|Year : 2013 | Volume
| Issue : 2 | Page : 53-56
Right anterolateral thoracotomy a minimally invasive approach to mitral valve replacement
Farooq Ahmad Ganie, AG Ahangar, Zamir Ahmad Shah, GN Lone, Hafeezulla Lone, Mohd. Lateef Wani, Abdual Majeed Dar, Mohd Akbar Bhat, Shyam Singh, Syeed Whaid, Nadeem Ul Nazeer Kawoosa
Department of Cardiovascular and Thoracic Surgery, SKIMS, Soura, Kashmir, India
|Date of Web Publication||16-Sep-2013|
Farooq Ahmad Ganie
Department of Cardiovascular and Thoracic Surgery, SKIMS, Soura, Kashmir
Source of Support: None, Conflict of Interest: None
Background: The objectives of this study were to analyze the results of the right anterolateral thoracotomy approach for primary mitral valve replacement with reference to length of incision, surgical exposure, mean cross-clamp time, mean bypass time, intensive care unit (ICU) stay, hospital stay, overall comorbidity sepsis, dehiscence, healing cosmesis and cost-effectiveness. Materials and Methods: Thirty-three patients were operated for mitral valve disease in the Department of Cardiovascular and Thoracic Surgery at the Sher-i-Kashmir Institute of Medical Sciences from September 2009 to August 2011 and all patients underwent mitral valve replacement. Results: Of the 33 patients, 13 were male (40.6%) and 19 were female (59.4%). The length of incision was 14.8 ± 2.3 cm and, in thoracotomy, there was a significantly lesser duration of ICU stay the entire hospital stay. Scar visibility was around 25% in case of thoracotomy. Conclusion: Approach through a right anterolateral thoracotomy proved to be easy to perform while maintaining maximum security for the patients. Besides its better cosmetic result, especially in female patients, this approach proved to have several advantages. It offered a better exposure to the mitral apparatus even in patients with small left atrium, allowing mitral valve replacement to be performed easily. The shorter hospital stay and cost-effectiveness of thoracotomy approach is an additional relief to the family.
Keywords: Mitral valve, scar visibility, thoracotomy
|How to cite this article:|
Ganie FA, Ahangar A G, Shah ZA, Lone G N, Lone H, Wani ML, Dar AM, Bhat MA, Singh S, Whaid S, Kawoosa NU. Right anterolateral thoracotomy a minimally invasive approach to mitral valve replacement. Muller J Med Sci Res 2013;4:53-6
|How to cite this URL:|
Ganie FA, Ahangar A G, Shah ZA, Lone G N, Lone H, Wani ML, Dar AM, Bhat MA, Singh S, Whaid S, Kawoosa NU. Right anterolateral thoracotomy a minimally invasive approach to mitral valve replacement. Muller J Med Sci Res [serial online] 2013 [cited 2019 Sep 18];4:53-6. Available from: http://www.mjmsr.net/text.asp?2013/4/2/53/118223
| Introduction|| |
The heart valves function to maintain pressure gradients between cardiac chambers and, therefore, ensure unidirectional flow of blood without reflux through the heart. Among the heart valves, the aortic and mitral valves are by far the most likely to acquire the disease. Mitral valve diseases have been one of the most interesting human maladies to be treated in this century from a public health, medical diagnostic and surgical technique perspective. , Rheumatic fever and rheumatic heart disease affect the mitral valve by causing stenosis of both the anteromedial and the posterior commusures of the valve, subsequently leading to mitral regurgitation (MR). The compensatory mechanisms of the ventricles permit the heart to tolerate these lesions for varying periods of time. Heart failure from mitral stenosis (MS) was well recognized by the 19 th century and surgical correction began well before the heart lung machine was available. , Valvular heart diseases may be considered surgical illnesses. Lillehei repaired multiple valvular lesions through a right thoracotomy using cardiopulmonary bypass in 1956. A few years later, in 1961, A. Starr successfully replaced a mitral valve with a prosthetic valve. ,
