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Experience with a Minimally Invasive Approach to Combined Valve Surgery and Coronary Artery Bypass Grafting Through Bilateral Thoracotomies
Joseph T. McGinn, Jr, Pieter JS Smit, MASOOD A. SHARIFF, Robert Carlucci, Scott Sadel, John P. Nabagiez.
STATEN ISLAND UNIVERSITY HOSPITAL, STATEN ISLAND, NY, USA.
Objective
Coronary artery bypass grafting (CABG) with aortic valve replacement (AVR) or mitral valve replacement (MVR) or repair (MVP) is traditionally performed via sternotomy. Minimally invasive coronary artery bypass grafting (MICS) and minimally invasive valve surgery (MIVS) have been successfully utilized independently. We present our series of 11 patients who underwent a combined MICS-MIVS via bilateral small thoracotomies.
Methods
Between April 2010 and June 2011 eleven patients underwent MICS- MIVS (six AVRs, three MVPs and two MVRs) via bilateral mini-thoracotomies. Peri-operative data were prospectively recorded and compared with patient data from a cohort that had undergone CABG with valve repair/replacement via sternotomy by the same surgeon at the same institution.
Results
Average cardiopulmonary bypass time was 159±47.6 minutes in the MICS-MIVS group and 142±56.2 minutes for sternotomy; average aortic cross-clamp time was 88±24.2 minutes for MICS- MIVS and 78±48.9 minutes for sternotomy; the average number of bypasses was 1.9±0.57 in the MICS-MIVS group and 2.6±1.5 in the sternotomy group; average time intubated was 24.6±12.5 hours in the MICS-MIVS and 50.5±119.9 hours in the sternotomy group; and average length of stay was 8±4.7 days in the MICS-MIVS and 8±8.5 days in the sternotomy group. Intra-operative transfusion requirements were not significantly different between the two groups (p= 0.732). No patients required conversion to sternotomy or reoperation and there was one post-operative mortality secondary to mesenteric ischemia.
Conclusions
In our initial experience, MICS combined with MIVS via bilateral mini-thoracotomies exhibits non-inferiority when compared with sternotomy based surgery. There are suggestions of possible advantages to a minimally invasive approach, such as earlier extubation and discharge from the hospital that will require a larger number of patients to validate. In the appropriate patient population, combined CABG and valve surgery can be safely performed via bilateral thoracotomies.
| MICS-MIVS: AVR/CABG | Sternotomy: AVR/CABG | p-value | MICS-MIVS: MVR/CABG | Sternotomy: MVR/CABG | p-value | |
| n | 5 | 32 | 5 | 10 | ||
| Age (years) | 77 ± 7 | 74 ± 11 | 0.5607 | 76 ± 5 | 71 ± 9 | 0.2736 |
| Ejection fraction (%) | 39 ± 8.9 | 46 ± 11.4 | 0.1999 | 35 ± 15 | 37 ± 11.1 | 0.7736 |
| Number of diseased vessels | 2.2 ± 1.1 | 2.1 ± 0.93 | 0.8282 | 2.2 ± 0.84 | 2.2 ± 0.79 | 1 |
| Chronic obstructive pulmonary disease | 1 (20%) | 6 (18.8%) | 1 (20%) | 2 (20%) | ||
| Peripheral artery disease | 1 (20%) | 8 (25%) | 1 (20%) | 1 (10%) | ||
| Congestive heart failure | 0 | 4 (12.5%) | 3 (60%) | 6 (60%) | ||
| MICS-MIVS: AVR/CABG | Sternotomy: AVR/CABG | p-value | MICS-MIVS: MVR/CABG | Sternotomy: MVR/CABG | p-value | |
| n | 5 | 32 | 5 | 10 | ||
| Total bypasses performed | 2 ± 0.71 | 2.4 ± 1.1 | 0.4391 | 1.8 ± 0.45 | 2.0 ± 1.3 | 0.7474 |
| Cardiopulmonary bypass (mins) | 184.8 ± 49.0 | 158.1 ± 53.0 | 0.298 | 134.0 ± 33.0 | 136.4 ± 37.0 | 0.9045 |
| Aortic cross clamp time (min) | 104.4 ± 25.0 | 102.0 ± 26.8 | 0.8523 | 71.6 ± 4.34 | 89.2 ± 26.7 | 0.1741 |
| Intra-Operative Blood Transfused (PRBC Units) | 3.2 ± 3.5 | 3.0 ± 2.4 | 0.8714 | 2.2 ± 2.0 | 2.3 ± 2.2 | 0.9333 |
| Time intubated (hours) | 6.22 ± 15.9 | 49.9 ± 125.1 | 0.4462 | 19.0 ± 4.47 | 52.4 ± 108.3 | 0.5108 |
| Atrial fibrillation | 4 (80%) | 5 (29%) | 2 (40%) | 3 (30%) | ||
| Prolonged ventilation | 4 (80%) | 7 (41%) | 4 (80%) | 1 (10%) | ||
| Length of stay (day) | 8 ± 7 | 9 ± 9 | 0.8145 | 7 ± 2 | 7 ± 5 | 1 |
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