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Minimal-Access “J” or “j” Sternotomy for Valvular, Aortic, and Coronary Operations or Reoperations

1997; Elsevier BV; Volume: 64; Issue: 5 Linguagem: Inglês

10.1016/s0003-4975(97)00927-2

1552-6259

Lars G. Svensson,

Aortic Disease and Treatment Approaches

For more complex aorta, valvular, and coronary operations or reoperations where the new minimal-access operations are difficult to apply, a "J" or "j" sternal incision from the first interspace or sternal notch into the right fourth intercostal space is a useful alternative. The approach has been used for aortic and mitral valve procedures, coronary artery bypass with or without cardiopulmonary bypass, aortic root rupture, atrial septal defect repair, hemiarch repair, maze procedure, and composite valve grafts, including reoperations and transan-nular mitral valve replacements in 30 patients without complication related to it. For more complex aorta, valvular, and coronary operations or reoperations where the new minimal-access operations are difficult to apply, a "J" or "j" sternal incision from the first interspace or sternal notch into the right fourth intercostal space is a useful alternative. The approach has been used for aortic and mitral valve procedures, coronary artery bypass with or without cardiopulmonary bypass, aortic root rupture, atrial septal defect repair, hemiarch repair, maze procedure, and composite valve grafts, including reoperations and transan-nular mitral valve replacements in 30 patients without complication related to it. Before the operation, a pacing Swan-Ganz catheter and external defibrillation paddles are placed [1.Navia J.L. Cosgrove III, D.M. Minimally invasive mitral valve operations.Ann Thorac Surg. 1996; 62: 1542-1544Abstract Full Text PDF PubMed Scopus (265) Google Scholar]. A straight skin incision of approximately 7 cm to 8 cm is then made from the level of the head of the second rib in the midline over the sternum and extended down to the level of the head of the fourth rib (Fig 1). Next, for an aortic procedure, the skin and subcutaneous tissue are undermined up to either the sternal notch or right first intercostal space and, at the lower extent, into the right third or fourth intercostal space. Either a regular saw or a oscillating saw can be used, but particularly for reoperations, it is essential to use an oscillating saw to open the sternum because of adhesions. For those patients in whom the upper extent of the incision requires good exposure of the distal ascending aorta and aortic arch, the sternotomy is extended up into the sternal notch ("j" incision) (Fig 2). In patients in whom an aortic valve or mitral valve procedure alone is required, the incision can be made into the right first intercostal space immediately above the second rib to leave the upper chest intact ("J" incision or reversed "C" incision) (see Fig 2). No attempt is made to identify or dissect out the right intercostal artery because it is unnecessary to ligate the artery. The retractor is spread with a towel under the handle to prevent the right side of the sternum from breaking and becoming a trap door. Critical to good exposure is the use of multiple, heavy silk sutures on the pericardium to pull the aorta and right atrium into good view. This may result in ventricular diastolic filling dysfunction and increased right-sided pressures, but these are reversed by release of the sutures after cardiopulmonary bypass. The distal ascending aorta or aortic arch is cannulated in a conventional manner, the latter being used when the ascending aorta needs to be replaced (Fig 3). For reoperations or proximal hemiarch repairs, however, it is more convenient to use either the femoral artery or the right subclavian artery for cannulation. If the aortic valve or the ascending aorta is to be replaced, then a conventional two-stage cannula is placed through a pursestring in the auricle of the right atrium. The cannula can be brought out through the chest wall and the hole used later for the chest tube insertion. Nonetheless, when an extended period of aortic cross-clamping is anticipated and retrograde cardioplegia may be required, then the retrograde cardioplegia cannula will need to be inserted blindly before insertion of the two-stage venous cannula. The position of the retrograde cannula should be confirmed by observing the return of semipulsatile dark, deoxygenated blood. For aortic valve procedures, exposure of the aortic valve is aided by placing commissure sutures under tension. For composite valve graft insertion, a tube graft is sewn to the left main artery first, followed by placement of the aortic annular sutures, seating of the composite valve graft, performance of the distal aortic anastomosis, and then reimplantation of the right coronary artery and the tube graft to the left main anastomosis as described previously [2.Svensson L.G. Approach for insertion of aortic composite