Median sternotomy has been the standard approach to the heart and great vessels for more than 30 years. This approach provides excellent exposure of all cardiac structures and allows central cannulation for cardiopulmonary bypass (CPB). The ascending aorta and aortic valve are easily accessible through this incision. The last 5 years have brought considerable progress in the development of less-invasive approaches to heart valve surgery. These advances involve smaller chest wall incisions to gain access to the heart; currently, all heart valve operations require the use of CPB. Potential advantages of these incisions include increased cosmetic appeal, decreased pain, decreased bleeding and infection, shorter intensive-care unit and hospital stays, and reduced costs. However, reduction in the size of the operative field may increase the technical demands of cardiac surgical procedures. Adequate exposure is essential to successful operative technique, and less-invasive approaches to the heart cannot compromise the quality of the operation. In 1995, we began to develop techniques for less-invasive aortic valve operations. Our initial efforts involved a right parasternal incision. In most instances, this incision afforded good exposure of the aortic valve. Disadvantages of this approach included sacrifice of the right internal thoracic artery, a frequent need for femoral cannulation, difficult conversion to full sternotomy, and occasional postoperative chest wall instability. Subsequently, we found that a transverse transecting sternotomy at the second interspace provided superior exposure of the aortic root. This incision required sacrifice of both internal thoracic arteries and was difficult to convert to a standard sternotomy; in addition, several patients developed late chest wall instability. Although the aforementioned approaches were generally successful, both had significant disadvantages. Further experience has demonstrated that a partial upper sternotomy is a superior approach. A partial upper sternotomy “J'd” into the right fourth intercostal space provides the surgeon with a familiar operative field and easy access for central cannulation. If conversion to a full sternotomy becomes necessary, this is easily accomplished. A midline structure, the aortic valve is in the center of the field. Cardiac reoperation and the need for coronary artery bypass grafting are our only contraindications to this approach. In all other patients, partial upper sternotomy is currently our incision of choice for minimally invasive aortic valve surgery. From 1997 to 1999, 365 patients underwent aortic valve surgery through a partial upper sternotomy. Mean patient age was 55 ± 16 years (range of 18 to 87 years); 69% of the patients were men. Aortic valve replacement was performed in 77%; aortic valve repair, in 23%. Aortic prostheses included stented bioprostheses (38%), allografts (29%), and mechanical prostheses (10%). All allografts were implanted as full aortic roots with coronary transfer. Associated procedures included mitral valve repair or replacement (22 patients), ascending aortic aneurysm repair (12 patients), and coronary artery bypass grafting (6 patients); 8 patients required conversion to full sternotomy. Reasons for conversion included the need for coronary artery bypass grafting (3 patients), bleeding (3 patients), and inadequate exposure (2 patients). All patients remained intubated after surgery and were taken to the ICU for recovery. Mean time to extubation was 11 ± 5 hours, with 43% of patients extubated in less than 6 hours. Mean hospital length of stay was 6.7 ± 4.9 days, and 68% of patients were discharged within 6 days of surgery. Only 21% of patients received blood products during hospitalization. Postoperative complications included reoperation for bleeding (5%), stroke (3%), respiratory insufficiency (2%), and wound infection (0.3%). Six in-hospital deaths occurred, giving a hospital mortality of 1.6%. Although the right parasternal incision1Gillinov AM Casselman FP Cosgrove DM Minimally invasive heart valve surgery: Operative techniques and results.in: Yim AP Hazelrigg SR Izzat B Minimal Access Cardiothoracic Surgery. WB Saunders, Philadelphia, PA1999: 1452-1456Google Scholar, 2Cohn LH Adams DH Couper DS et al.Minimally invasive aortic valve replacement.Semin Thorac Cardiovase Surg. 1997; 9: 331-336PubMed Google Scholar, 3Cosgrove DM Sabik JF Navia JL Minimally invasive valve operations.Ann Thorac Surg. 1998; 65: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar and transecting sternotomy1Gillinov AM Casselman FP Cosgrove DM Minimally invasive heart valve surgery: Operative techniques and results.in: Yim AP Hazelrigg SR Izzat B Minimal Access Cardiothoracic Surgery. WB Saunders, Philadelphia, PA1999: 1452-1456Google Scholar have been used successfully for aortic valve surgery, most surgeons now favor the partial upper sternotomy.1Gillinov AM Casselman FP Cosgrove DM Minimally invasive heart valve surgery: Operative techniques and results.in: Yim AP Hazelrigg SR Izzat B Minimal Access Cardiothoracic Surgery. WB Saunders, Philadelphia, PA1999: 1452-1456Google Scholar, 4Gundry SR Shattuck OH Anees PA et al.Facile minimally invasive cardiac surgery via ministernotomy.Ann Thorac Surg. 1998; 65: 1100-1104Abstract Full Text Full Text PDF PubMed Google Scholar, 5Svensson LG Minimal-access “J” or “j” sternotomy for valvular, aortic, and coronary operations or reoperations.Ann Thorac Surg. 1997; 64: 1501-1503Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar, 6Gillinov AM Banbury MK Cosgrove DM Is minimally invasive heart valve surgery a Paradigm for the future?.Current Card Reports. 