IS THE FEMORAL CANNULATION FOR MINIMALLY INVASIVE AORTIC-VALVE REPLACEMENT NECESSARY

Introduction: Minimally invasive cardiac surgery through a small trans verse sternotomy is a new promising technique that can be considered a n alternative in most cases to aortic valve replacement thus reducing surgical trauma and subsequent time of hospitalization. The need to av oid the risks associated with femoro-femoral bypass has lead to the in terest in aortic valve replacement (AVR) operations without femoral ve ssels cannulation. We want to emphasize a few important points of our technique, which differs somewhat from the one applied by Cosgrove and associates. Objective: This study details the approach to the minimal ly invasive AVR as first described by. Cosgrove et al. without standar d femoral cannulation and points out our preliminary clinical experien ce. Patients and methods: From October 1996 to May 1997 we have operat ed on 25 patients using minimally invasive AVR (MI-AVR) In 23 cases, a ccess through transverse sternotomy as described by Cosgrove et al., w as performed. In two additional cases the chest is opened via a mini-m edian sternotomy with an 'L'-shape extending from the sternal notch to the superior edge of the third interspace. Twenty-three patients unde rwent AVR through transverse sternotomy. The male/female ratio was 13. 10. The mean age was 67 years (range 45-78 years). Seventy-four percen t of the patients were over 65. Predominantly, in 43% of cases aortic valve stenosis and in 25% of cases aortic valve regurgitation isolated is presented. In 19 cases, a 10-cm transverse incision is performed o ver the second interspace. Likewise, in four cases over the third inte rspace according to the thorax morphology and length of the ascending aorta assessed by chest X-ray films. By convention, cannulation of the ascending aorta and right atrial appendage was performed as usual. In contrast, in one patient (5.5%), cannulation was placed in the superi or vena cava and right common femoral vein into the inferior vena cava . rn the present series, 15 mechanical prostheses and eight bioprosthe ses whose used sizes were 19, 21,23, and 25 mm in diameter were placed in four, nine, nine, and one of the cases, respectively. All patients underwent AVR electively and a transesophageal echocardiography probe is made. Results: During surgery, conversion to median sternotomy was not required in any patient. Mean aortic cross-clamp time was 68 min (range 38-90 min). Mean total bypass time was 87 min (range 50-120 min ). Mean postoperative bleeding was 434 mi. (range 200-850 mi). Periope rative blood transfusion was required in 17% of the patients. Mean mec hanical ventilation time was 7.3 h (range 3-24 h), with a mean ICU sta y of 18 h. Mean postoperative hospital stay was 4.5 days (range 3-10 d ays). In all cases, transthoracic and transesophageal echocardiography were performed postoperatively Prosthetic valve dysfunction was not o bserved. On the other hand, just one patient (4%) died 5 days after op eration due to sudden cardiac death. Further, in two patients (8%), du ring follow-up, pericardial effusion is detected. In one case, cardiac tamponade with hemodynamic instability required a pericardial window procedure. In addition, in two patients (8%), non-infectious sternal d ehiscence required reinforced sternal closure. Conclusions: Minimally invasive AVR surgery without femoral vessel cannulation is a safe proc edure with less surgical aggression. After a learning curve, benefits on fast-track programs will be accomplished. (C) 1998 Elsevier Science B.V. All rights reserved.