Minimally Invasive Thoracic Surgery Definition

Background

With increasing patient interest in minimally invasive procedures, it is more important than ever for surgeons to be current on the most common minimally invasive techniques in cardiac surgery. As minimally invasive cardiac surgery has evolved, the strategies and approaches to cardiopulmonary bypass access have evolved. Peripheral cannulation is convenient but carries a risk of retrograde dissection, embolization, stroke, and ipsilateral limb ischemia, whereas central aortic cannulation has the advantage of antegrade flow.

Methods

We report our experience with direct arterial and venous cannulation through a thoracotomy approach without compromising the results. From January 2017 to December 2018, 140 consecutive patients were studied. Mean age was 26 ± 18 years (range, 11 months to 83 years), with 46 patients (32.8%) younger than 12 years and 12 patients weighing less than 10 kg. Spectrum of procedures include atrial septal defect closure (53%), mitral valve repair (14%), ventricular septal defect closure (9%), aortic valve replacement (10%), mitral valve replacement (6%), repair of partial anomalous pulmonary venous drainage (9%), myxoma excision (1%), and ventricular septal defect closure with pulmonary valvotomy (1%).

Results

None of the patients was converted from a minimally invasive to standard median sternotomy. One patient with ventricular septal defect died due to pulmonary hypertensive crises. No patient required reexploration for bleeding, and none had stroke or renal failure. There were no myocardial infarctions or aortic dissections.

Conclusions

In our experience this approach is a reliable platform for a variety of minimally invasive cardiac surgical procedures and has resulted in low complication rates. The technique can be applied safely to both pediatric and adult populations. Also, it is very cost-effective because regular instruments and cannulas are used.

Providing the option of a small incision with a favorable cosmetic effect without the disadvantage of inferior durability or surveillance drives further development of minimally invasive access and changes treatment paradigms in favor of patient treatment at earlier disease stage before adverse effects of disease appear. The number of operations performed using less-invasive techniques has increased dramatically over the last 2 decades. A key determinant of technical difficulty and clinical outcomes in minimally invasive cardiac surgery (MICS) requiring cardiopulmonary bypass (CPB) seems to be cannulation techniques. Conventionally MICS is done with peripheral cannulation, which has its own disadvantages.

Material and Methods

From January 2017 to December 2018 we studied 140 consecutive patients who underwent MICS at our institution. Minimally invasive direct coronary artery bypass surgery was excluded from the study because all were done off pump. After institutional review board approval was obtained, data were acquired on patient demographics, operative variables, and postoperative complications from our institutional medical records.

Approach to Mitral Valve Operations and Congenital Heart Disease

The mitral valve is approached through a right minithoracotomy, and a 5- to 6-cm inframammary incision is made in the midaxillary line. This primary incision is made 1 to 2 cm inferior to the nipple in men and about 1 cm above the breast crease in women, with subsequent soft tissue dissection directed cephalad toward the chest wall to allow entry into the thoracic cavity through the fourth intercostal space. In operations for congenital heart diseases the incision is typically made medially to minimize the working distance. We use standard chest spreaders to open up the intercostal space. At times additional chest spreaders are used perpendicular to the first one. The pericardium is pulled up with stay sutures. We routinely place the aortic, superior vena cava, antegrade cardioplegia, left atrial vent, and inferior vena cava cannulas centrally through the primary incision. Positioning the patient, the site of incision, and placement of retraction sutures are crucial for cannulation. Aortic cannulation-double pursestring sutures are placed (relative hypotension systolic blood pressure ∼90 mm Hg). The aorta is retracted down with long artery forceps, the adventitia is cut over the incision site, the aorta is stabilized with 2 pickups at the incision site, and lungs are deflated during cannulation. For venous cannulation, the superior vena cava cannula is inserted first as easily accessible, and then the inferior vena cava cannula is inserted when the heart is decompressed and lungs deflated.