1999; 1: 318-322Crossref PubMed Scopus (10) Google Scholar With this approach, the sternum can be spread without deviation into the chest,7Tam RK Almeida AA Minimally invasive aortic valve replacement via partial sternotomy.Ann Thorac Surg. 1998; 65: 275-276Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar or the incision can be “J'd” off into an interspace.4Gundry SR Shattuck OH Anees PA et al.Facile minimally invasive cardiac surgery via ministernotomy.Ann Thorac Surg. 1998; 65: 1100-1104Abstract Full Text Full Text PDF PubMed Google Scholar, 5Svensson LG Minimal-access “J” or “j” sternotomy for valvular, aortic, and coronary operations or reoperations.Ann Thorac Surg. 1997; 64: 1501-1503Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar, 6Gillinov AM Banbury MK Cosgrove DM Is minimally invasive heart valve surgery a Paradigm for the future?.Current Card Reports. 1999; 1: 318-322Crossref PubMed Scopus (10) Google Scholar As stated previously, the partial upper sternotomy has several advantages over other approaches. Central cannulation is accomplished easily, and exposure of the aorta and aortic valve are excellent. The internal thoracic arteries are preserved, and conversion to full sternotomy is readily accomplished. There are few contraindications to this approach, and some surgeons have reported successful aortic valve reoperations with this incision.8Tam RK Garlick RB Almeida AA Minimally invasive redo aortic valve replacement.J Thorac Cardiovase Surg. 1997; 114: 682-683Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 9Byrne JG Aranki SF Couper GS et al.Reoperative aortic valve replacement: Partial upper sternotomy versus conventional full sternotomy.J Thorac Cardiovase Surg. 1999; 118: 991-997Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar The purpose of minimally invasive heart valve surgery is to provide some benefit to the patient. The feasibility of less-invasive aortic valve surgery has been confirmed by numerous investigators. Recent data demonstrate that these new approaches to heart valve surgery result in tangible benefits. Several studies demonstrate substantial reductions in blood loss and transfusion requirements using smaller incisions.3Cosgrove DM Sabik JF Navia JL Minimally invasive valve operations.Ann Thorac Surg. 1998; 65: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar, 9Byrne JG Aranki SF Couper GS et al.Reoperative aortic valve replacement: Partial upper sternotomy versus conventional full sternotomy.J Thorac Cardiovase Surg. 1999; 118: 991-997Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 10Cohn LH Adams DH Couper GS et al.Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.Ann Thorac Surg. 1997; 226: 421-428Google Scholar, 11Chitwood WR Wixon CL Elbeery JR et al.Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovase Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar, 12Frazier BL Derrick MJ Purewal SS et al.Minimally invasive aortic valve replacement.Euro J Cardiothorac Surg. 1998; 14: S122-S125Crossref PubMed Google Scholar, 13Rodriguez JE Cortina J de la Sota EP et al.A new approach to cardiac valve replacement through a small midline incision and inverted L-shape partial sternotomy.Euro J Cardiothorac Surg. 1998; 14: S115-S116Crossref PubMed Google Scholar, 14Machler HE Bergmann P Anelli-Monti M et al.Minimally invasive versus conventional aortic valve operations: A prospective study in 120 patients.Ann Thorac Surg. 1999; 67: 1001-1005Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar The smaller incision and reduced surgical trauma result in earlier extubation, shorter ICU stays, and shorter hospital stays.3Cosgrove DM Sabik JF Navia JL Minimally invasive valve operations.Ann Thorac Surg. 1998; 65: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar, 11Chitwood WR Wixon CL Elbeery JR et al.Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovase Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar, 12Frazier BL Derrick MJ Purewal SS et al.Minimally invasive aortic valve replacement.Euro J Cardiothorac Surg. 1998; 14: S122-S125Crossref PubMed Google Scholar These factors in turn decrease hospital costs and charges by 10% to 20%.3Cosgrove DM Sabik JF Navia JL Minimally invasive valve operations.Ann Thorac Surg. 1998; 65: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar, 10Cohn LH Adams DH Couper GS et al.Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.Ann Thorac Surg. 1997; 226: 421-428Google Scholar, 11Chitwood WR Wixon CL Elbeery JR et al.Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovase Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar Although most of these data come from retrospective studies, Machler et al.14Machler HE Bergmann P Anelli-Monti M et al.Minimally invasive versus conventional aortic valve operations: A prospective study in 120 patients.Ann Thorac Surg. 1999; 67: 1001-1005Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar confirmed several of these findings in a large prospective study of patients undergoing aortic valve surgery. The benefits of minimally invasive heart valve surgery may be realized after a relatively short learning curve by the surgeon. With experience, CPB and aortic cross-clamp times approach those achieved with median sternotomy.3Cosgrove DM Sabik JF Navia JL Minimally invasive valve operations.Ann Thorac Surg. 1998; 65: 1535-1539Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar All primary valve operations can be performed safely through smaller incisions. Recent developments in robotics and three-dimensional intracardiac cameras are likely to pave the way for truly microinvasive cardiac valve surgery.11Chitwood WR Wixon CL Elbeery JR et al.Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovase Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar
