Mini-reoperative mitral valve surgery

Background: Reoperative surgery involving the atrioventricular valves places the patient at risk for cardiac or bypass graft injury upon reoperative sternotomy. Standard right thoracotomy can avoid these problems but is associated with a large incision and possibly more pulmonary complications. Methods and Results: An alternative, minimally invasive approach for reoperative atrioventricular valve surgery was studied in 22 patients. Patient age was 66 ± 10 years. Postoperative mitral regurgitation was 3.4 ± 0.3 and New York Heart Association (NYHA) Class was III/IV, despite a mean ejection fraction of 44 ± 14%. These patients had 1-4 prior procedures a mean of 5 years previously. An anterior 5th interspace incision of 5- to 10-cm was performed. A 1-cm segment of 5th rib was removed to facilitate exposure. Cardiopulmonary bypass was performed via ascending aorta or femoral artery cannula and bicaval venous cannulae. Systemic cooling (25°) and fibrillatory arrest was used. Operations performed included mitral valve repair (12), mitral valve replacement (5), prosthetic mitral valve rereplacement (4), repair of perivalvular leak (3), tricuspid valve repair (5), and atrial septal defect closures (7). Mean bypass time was 109 ± 21 minutes with a mean fibrillatory time of 62 ± 12 minutes. There was no intraoperative or 30-day mortality. Patients were weaned from ventilation at a mean of 5 hours postoperatively and received 1.3 ± 1 unit of blood. There were no wound complications or reexplorations for bleeding. At a mean follow- up of 15 ± 8 months, survivors are NYHA Class I-II. When interviewed, all patients felt their recovery was more rapid and less painful than their original sternotomy. Conclusion: This minimally invasive approach to reoperative atrioventricular valve surgery is safe and technically feasible. It has become our preferred approach to the atrioventricular valves in patients with a previous sternotomy.