At times the inferior vena cava cannula/superior vena cava cannula is placed through a separate incision in the midaxillary line, 1 space below the incision. A transthoracic Chitwood clamp is then inserted through a stab wound in the third interspace in the right midaxillary line. In congenital diseases a straight clamp is used directly through the incision (Figures 1 and 2). Del Nido cardioplegia is used in all the patients. Pacing wires are placed before releasing the cross-clamp. We follow an extensive deairing protocol that includes positioning the patient in a deep Trendelenburg position during aortic unclamping, aggressive volume loading of the heart, positive pressure ventilation to clear pulmonary venous air, and alternation of left-right table positioning to remove air trapped. We performed transesophageal echocardiography whenever feasible. A local nerve block was applied before the chest was closed.

Minithoracotomy for Aortic Valve Replacement

A 5- to 6-cm incision into the right third intercostal space was performed. The fourth rib was sheered at the costochondral junction. The specific intercostal space used can be tailored to the patient. We prefer using the standard, centrally placed ascending aortic cannula, angled high superior vena caval cannulation, and straight inferior vena cava cannula passed through separate superior vena cava incision. Standard bicaval cannulation can be done if accessible. Also, we use a right superior pulmonary vein vent (Figure 3). Standard aortic cross-clamp and Del Nido cardioplegia were used in all patients. Becasue this strategy is similar to that used in a full sternotomy operation, it minimizes the new techniques that must be learned to successfully perform the procedure.

Results

Primary outcome measures were short- and long-term mortality. Short-term mortality was defined as death within 30 days of surgery. Other outcomes of interest included stroke and major postoperative complications. Major complications include prolonged intubation (>72 hours), renal failure, reoperation for bleeding, sepsis, myocardial infarction, and unplanned cardiac reoperation.

One hundred forty patients underwent elective MICS at our institution with CPB between January 2017 and December 2018. Demographic information is listed in Table 1. Within the study population mean age was 26 ± 18 years, with 46 patients (32.8%) younger than 12 years. The youngest patient was 11 months old and oldest 83 years old. Mean weight in the pediatric age group was 16.27 ± 6.94 kg (range, 7-27), whereas in adults it was 54.79 ± 17.4 kg (range, 27.2-110). Twelve patients weighed less than 10 kg, and the heaviest patient was 110 kg. The total population mean body surface area was 1.27 (range, .36-2.45), below 12 years old it was .75 (range, .36-1.11), and above 12 years old 1.533 (range, .92-2.45).

Table 1 Demographics

Demographics	Value
Age, y	26 ± 18 (11 mo-83 y)
Age < 12 y	46
Age > 12 y	94
Male-to-female ratio	37:33
Weight, <12 y	16.27 ± 6.94 (7-27)
Weight, >12 y	54.79 ± 17.82 (27-110)
Patients < 10 kg	12

Values are mean ± SD (range) or n unless otherwise indicated.

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The most common MICSs were atrial septal defect repair (53%). The next most common operations were mitral valve procedures (28 cases, 20%), including 20 mitral valve repairs and 8 mitral valve replacements, aortic valve replacement 14 (10%), and resection of cardiac tumor 2 (1%) (Table 2, Figures 4 and 5). In the pediatric age group the most common operation was atrial septal defect (65%), followed by ventricular septal defect (26%), atrial septal defect + pulmonary valvotomy (4%), and atrial septal defect + tricuspid valve repair (5%) (Figure 6).

Table 2 Spectrum of Cases

Intraoperative Variables	Value
Cardiopulmonary bypass time, min	82.5 ± 10
Aortic cross-clamp time, min	48.6 ± 16
Mitral valve repairs	20
Mitral valve replacement	8
Aortic valve replacement	14
Cardiac tumor resections	2
ASD closure	74
ASD and partial anomalous pulmonary venous drainage repair	4
ASD and pulmonary valvotomy	2
ASD and tricuspid valve repair	2
Ventricular septal defect closure	12
Ventricular septal defect + pulmonary valvotomy	2

Values are mean ± SD or n.

