 14 patients (6.2%) during the first post-operative day because of bleeding. The median hospital stay was 8 days and the mortality 4.9% (11/225 pts).
Conclusion: Port-Access video-assisted mini-thoracotomy allows good results in a difficult subset of patients, it avoids dissection of the anterior mediastinum and it permits minimal adhesion dissection. The survival favourably compares with literature, with acceptable CPB and endo-clamp time. Port-Access surgery has become in our practice the technique of choice for mitral redoes.
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