In 1965, Dr. Jai-Si Haung performed the first open heart mitral valve replacement at the Shanghai Hospital, China. The ensuing years witnessed the rapid development of various valvular prostheses placed via a conventional approach - a full sternotomy with cardiopulmonary bypass (CBP).  However, over the past few decades, minimally invasive mitral valve surgery has grown in popularity and has evolved significantly over the past 10 years and now comprises safe and efficient operations for most patients. At the Brigham and Women's Hospital (BWH), mini-VS does not involve a complete sternotomy but, instead, uses a partial sternotomy or limited thoracotomy incision.  A variety of techniques have been described to reduce surgical access in mitral valve surgery. The most common minimally invasive approach to the mitral valve includes a partial sternotomy and a right mini-thoracotomy; either approach may be performed using standard conventional access, port access, indirect endoscopic techniques and, more recently, robotic techniques.  Although there has been great enthusiasm in recent years to perform mitral valve surgery through small multiple incisions with the use of the Port Access technique, however, the procedure is costly, involves a relatively long training curve and leaves the patient with multiple scars in the chest and groin. Median sternotomy, which is generally used as a standard access for mitral valve operations, has a significant risk of post-operative instability/osteomyelitis of the sternum. Moreover, especially in young women, the resulting large scar is a poor cosmetic result that may have adverse psychological consequences. Sternotomy independently increases the risk of post-operative morbidity and mortality in patients of cardiac surgery, especially when associated with other comorbid conditions like diabetes.  Approach to mitral valve via the right anterolateral thoracotomy is not new. The principle of this kind of an approach is to reduce the morbidity and the cost, to speed hospital discharge and to shorten the rehabilitation time. , Right anterolateral thoracotomy has been recommended as an alternative to standard median sternotomy for patients undergoing mitral valve replacement. The purpose of this study was to compare right anterolateral thoracotomy with standard median sternotomy for mitral valve replacement in terms of cost benefits and other variables, including cosmesis.
| Materials and Methods|| |
Thirty-three patients were operated for mitral valve disease in the Department of Cardiovascular and Thoracic Surgery at the Sher-i-Kashmir Institute of Medical Sciences from September 2009 to August 2011, and all patients underwent mitral valve replacement. One patient in thoracotomy who expired during the course of the study was excluded from the study. The following observations were made. The mean age was 44.41 ± 8.2 years in our study. Thirteen patients (40.6%) were male and 19 patients were female (59.4%). Twenty-four (75%) patients were class III and eight (25%) patients were class IV (NYH).
Twenty-five (78.1%) of the patients had an ejection fraction (EF) of 30-50%, five (15.6%) patients had an EF of >50% and two (6.3%) patients had an EF of <30%. The mean length of incision was 14.8 cm. The mean cross-clamp time was 41.7 min. The bypass time was 83.3 min. The total operating time was 4.7 ± 0.4 h in our cases. Duration of intensive care unit (ICU) stay was 17.1 ± 4.2 h. The mean hospital stay post-operatively was 9.2 days. Wound infection was seen one (3.1%) patients and 31 (96.9%) patients had no infection. Wound dehiscence was not seen in any of the cases. Scar visibility was 25% in our case of thoracotomy. Scar complication was seen in only two (6.3%) patients of thoracotomy. Scar hypertrophy and stretching was seen in only one (3.1%) of the patients and scar stretching alone was also seen in one (3.1%) of the patients. Seventy-five percent of the patients were satisfied with the cosmetic outcome in thoracotomy. Fifteen (80%) females in thoracotomy of 19 females in the study were satisfied with their scar appearance and cosmesis. The post-operative drug cost was 9.2 ±1.5 thousand in thoracotomy. Conversion to sternotomy for need of adequate exposure to valve was not seen in any case.
| Discussion|| |
The study was completed in the Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura.
Median sternotomy, which is generally used as a standard access for mitral valve operations has a significant risk of post-operative infection and dehiscence. Moreover, especially in young women, the resulting large scar is a poor cosmetic result that may have adverse psychological consequences.  These difficulties may be avoided by the use of a less-invasive approach consisting of a limited anterolateral thoracotomy with standard cannulation. We studied whether such complications can be avoided by using right anterolateral thoracotomy.
