Application of Lower Sternal Incision with On-pump， Beating Heart Intracardiac Procedures in Mitral Valve Replacement_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHENG Wei , XIAO Yingbin , CHEN Lin , LIU Hong.

Cardiovascular Surgery Center， Xinqiao Hospital of the Third Military Medical University， Chongqing 400037， P. R. China;

Corresponding author：

Keywords：

Lower sternal incision; Beating heart; Mitral valve replacement

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Abstract：　Objective　To explore the application of lower sternal incision with on-pump， beating heart intracardiac procedures in mitral valve replacement （MVR）. Methods We retrospectively analyzed clinical data of 42 patients （minimal incision group） with valvular heart diseases who underwent MVR via lower sternal incision under the beating heart condition in Xinqiao Hospital of the Third Military Medical University from January 2011 to December 2011. There were 16 male and 26 female patients with their average age of 42.3±12.7 years in the minimal incision group. We also randomly selected 42 patients with valvular heart diseases who underwent MVR via routine midline sternotomy during the same period in our department as the control group. There were 18 male and 24 female patients with their average age of 43.8±13.1 years in the control group. Operation time， cardiopulmonary bypass time， major complications， chest drainage　 in postoperative 24 hours， skin incision length and average postoperative hospital stay were observed and compared　 between the two groups. Results There was no major perioperative complication such as in-hospital death. There was no reexploration for postoperative bleeding， complete atrioventricular block， embolism or perivalvular leakage in the minimal incision group. There was no statistical difference in cardiopulmonary bypass time， operation time， or the incidence of　 reexploration for postoperative bleeding， wound infection and perivalvular leakage between the two groups（P＞0.05）. The skin incision length in the minimal incision group was shortened by 5.2 cm compared to that in the control group （7.9±1.4 cm vs. 13.1±3.3 cm， P=0.000）. Chest drainage in postoperative 24 hours in the minimal incision group was significantly less than that of the control group （183.6±40.2 ml vs. 273.4±59.9 ml， P=0.000）. Postoperative hospital stay in the minimal incision group was significantly shorter than that of the control group （8.1±1.3 d vs. 10.6±2.1 d， P=0.000）. Forty patients in the minimal incision group were followed up for 3-15 months and 2 patients were lost during follow-up. Four patients had postoperative wound pain， and the majority of patients didn’t have significant wound scar formation but a satisfactory quality of life. Thirty-eight patients in the control group were followed up for 3-15 months， 4 patients were lost during follow-up， and 17 patients had postoperative wound pain. Conclusion Lower sternal incision with beating heart can reduce the surgical injury， simplify the operation procedure and improve the therapeutic efficacy. It is a safe， effective and esthetic surgical approach for MVR.

Citation： CHENG Wei,XIAO Yingbin,CHEN Lin,LIU Hong.. Application of Lower Sternal Incision with On-pump， Beating Heart Intracardiac Procedures in Mitral Valve Replacement. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2013, 20(1): 33-36. doi: Copy

