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OBJECTIVE:
Upper sternotomy is the standard of care for aortic valve replacement (AVR). We present the “transcutaneous cannulation” in case of upper sternotomy as a trick to reduce the extension of the skin incision.
METHODS:
From November 2009 to May 2011, 60 patients (46 females, mean age 75.6±8.6 years) underwent AVR via a T shaped upper sternotomy (skin incision of about 6.9±0.3 cm), reaching the 4th intercostal space (ICS). Two incisions (1 cm) were performed just above the manubrium (arterial insertion) and 2 cm below the right nipple (venous insertion) (Figure 1 A-B). Both the arterial cannula (OPTISITE™, Edwards Lifesciences LLC, Irvine, CA) and the venous cannula were inserted from outside through the 1 cm skin incisions, to establish a cardiopulmonary by-pass amongst the ascending aorta and the right atrium.
One chest drain was delivered to the pericardial cavity through the “venous” site of insertion.
RESULTS:
No conversion to full sternotomy is reported. The aortic cross clamp was 54.5±10.6 minutes and mechanical ventilation was 5.5±1.7 hours. Bleeding was about 294.1±149.4 ml and noone blood package or re-exploration was required. The thirty day mortality was 1 (1.6%) due to acute renal failure; a late complication was a pericardial effusion, requiring pericardiocentesis. No cases of mediastinitis or wound infections have been noted so far
CONCLUSIONS:
The “trans-cutaneous cannulation” has no specific complications and improves the surgical vision because the cannulae are away from the surgical field. Moreover, the “venous” incision is used to negotiate a chest drain to the pericardial cavity whereas the arterial insertion may be easily sutured. The nearly absent risk of wound infection or mediastinitis is the major advantage of this approach because it allows a safe AVR by means of a very short skin incision (about 6 cm) when compared to traditional upper sternotomy. Moreover, the very low rate of bleeding and a good 30-day mortality make this approach a safe variation of the upper sternotomy.