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A new way forward from London Bridge Hospital

New Procedures

5

Background

In the last decade surgeons have begun to make innovative changes in cardiac surgery.

This is epitomised by the new approaches to operations on the mitral valve.

Traditionally, mitral valve surgery involves a median sternotomy. With this approach,

there is a long scar and there is a small chance of sternal dehiscence which has

disastrous consequences.

Cosgrove and colleagues, Cohn and colleagues, and Navia and Cosgrove first showed

mitral and aortic operations could be performed safely and efficiently after modifying

the conventional sternotomy. Subsequently, a variety of instruments were developed;

alternative perfusion techniques came up; video-assisted devices and robots helped in

evolving even less invasive cardiac procedures.

Because of excellent long-term results after sternotomy, most surgeons still regard

minimally invasive valve procedures as unnecessary and unsafe due to limited exposure

and increased technical demands.The other criticism is that these technological

advances are being driven by the high-tech industry, leading to increased costs without

demonstrated positive clinical outcomes.

These criticisms have forced minimally invasive valve operations to evolve slowly.The

challenge now is to develop minimally invasive valve approaches with gold standard

results that are reproducible among centres.

Patients are intubated for single left-sided ventilation to facilitate exposure before

commencing cardiopulmonary bypass. A transesophageal echocardiographic probe is

used for evaluation of ventricular function and mitral valve evaluation. Femoral vessel

cannulation for cardiopulmonary bypass is performed using the Seldinger technique.

Most cases need assisted-suction venous drainage.

A transthoracic aortic cross clamp is positioned under close video-assisted control and

cardioplegia is administered. For valve exposure, a chest retractor is placed across the

chest wall through the anterior fourth interspace near the right sternal border. A 5mm,

thoracoscope is inserted through the fourth or fifth intercostal space. An assistant,

directed by the surgeon, manipulates the camera. In each operation, the majority of the

valve procedure is performed using assisted vision through the thoracoscope. Long-

shafted instruments, passed through the incision, allow operation on the mitral valve

through this small incision. After the operation, the patient is monitored in ITU for a day

or two. He is mobilised in the wards and sent home 3-4 days after the operation.

The major advantages would be avoiding a median sternotomy with its risks of infection,

as well as sternal dehiscence which causes major morbidity as well as increased risks of

mortality.The risks include need for a median sternotomy in case of problems during

the operation or postoperative complications, like bleeding, which might not be able to

be tackled by minimally invasive incisions.

As technology improves and surgeons are more well versed with these novel

approaches to heart operations, the future lies with these kind of minimally invasive

operations.

Minimally Invasive

Mitral Valve Surgery

Traditional Incision

MIMs Scar

MIMs Incision

MitralValve Repair

Chordal Rupture

Key Points

The benefits of minimally invasive heart

surgery:

• A smaller incision

• A smaller scar

Other possible benefits:

• Reduced risk of infection

• Less bleeding with minimally invasive heart

surgery

• Less pain and trauma

• Decreased length of stay in hospital after

the procedure: the average stay is 3-4 days

after minimally invasive surgery, while the

average stay after traditional heart surgery

is 7-10 days

• Decreased recovery time:

the average recovery time after minimally

invasive heart surgery is 2-4 weeks, while

the average recovery time after traditional

heart surgery is 6-8 weeks

MR shyam

kolvekar frcscth

Consultant Cardiothoracic

Surgeon

UCLHThe Heart Hospital

and London Bridge Hospital

Contact Mr Kolvekar’s secretary,

Amy Gooding:

Tel: +44 (0) 20 7504 8946