The introduction of the laparoscopic procedure, as well as later scope-based interventions by other surgical disciplines have resulted in the development of minimally invasive cardiac surgical procedures. These incisions are often foreign to traditional cardiac surgeons, but are now being increasingly used to approach aortic and/or mitral valves. Although important contributions in these areas continue to accrue almost daily, our group became convinced several years ago that access to the heart could be achieved by a modification of the traditional sternotomy, incorporating traditional cannulation techniques with a more limited exposure of the heart. Beginning in January 1996, we began performing pediatric heart operations through a partial division of the sternum, ie, only a portion of the sternum was divided in the midline. Owing to the flexibility of children’s tissues, the partially divided sternum could be stretched open with a retractor. In March 1996, we began performing aortic and mitral valve operations in adults through a similar upper sternal division. The rationale for this approach is simple: both the aortic and mitral valves are midline structures and both lie in a plane than can be best viewed obliquely from above the right shoulder. Furthermore, upper sternal division brings the surgeon directly down to the aorta and the right atrial appendage for cannulation of these traditional structures for venous return and arterial inflow. However, unlike children, the inflexible adult sternum was “T-ed” off at the second, third, o r fourth intercostal space in addition to dividing it in the midline. Although many terms can be used to describe these sternal divisions and many variations of the inverted T now exist (ie, the J, the reverse J, the L, the S, and the C, and many terms for this partial sternal division can now be found in the literature, such as hemisternotomy, partial sternotomy, limited sternotomy, and more), we coined the term mini-sternotomy (1994) to describe coronary artery bypass off-pump.” We have now had the opportunity to apply this technique to over 250 patients, but this report will limit itself to the first 110 patients who have had aortic valve procedures by mini-sternotomy. ( 6
Aortic valve replacement for the stenotic or regurgitant aortic valve has been one of the major advances of medical science in the 20th century. Patients who have severe pressure gradients between the left ventricle and the aorta, or who have severely dilated hearts due to massive aortic regurgitation, are treated by insertion of a reliable mechanical or bioprosthetic device to relieve these hemodynamic abnormalities. This technique has saved hundreds of thousands of lives since the first successful aortic valve replacements by Harken et al,' and Starr et a12 in 1960. Since 1960, valve devices, incisions, and surgical techniques have evolved to the extent that, by the early 1990s, the risk of aortic valve replacement in patients without coronary disease was under 3% in most large centers in the world that do aortic valve replacement .3 The complete median sternotomy became the standard incision for aortic valve replacement in the late 1960s. This incision is flexible and relatively painless because it is a midline incision. It allows maximal exposure of all parts of the cardiac structure, and most importantly, enables physicians to effectively remove air from intracardiac structures. As interest in minimizing surgical trauma has increased, minimally invasive incisions for cardiac surgery are receiving increasing attention. The evolution of minimally invasive surgery in all surgical specialties began with Fogarty's conversion of the vastly complicated aortoiliac embolectomy to a balloon catheter technique via the groin vessels in the early 1960s. In orthopaedics, endoscopy for joint operations replaced open operations about 15 years ago. Approximately 10 to 15 years ago in general surgery, laparoscopic colocystectomy became the treatment of choice, replacing the open colocystectomy. In the last 5 years, the use of video-assisted thoracic surgery has been enormously important in redefining general thoracic surgical procedures to a much less invasive type of surgery for many pulmonary lesions. Minimally invasive cardiac surgery began with the use of techniques for the so-called direct-access coronary bypass, off cardiopulmonary bypass, performed through small incisions, primarily using the left anterior descending coronary artery and applied directly to it. At the same time, Port-Access systems, popularized by Heartport, Inc, Redwood City, CA,5 were developed to afford a minimally invasive incision for a coronary artery bypass graft that had the advantages of cardiopulmonary bypass, aortic cross-clamping by endoclamp, and cardioplegia for myocardial protection. Finally, the use of minimally invasive direct access incisions for cardiac valve surgery were developed in the early part of 1996, when investigators believed that small incisions, accessing only those chambers or vessels where the valve surgery would take place and aided by femoro-femoral bypass, would be an advantage for patients undergoing cardiac valve surgery without combined coronary These approaches have been extended widely, and include a Port-Access system9 for mitral but not aortic valve replacement.