ASD, atrial septal defect.

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Figure 4 Case spectrum in the total population. (ASD, atrial septal defect; MV, mitral valve; PDA, patent ductus arteriosus; PV, pulmonary valvotomy; PAPVC, partial anomalous pulmonary venous drainage; TV, tricuspid valve; VSD, ventricular septal defect.)

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The mean CPB time was 82.5 ± 10 minutes and mean aortic cross-clamp time 48.6 ± 16 minutes. All patients were extubated 4 to 6 hours after surgery and were on fentanyl infusion for 24 hours.

The median length of hospital stay was 5 days (range, 4–8). None of the patients was converted from a minimally invasive to a standard median sternotomy. One patient with ventricular septal defect died due to pulmonary hypertensive crises. No patient required reexploration for bleeding, and none had stroke or renal failure. There were no myocardial infarctions or aortic dissections.

All patients were followed regularly at 1 week, 1 month, 3 months, 6 months, 12 months, and yearly thereafter. Only 2 patients had a superficial wound infection.

Comment

In their pioneering cases Cohn and coworkers

¹

• Cohn L.H.
• Adams D.H.
• Couper G.S.
• et al.

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.

• Crossref
• PubMed
• Scopus (408)
• Google Scholar

and Navia and Cosgrove

used a right parasternal approach for minimally invasive mitral valve surgery. Several years later Mohr and coworkers

and Chitwood and coworkers

performed the first mitral valve case through a right thoracotomy. Since then alternative approaches such as hemisternotomy, left thoracotomy, and right minithoracotomy have been developed. The right minithoracotomy has been established as the most commonly used incision for minimally invasive mitral valve surgery and is now the standard minimally invasive approach at most centers.

As MICS has evolved, the strategies and approaches to CPB access have evolved. The port access system was developed and widely adopted, and arterial access through the femoral artery and endovascular aortic balloon occlusion were used.

When performing femoral artery cannulation, it is important to rule out patients with aortoiliac disease and small femoral arteries. Femoral artery cannulation is convenient but carries a risk of retrograde dissection, embolization, stroke, and ipsilateral limb ischemia,

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• Murzi M.
• Glauber M.

Central versus femoral cannulation during minimally invasive aortic valve replacement.

• PubMed
• Google Scholar

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whereas central aortic cannulation has the advantage of antegrade flow.

To minimize the risk of aortic dissection, the endovascular balloon was replaced with a percutaneous transaxillary aortic cross-clamp that allowed for direct aortic occlusion.

^,

¹⁵

• Onnasch J.F.
• Schneider F.
• Falk V.
• et al.

Five years of less invasive mitral valve surgery: from experimental to routine approach.

• PubMed
• Google Scholar

^,

Studies have shown that a minimally invasive approach with antegrade perfusion does not result in increased neurologic consequences, whereas retrograde perfusion has benn shown to be associated with increased neurologic risk in older or high-risk patients.

¹⁷

• Murzi M.
• Cerillo A.G.
• Miceli A.
• et al.

Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.

• Crossref
• PubMed
• Scopus (67)
• Google Scholar

^,

Original cannulation techniques for mitral valve involved percutaneous bicaval venous drainage, with superior vena cava access through the right internal jugular vein and inferior vena cava access from the right femoral vein. Drawbacks to this technique were location of the right internal jugular vein cannula outside the sterile operative field by anesthesiologists and the creation of a large defect in the vein. Potential complications include perforation of the inferior vena cava during cannula insertion and entrapment of air with airlock during CPB. In addition the length of the femoral vein cannula usually creates increased resistance to effective drainage.

^,

¹⁹

• Colangelo N.
• Torracca L.
• Lapenna E.
• Moriggia S.
• Crescenzi G.
• Alfieri O.

Vacuum-assisted venous drainage in extrathoracic cardiopulmonary bypass management during minimally invasive cardiac surgery.