1.	Magalhães MG， Alves LM， Alcantara LF， et al. Post-operative mediastinitis in a heart hospital of Recife：contributions for nursing care. Rev Esc Enferm USP， 2012， 46 （4）：865-871.
2.	Tiveron MG， Fiorelli AI， Mota EM， et al. Preoperative risk factors for mediastinitis after cardiac surgery：analysis of 2768 patients. Rev Bras Cir Cardiovasc， 2012， 27 （2）：203-210.
3.	Kim HS， Kim KB， Hwang HY， et al. Subxiphoid incisional hernia development after coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg， 2012， 45 （3）：161-165.
4.	胡义杰，钟前进，陈建明，等. 右侧腋下小切口先天性心脏病直视手术的临床应用. 中国胸心血管外科临床杂志， 2012， 19 （4）：427-429.
5.	何发明，王平凡，梁志强，等. 右腋下小切口心脏直视手术3 012例的临床应用. 中国胸心血管外科临床杂志， 2010， 17 （3）：247-249.
6.	Murashita T， Hatta E， Ooka T， et al. Minimal access surgery for the repair of simple congenital heart defects：factors affecting hospital stay after surgery. Thorac Cardiovasc Surg， 2004， 52 （3）：127-134.
7.	Cherup LL， Siewers RD， Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg， 1986， 41 （5）：492-497.
8.	Massetti M， Babatasi G， Rossi A， et al. Operation for atrial septal defect through a right anterolateral thoracotomy：current outcome. Ann Thorac Surg， 1996， 62 （4）：1100-1103.
9.	Grinda JM， Folliguet TA， Dervanian P， et al. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg， 1996， 62 （1）：175-178.
10.	Benetti F， Prapas S， Angeletti E， et al. Xiphoid lower-sternotomy approach for multivessel revascularization of the left internal mammary　 artery to the left anterior descending artery and right internal mammary artery inflow to the other vessels. Heart Surg Forum， 2010， 13 （1）：E36-E39.
11.	Takata M， Watanabe G， Ushijima T， et al. A novel internal thoracic artery harvesting technique via subxiphoid approach——for the least invasive coronary artery bypass grafting. Interact Cardiovasc Thorac Surg， 2009， 9 （5）：891-892. 12 Niinami H， Takeuchi Y， Ichikawa S， et al. Partial median sternotomy 　as a minimal access for off-pump coronary artery bypass grafting：feasibility of the lower-end sternal splitting approach. Ann Thorac Surg， 2001， 72 （3）：S1041-S1045.
12.	Tamis-Holland JE， Homel P， Durani M， et al. Atrial fibrillation after minimally invasive direct coronary artery bypass surgery. J Am Coll Cardiol， 2000， 36 （6）：1884-1888.
13.	Karthekeyan BR， Vakamudi M， Thangavelu P， et al. Lower ministernotomy and fast tracking for atrial septal defect. Asian Cardiovasc Thorac Ann， 2010， 18 （2）：166-169.
14.	Castro NJ， Melo E， Fernandes J， et al. Mitral valve and atrial septal defect surgery：minimally invasive or sternotomy approach. Arq Bras Cardiol， 2012， 99 （2）：681-687.
15.	Mcclure RS， Cohn LH， Wiegerinck E， et al. Early and late outcomes in minimally invasive mitral valve repair：an eleven-year experience in 707 patients. J Thorac Cardiovasc Surg， 2009， 137 （1）：70-75.
16.	Massetti M， Babatasi G， Bhoyroo S， et al. A special adapted retractor　for the mini-sternotomy approach. Ann Thorac Surg， 1999， 68 （1）：274-277.
17.	Borowski A， Korb H. Myocardial protection by pressure-and　volume-controlled continuous hypothermic coronary perfusion （PVC-CONTHY-CAP） in combination with ultra-short beta-blockade and nitroglycerine. Thorac Cardiovasc Surg， 1997， 45 （2）：51-54.
18.	Wang J， Liu HY， Xiang B， et al. Keeping the heart empty and beating improves preservation of hypertrophied hearts for valve surgery. J Thorac Cardiovasc Surg， 2006， 132 （6）：1314-1320.
19.	Mo A， Lin H， Wen Z， et al. Efficacy and safety of on-pump beating heart surgery. Ann Thorac Surg， 2008 ， 86 （6）：1914-1918.
20.	Gersak B， Sutlic Z. Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time. Heart Surg Forum， 2002， 5 （2）：182-186.
21.	Gersak B. Mitral valve repair or replacement on the beating heart. Heart Surg Forum， 2000， 3 （3）：232-237.
22.	Cicekcioglu F， Tutun U， Babaroglu S， et al. Aortic valve replacement with on-pump beating heart technique. J Card Surg， 2007， 22 （3）：211-214.
23.	Wan S， De Smet JM， Barvais L， et al. Myocardium is a major source of proinflammatory cytokines in patients undergoing cardiopulmonary bypass. J Thorac Cardiovasc Surg， 1996， 112 （3）：806-811.
24.	Karadeniz U， Erdemli O， Yamak B， et al. On-pump beating heart versus hypothermic arrested heart valve replacement surgery. J Card Surg， 2008， 23 （2）：107-113.
25.	肖颖彬，陈林，王学锋，等. 浅低温体外循环心脏跳动中心内直视手术1032例临床分析. 第三军医大学学报， 2001， 23 （5）：502-504.