Bidirectional cavopulmonary anastomosis may either be performed as part of a total cavopulmonary connection or as a palliative procedure in a staged approach towards the Fontan operation. It can be performed primarily in cyanotic patients older than 3 months of age (preferably older than 6 months) or secondarily after a previous systemic to pulmonary artery shunt or a banding of the pulmonary artery o r a Norwood It can be associated with other palliative procedures such as atrioseptectomy, take down of previous systemic to pulmonary artery shunts, patch arterioplasty of stenotic or distorted pulmonary artery, and main pulmonary artery to aorta anastomosis for bypass of subaortic o b s t r ~ c t i o n . ~ ~ ~ Since October 1988, our approach to the Fontan operation is an association, simultaneous or sequential, of BCPA as described previously, and conduit interposition between the transected inferior vena cava (IVC) and RPA.5 The idea came following the work of Puga et a16 with the aim to provide the best pattern of laminar flow from the IVC to the pulmonary tree with a complete extracardiac surgery. We will describe both procedures.
The insertion of a cryopreserved aortic homograft valve by the mini-root or inclusion cylinder technique is used less frequently than either the scalloped free-hand technique or the total root replacement. Indications for the use of the mini-root or cylinder inclusion technique are relatively infrequent. This procedure is a compromise between the scalloped technique and the root technique and is, therefore, useful in patients who have an aortic root that measures 27 mm to 31 mm in diameter and, thus, would be a bit large for the scallop technique. The mini-root is also somewhat helpful in the moderately distorted aortic root. It has the advantage of an inclusion technique, and therefore, bleeding from the root after insertion is not seen. In some situations, the mini-root inclusion technique may solve problems of distortion, enlarged or bulbous sinuses of Valsalva, or small root abscesses.
Aortic valve replacement using the homograft valve has an important place in the cardiac surgical armamentarium. Despite this, the homograft valve is still not widely used, in part due to the perceived difficulty of the procedure compared with aortic valve replacement using prosthetic devices , less convenient availability of the homograft compared with that of prosthetic devices, and concerns regarding homograft valve failure. This section outlines the subcoronary technique (and its variations) and cylindrical technique for aortic valve replacement using the homograft aortic valve. Homograft aortic valves had a short investigational' and clinical2 application by insertion in the descending thoracic aorta. However, it was Ross3 who first performed a homograft aortic valve replacement in the orthotopic position using a single suture line technique based on the work of Duran and Gunning4 In the same year, working independently, Barrett-Boyes5 also described the subcoronary technique using a double
Evolution of surgical techniques for repair of postinfarction ventricular septal rupture initially involved differentiation of these lesions from prior experience with surgical approaches to congenital ventricular septal defects, which were in the main not applicable. Second, understanding of the differing anatomical locations of postinfarction ventricular septal defects required innovation in terms of the location of the cardiotomy and type of repair necessary to achieve a successful result in any given patient. The gradual appreciation of different clinical courses pursued by patients after postinfarction ventricular septal rupture both in terms of location of the defect and the degree of right ventricular functional impairment has led to increased urgency relative to the timing of surgical repair. The incorporation of specific anatomical concepts of surgical repair and better understanding of the time course of physiological deterioration of patients can ultimately lead to an integrated approach aimed toward improved salvage of patients suffering this catastrophic complication of acute myocardial infarction.