• Crossref
• PubMed
• Scopus (40)
• Google Scholar

^,

²⁰

• Vaughan P.
• Fenwick N.
• Kumar P.

Assisted venous drainage on cardiopulmonary bypass for minimally invasive aortic valve replacement: is it necessary, useful or desirable?.

• Crossref
• Scopus (8)
• Google Scholar

^,

Our cannulation strategy for MICS has evolved to favor central aortic over femoral artery cannulation, direct bicaval cannulation over percutaneous femoral dual-stage bicaval venous drainage, percutaneous neck access, and direct transaxillary aortic clamping over endoaortic balloon occlusion of the aorta. In our series the mean CPB and aortic cross-clamp times of 82 and 48 minutes, respectively, demonstrate that despite a learning curve associated with new techniques, our cannulation strategies are feasible with reasonable operative times.

Multiple retrospective series have assessed outcomes after mitral valve surgery through a right minithoracotomy, with reported advantages including a more en face view of the valve, a decreased risk of infection because of the well-vascularized overlying pectoralis muscle and avoidance of sternal division, shorter hospital length of stay, decreased postoperative bleeding, and improved postoperative pain.

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MICS has been shown in numerous studies to have comparable mortality rates when compared with standard median sternotomy.

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¹⁵

• Onnasch J.F.
• Schneider F.
• Falk V.
• et al.

Five years of less invasive mitral valve surgery: from experimental to routine approach.

• PubMed
• Google Scholar

^,

^,

^,

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^,

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³¹

• Casselman F.P.
• Van Slycke S.
• Wellens F.
• et al.

Mitral valve surgery can now routinely be performed endoscopically.

• PubMed
• Google Scholar

^,

However, serious concerns have been raised regarding increased morbidity associated with MICS. After analysis of minimally invasive procedures at our institution, we did not find any increase in the relative number of strokes,

a difference we attribute, in part, to our methods of central aortic cannulation, meticulous deairing, and direct aortic clamping.

MICS patients require strong pain medications in first 24 to 48 hours after surgery. We use fentanyl infusion for 24 hours then oral gabapentin, and, if required, tramadol injections. Postoperative pain score is 1 to 3. Less invasive techniques have shown to result in decreased length of hospital stay, improved patient satisfaction, faster return to daily physical activities, and higher quality of life.

Patient selection is paramount for a successful outcome in MICS. The ideal patient is not obese and has no prior right intrapleural operations, chest wall deformities, or serious lung disease.

We performed all our operations without any additional cost. We used standard thoracotomy retractors instead of special retractors. Femoral cannulation, percutaneous cannulas, and endoaortic balloon occlusion will add additional cost to the patient and hence are not used. We also used single-lumen endotracheal tubes, hence no diversion in anesthesia techniques. We have shown in our study that MICS can be performed with regular instruments and cannulas with comparable results. In developing countries this technique is an asset because it significantly reduces the cost of surgery. Limitations to our study include the retrospective nature of the analysis and the lack of patient-matched control subjects for different cannulation techniques across time periods.

In our experience this approach has resulted in low complication rates and a reliable platform for a variety of MICS procedures. It can be applied to both adult and pediatric patient populations without any increase in morbidity and mortality. This technique is an asset in developing countries because MICS can be performed without any additional costs.

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Article Info

Publication History

Published online: July 20, 2019

Accepted: May 22, 2019

Identification

DOI: https://doi.org/10.1016/j.athoracsur.2019.05.075

Copyright

© 2020 by The Society of Thoracic Surgeons Published by Elsevier

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  The Annals of Thoracic Surgery Vol. 109 Issue 4

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    Kandakure PR, Batra M, Garre S, Banovath SN, Shaikh F, Pani K. Direct Cannulation in Minimally Invasive Cardiac Surgery With Limited Resources. Ann Thorac Surg. 2020;109(2):512-516.

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