In our study, the mean age of the patients in thoracotomy was 44.4 ± 8.2 years. Patients could remain asymptomatic for many years as long as the MS was mild and was not accompanied by more than mild MR. Moreover, in developing countries, rheumatic MS manifests 10-30 years after the initial rheumatic insult to the mitral valve. Similar results were reported by Carapetis.  Sliwa et al. reported the highest prevalence of rheumatic heart disease in females at 45-54 years of age and in males in those who were 55-64 years of age. 
In our study, females formed the majority of the study population. Most of our patients were females because of the reason that although rheumatic fever affects both sexes equally, in those who acquire rheumatic heart disease, MS/MR is more common in women. Females formed the majority of patients in the study performed by Kumar et al.  at AIIMS, where 38 patients (34 female and four male) underwent mitral valve surgery through a limited right anterior thoracotomy. Srivastava  enrolled 30 females for 22 male of the 52 patients in his study. Two-thirds of the patients who came for mitral valve surgery were young women in the study by Mishra et al. 
In our study, all patients (100%) belonged to NYHA class III and IV, which is consistent with the study by Thompson et al., where 86% of the patients belonged to NYHA classes III and IV pre-operatively. Twenty-four (75%) of the patients in thoracotomy were class III while the remaining were class IV. This is consistent with the study by Apostolos et al., who reported that most of the patients who present for mitral valve surgery are in NYHA symptom class III and IV. No statistically significant difference was seen between the two groups.
Majority of the patients had an EF below 60%, which is the indication for surgical intervention according to the ACC/AHA guidelines for management of patients with valvular heart disease. In our study, five (15.1%) patients had an EF >50%, 25 (78.1%) patients had an EF 30-50% and two (6.3%) patients had an EF below 30%. Hence, the groups were comparable with respect to EF.
The mean aortic cross-clamp was 41.7 ± 5.7 min in our study. The observed values are well below the highest cut-off value for a cross-clamp time of 150 min, which is significantly associated with post-operative morbidity, particularly with post-operative stroke.  The lesser cross-clamp time in thoracotomy was due to easy accessibility to the left atrium even with a smaller atrial size. The observed cross-clamp time is consistent with the studies by El-Fiky et al. (27 ± 8 min),  Zapolanski et al. (70 min),  Riess et al. (51.8 ± 21.9 min),  Grossi et al. (92 h),  Chiu et al. (43.7 min)  and Seeburger et al. (70 ± 38 min). 
The mean bypass time was 83.3 ± 10.7 in thoracotomy. The observed values are well below the highest cut-off value for a total bypass time of 240 min, which is significantly associated with post-operative morbidity, particularly with post-operative stroke.  The total bypass time in our study is comparable with that of other studies and the study group: . El-Fiky et al. (59 ± 11 min),  Zapolanski et al. (77 ± 25.8 h),  Grossi et al. (127 h),  Aybek et al. (142 ± 40 h),  Chiu et al. (91.1 h)  and Seeburger et al. (121 ± 38 h). 
The total operating time was 4.7 ± 0.4 h (282 ± 24 min) in thoracotomy. Holman et al. reported a mean time in the operating room of 185 ± 73 min.  Riess et al. reported an operating time of 211.9 ± 36 min.  The difference appears because, in our study, the total operating time started with intubation of the patient, putting in the central venous catheter and arterial line and positioning the patient until shifting the patient to the ICU.
The overall surgical exposure was good, cannulation of the vessels, aortic clamping and instituting cardioplegia were performed using standard techniques; so were the atriotomy, valve excision and replacement. No technical difficulty was encountered during aortic and major vessel cannulation in thoracotomy. The left atrium was sufficiently exposed while the accessibility to the valve during excision of the valve and valve replacement was adequate. This is supported by the fact that the conversion rate to sternotomy for need of adequate exposure to the valve apparatus was zero and comparable results of bypass time, cross-clamp time and total operating time. This observation is consistent with the studies by Kumar et al.,  Calleja,  Srivastava et al.,  Holman et al.,  Yung et al.  and Thompson. 
In our study, we had a choice of shifting the patients early to the high-dependency area of our general post-operative ward. The duration of ICU stay was 17.1 ± 4.2 h. This is consistent with other studies by Yung et al. (36.3 ± 5 h),  Reiss et al. (28.8 ± 9 h),  Grossi et al. 31.6±7 (hours)  and Aybek et al. (18 h).  Thoracotomy proved to be better than sternotomy in terms of post-operative ICU stay.