1. Magalhães MG， Alves LM， Alcantara LF， et al. Post-operative mediastinitis in a heart hospital of Recife：contributions for nursing care. Rev Esc Enferm USP， 2012， 46 （4）：865-871.
2. Tiveron MG， Fiorelli AI， Mota EM， et al. Preoperative risk factors for mediastinitis after cardiac surgery：analysis of 2768 patients. Rev Bras Cir Cardiovasc， 2012， 27 （2）：203-210.
3. Kim HS， Kim KB， Hwang HY， et al. Subxiphoid incisional hernia development after coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg， 2012， 45 （3）：161-165.
4. 胡义杰，钟前进，陈建明，等. 右侧腋下小切口先天性心脏病直视手术的临床应用. 中国胸心血管外科临床杂志， 2012， 19 （4）：427-429.
5. 何发明，王平凡，梁志强，等. 右腋下小切口心脏直视手术3 012例的临床应用. 中国胸心血管外科临床杂志， 2010， 17 （3）：247-249.
6. Murashita T， Hatta E， Ooka T， et al. Minimal access surgery for the repair of simple congenital heart defects：factors affecting hospital stay after surgery. Thorac Cardiovasc Surg， 2004， 52 （3）：127-134.
7. Cherup LL， Siewers RD， Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg， 1986， 41 （5）：492-497.
8. Massetti M， Babatasi G， Rossi A， et al. Operation for atrial septal defect through a right anterolateral thoracotomy：current outcome. Ann Thorac Surg， 1996， 62 （4）：1100-1103.
9. Grinda JM， Folliguet TA， Dervanian P， et al. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg， 1996， 62 （1）：175-178.
10. Benetti F， Prapas S， Angeletti E， et al. Xiphoid lower-sternotomy approach for multivessel revascularization of the left internal mammary　 artery to the left anterior descending artery and right internal mammary artery inflow to the other vessels. Heart Surg Forum， 2010， 13 （1）：E36-E39.
11. Takata M， Watanabe G， Ushijima T， et al. A novel internal thoracic artery harvesting technique via subxiphoid approach——for the least invasive coronary artery bypass grafting. Interact Cardiovasc Thorac Surg， 2009， 9 （5）：891-892. 12 Niinami H， Takeuchi Y， Ichikawa S， et al. Partial median sternotomy 　as a minimal access for off-pump coronary artery bypass grafting：feasibility of the lower-end sternal splitting approach. Ann Thorac Surg， 2001， 72 （3）：S1041-S1045.
12. Tamis-Holland JE， Homel P， Durani M， et al. Atrial fibrillation after minimally invasive direct coronary artery bypass surgery. J Am Coll Cardiol， 2000， 36 （6）：1884-1888.
13. Karthekeyan BR， Vakamudi M， Thangavelu P， et al. Lower ministernotomy and fast tracking for atrial septal defect. Asian Cardiovasc Thorac Ann， 2010， 18 （2）：166-169.
14. Castro NJ， Melo E， Fernandes J， et al. Mitral valve and atrial septal defect surgery：minimally invasive or sternotomy approach. Arq Bras Cardiol， 2012， 99 （2）：681-687.
15. Mcclure RS， Cohn LH， Wiegerinck E， et al. Early and late outcomes in minimally invasive mitral valve repair：an eleven-year experience in 707 patients. J Thorac Cardiovasc Surg， 2009， 137 （1）：70-75.
16. Massetti M， Babatasi G， Bhoyroo S， et al. A special adapted retractor　for the mini-sternotomy approach. Ann Thorac Surg， 1999， 68 （1）：274-277.
17. Borowski A， Korb H. Myocardial protection by pressure-and　volume-controlled continuous hypothermic coronary perfusion （PVC-CONTHY-CAP） in combination with ultra-short beta-blockade and nitroglycerine. Thorac Cardiovasc Surg， 1997， 45 （2）：51-54.
18. Wang J， Liu HY， Xiang B， et al. Keeping the heart empty and beating improves preservation of hypertrophied hearts for valve surgery. J Thorac Cardiovasc Surg， 2006， 132 （6）：1314-1320.
19. Mo A， Lin H， Wen Z， et al. Efficacy and safety of on-pump beating heart surgery. Ann Thorac Surg， 2008 ， 86 （6）：1914-1918.
20. Gersak B， Sutlic Z. Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time. Heart Surg Forum， 2002， 5 （2）：182-186.
21. Gersak B. Mitral valve repair or replacement on the beating heart. Heart Surg Forum， 2000， 3 （3）：232-237.
22. Cicekcioglu F， Tutun U， Babaroglu S， et al. Aortic valve replacement with on-pump beating heart technique. J Card Surg， 2007， 22 （3）：211-214.
23. Wan S， De Smet JM， Barvais L， et al. Myocardium is a major source of proinflammatory cytokines in patients undergoing cardiopulmonary bypass. J Thorac Cardiovasc Surg， 1996， 112 （3）：806-811.
24. Karadeniz U， Erdemli O， Yamak B， et al. On-pump beating heart versus hypothermic arrested heart valve replacement surgery. J Card Surg， 2008， 23 （2）：107-113.
25. 肖颖彬，陈林，王学锋，等. 浅低温体外循环心脏跳动中心内直视手术1032例临床分析. 第三军医大学学报， 2001， 23 （5）：502-504.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Application of Lower Sternal Incision with On-pump， Beating Heart Intracardiac Procedures in Mitral Valve Replacement

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