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OBJECTIVE:
In the past decade the quest to decrease the morbidity from cardiothoracic surgery has led to the development of approaches that avoid complete sternotomy incisions. Utilising a mini-sternotomy gives good exposure to the aorta, left ventricular outflow tract, aortic valve and the ascending aorta. Benefits for minimally invasive aortic valve replacement (MIAVR) include reduction in blood loss, preservation of pulmonary function and reduced post operative pain. We present our experience over 24 months having started a MIAVR program without any specialist equipment.
METHODS:
Data was retrieved from the national adult cardiac surgery database and hospital records. A mini sternotomy is identified as an upper midline incision of 5cm, a sternotomy through the manubrium and upper sternum with extension through the third or fourth interspace laterally. The first 20 patients were operated on using standard equipment including the sternal retractors and cardiopulmonary bypass cannulae. The only investment has been the purchase of a dedicated MIAVR retractor. All patients were from a single surgeon in one centre.
RESULTS:
43 patients, 61% were male with a mean age of 66yrs [42-82]. Significant co-morbidities included diabetes [11%], COPD/Asthma[23%], previous CVA/TIA[14%] and the mean logistic Euroscore was 7.04.
In-hospital survival was 100% with no wound infections and no re-operations. Biological valves predominated in 63% of patients. The median cardiopulmonary bypass time was 112mins[88-276] and cross clamp time 82mins[39-169]. 74% of patients were extubated in less than 12 hours with 51% under 8hours. 74% stayed only one day in ICU. Median post operative stay was 9 days[5-50]. Two patients required conversion to a full sternotomy for bleeding. Two patients were reopened for bleeding but not converted to a full sternotomy. The median blood loss was 550mls (range 105 to 3620) however 49% of people were transfused because of preoperative anaemia.
CONCLUSIONS:
A MIAVR program can be introduced with minimal capital investment without compromising results or patient outcomes. This is an important consideration in the cost effectiveness of the procedure which may have been previously overlooked.