The total hospital stay was 9.2 ± 1.7 days. Our result was consistent with the studies by El-Fiky et al. (7 ± 2 days),  Yung et al. (11.7 ± 0.6 days),  Zopalinski et al. (8.1 days),  Riess et al. (7.8 ± 2.2 days),  Grossi et al. (6 days),  Thompson et al. (12 days)  and Alexander Iribane (7.7 ± 0.4 days).  Early ambulation, with consequent early appreciation of self well being and faster recovery reduced the overall hospital stay in the thoracotomy group. 
The thoracotomy approach incision length was 12-15 cm. Reduction in the size of the operative incision for cardiac valve surgery has been associated with reduced post-operative discomfort, shorter intensive care and hospital lengths of stay, earlier recovery and return to work and improved overall patient satisfaction as reported by Apostolos et al. 
In our study, 3.1% of the patients suffered wound infection. Thoracotomy wounds are less-prone to infection.
Cosmetically, the incision in thoracotomy was better. The thoracotomy scar was less obvious and more laterally placed even in males. In females, most of the incision length was hidden under the breast. This made it more convenient psychologically. El-Fiky et al. reported that the wound was totally inapparent in his patients and that more patients requested this approach. 
The post-operative drug cost was less in thoracotomy operative pain due to use of intercostal nerve block, which reduced the need for frequent analgesia. Lesser inhibition of respiratory movements due to less pain helped in early ambulation and rehabilitation, consequently resulting in the lesser charges for drug usage and hospital stay. The post-operative drug cost was less, which is consistent with the studies by Hulusi Us et al.,  Chitwood et al.,  Cohn et al.  and Navia and Cosgrove.  The reduced hospital stay would also decrease the charges of the overall stay in the hospital, which, however, was not included in the study. 
| References|| |
|1.||Westaby S, Bosher C. Development of surgery for valvular heart diseases. In: Westaby S, Bosher C, editors. Landmarks in Cardiac Surgery. Oxford, UK: ISIS Medical Media; 1997. p. 139. |
|2.||Cohn LH, Soltesz EG. The evolution of mitral valve surgery: 1902-2002. Am Heart Hosp J 2003;1:40-6. |
|3.||Bisbos AD, Spanos PK. Mitral valve regurgitation: Surgical treatment. Hellenic J Cardiol 2003;44:418-26. |
|4.||Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol 2010;56:455-62. |
|5.||Zapolanski A, Korver K, Pliam MB, Shaw RE, Laurel M, Mengarelli RN. Thoracotomy with central aortic cannulation and no endoscopic assistance. Paper Presented at the Fourth Annual Scientific Meeting of the International Society for Minimally Invasive Cardiac Surgery, Munich, Germany, June 27-30, 2001. |
|6.||Lone RA, Ahangar AG, Zubair H, Hussain Z, Dar AM. CABG at SKIMS - An initial experience. Indian J Pract Doct 2009;5:6. |
|7.||Neptune WB, Bailey CP. Mitral commissurotomy through the right thoracic approach: Technique and indications. J Thorac Surg 1954;28:15-22. |
|8.||Cosgrove D, Sabik J, Navia J. Minimally invasive valve operations. Ann Thorac Surg 1998;65:1535-9. |
|9.||Zapolanski A, Korver K, Pliam MB, Shaw RE, Mengarelli LM. Mitral valve surgery via a right anterior mini-thoracotomy with central aortic cannulation and no endoscopic assistance. Heart Surg Forum 2002;4:445-53. |
|10.||Carapetis JR. Rheumatic heart disease in Asia. Circulation 2008;118:2748-53. |
|11.||Sliwa K, Carrington M, Mayosi BM, Zigiriadis E, Mvungi R, Stewart S. Incidence and characteristics of newly diagnosed rheumatic heart disease in Urban African adults: Insights from the Heart of Soweto Study. Eur Heart J 2010;31:719-27. |
|12.||Kumar AS, Prasad S, Rai S, Saxena DK. Right thoracotomy revisited. Tex Heart Inst J 1993;20:40-2. |
|13.||Srivastava AK, Garg SK, Ganjoo AK. Approach for primary mitral valve surgery: Right anterolateral thoracotomy or median sternotomy. J Heart Valve Dis 1998;7:370-5. |
|14.||Mishra YK, Malhotra R, Mehta Y, Sharma KK, Kasliwal RR, Trehan N. Minimally invasive mitral valve surgery through right anterolateral minithoracotomy. Ann Thorac Surg 1999;68:1520-4. |
|15.||Nissinen J, Biancari F, Wistbacka JO, Peltola T, Loponen P, Tarkiainen P, et al. Safe time limits of aortic cross-clamping and cardiopulmonary bypass in adult cardiac surgery. Perfusion 2009;24:297-305. |
|16.||El-Fiky MM, El-Sayegh T, El-Beishry AS, Abdul Aziz M, Aboul Enein H, Waheid S, et al. Limited right anterolateral thoracotomy for mitral valve surgery. Eur J Cardiothorac Surg 2000;17:710-3. |
|17.||Modi P, Hassan A, Chitwood WR Jr. Minimally invasive mitral valve surgery: A systematic review and meta-analysis. Eur J Cardiothorac Surg 2008;34:943-52. |
|18.||Grossi EA, Galloway AC, LaPietra A, Ribakove GH, Ursomanno P, Delianides J, et al. Minimally invasive mitral valve surgery: A 6-year experience with 714 patients. Ann Thorac Surg 2002;74:660-4. |
|19.||Chiu KM, Lin TY, Li SJ, Chen JS, Chu SH. Less invasive mitral valve surgery via right minithoracotomy. J Formos Med Assoc 2006;105:715-21. |
|20.||Seeburger J, Borger MA, Falk V, Kuntze T, Czesla M, Walther T, et al. Minimal invasive mitral valve repair for mitral regurgitation: Results of 1339 consecutive patients. Eur J Cardiothorac Surg 2008;34:760-5. |
|21.||Grossi EA, LaPietra A, Ribakove GH, Delianides J, Esposito R, Culliford AT, et al. Minimally invasive versus sternotomy approaches for mitral reconstruction: Comparison of intermediate-term results. J Thorac Cardiovasc Surg 2001;121:708-13. |
|22.||Aybek T, Dogan S, Risteski PS, Zierer A, Wittlinger T, Wimmer-Greinecker G, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg 2006;81:1618-24. |
|23.||Holman WL, Goldberg SP, Early LJ, McGiffin DC, Kirklin JK, Cho DH, et al. Right thoracotomy for mitral reoperation: Analysis of technique and outcome. Ann Thorac Surg 2000;70:1970-3. |
|24.||Calleja F, Martinez JL, Gonzales De Vega N. Mitral valve surgery through right thoracotomy. J Cardiovasc Surg (Torino) 1996;37 Suppl 6:S49-52. |
|25.||Yung MC, Wang JS, Lai ST. Minimally invasive mitral valve surgery via submammary hidden incision. Zhonghua Yi Xue Za Zhi (Taipei) 2000;63:322-8. |
|26.||Thompson MJ, Behranwala A, Campanella C, Walker WS, Cameron EW. Immediate and long-term results of mitral prosthetic replacement using a right thoracotomy beating heart technique. Eur J Cardiothorac Surg 2003;24:47-51. |
|27.||Iribarne A, Russo MJ, Easterwood R, Hong KN, Yang J, Cheema FH, et al. Minimally invasive versus sternotomy approach for mitral valve surgery: A propensity analysis. Ann Thorac Surg 2010;90:1471-8. |
|28.||Meluh US, Inan K, Baltalarli K, Tarhan A, Ege T, Süngün M, et al. Mitral valve operations with right anterior minithoracotomy. Internet J Thorac Cardiovasc Surg 2000;3. |
|29.||Chitwood WR, Wixon CL, Elbeery JR. Video-assisted minimally invasive mitral valve surgery: "Micro-mitral" operation. J Thorac Cardiovasc Surg 1997;113:413-4. |
|30.||Cohn LH, Adams DH, Couper GS. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Cardiac Surg 1997;4:421-8. |
|31.||Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-4. |
|32.||Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007;116:2544-52. |