valve grafts.Ann Thorac Surg. 1992; 54: 376-378Abstract Full Text PDF PubMed Scopus (36) Google Scholar] (see Fig 3, top inset). For those patients in whom a mitral valve is also to be replaced, particularly if the patient has a large annulus and Marfan's syndrome, the mitral valve can be inserted as a transaortic annular procedure [3.Svensson L.G. Crawford E.S. Cardiovascular and vascular disease of the aorta. Saunders, Philadelphia1997Google Scholar] using this minimal-access technique. Visualization of the mitral valve annulus is good and after excision of the anterior mitral valve leaflet, the sutures are placed with the pledgets on the atrial side of the annulus. The valve is then seated into position with the sutures tied on the ventricular aspect, care being taken to ensure that the mitral valve is seated in the correct orientation. Once the aortic procedure is completed, the ventricle is deaired as much as possible by irrigation, the aorta is allowed to fill with blood, and air is evacuated out through the aortotomy aided by the anesthesiologist ventilating the lungs. After aortic un-clamping the aorta is further vented. For a mitral valve procedure, either the right first intercostal space or sternal notch is incised and, at the lower extent, the right fourth or fifth intercostal space is entered. Cannulation is similar to that for aortic procedures; however, a right-angled small superior vena caval cannula is inserted (see Fig 3). The inferior vena cava can be drained either through a femoral venous cannula inserted and positioned below the right atrium in the upper abdominal inferior vena cava as described by Cosgrove's group [1.Navia J.L. Cosgrove III, D.M. Minimally invasive mitral valve operations.Ann Thorac Surg. 1996; 62: 1542-1544Abstract Full Text PDF PubMed Scopus (265) Google Scholar] or via the right atrium. For the latter alternative, a pursestring suture is placed high on the right atrium immediately below the junction with the superior vena cava. The reason for this is that when the cannula is positioned at this level, there is little interference with visualization of the mitral valve. For mitral valve procedures, the venae cavae are occluded to prevent venous return. The right atrium is opened from the lower aspect of the right atrium via the auricle to the atrial septum as described by Cosgrove's [1.Navia J.L. Cosgrove III, D.M. Minimally invasive mitral valve operations.Ann Thorac Surg. 1996; 62: 1542-1544Abstract Full Text PDF PubMed Scopus (265) Google Scholar] and Guiraudon's [4.Guiraudon G.M. Ofiesh J.G. Kaushik R. Extended vertical transatrial septal approach to the mitral valve.Ann Thorac Surg. 1991; 52: 1058-1062Abstract Full Text PDF PubMed Scopus (147) Google Scholar] groups (see Fig 3, bottom inset). The atrial septum is then incised, often without the need for the left atrial dome to be incised. Stay sutures placed on the septal incision expose the left atrium. Mitral valve repair is best facilitated by the use of the Cosgrove-Edwards mitral valve system because the anterior mitral valve annulus does not need to be exposed for the placement of the annular sutures. For a patient undergoing coronary artery bypass grafting through this limited incision, the incision is instead carried into the left fourth intercostal space ("L" incision). The aorta and right atrium are cannulated in a standard manner, although the left internal mammary artery has been anastomosed to the left anterior descending coronary artery off bypass through this incision. Postoperatively, patients are extubated early and injection of bupivacaine into the wound appears to lessen postoperative pain. The transverse sternal incision described by Cosgrove's group [1.Navia J.L. Cosgrove III, D.M. Minimally invasive mitral valve operations.Ann Thorac Surg. 1996; 62: 1542-1544Abstract Full Text PDF PubMed Scopus (265) Google Scholar] for aortic valve operations and the parasternal incision for mitral valve operations provide good visualization for these operations. When the procedure, however, is more complex—for example, when the entire ascending aorta needs to be exposed, for patients who are undergoing reoperation, or when combined aortic and mitral valve procedures are needed—the "j" or "J" incisions are particularly useful alternatives. Neither the femoral artery nor vein has to be cannulated unless most of the ascending aorta needs to be replaced. This incision allows for a good cosmetic result and also for a stable chest wall after the operation with reduced patient discomfort and pain, especially if the upper extent of the incision can be extended into the first intercostal space rather than to the sternal notch. Moreover, there is no need to sacrifice either of the internal mammary arteries. Indeed, if the internal mammary artery is needed for a right coronary artery bypass graft, this can be dissected down without much difficulty. Alternatively, for coronary artery bypass operations, with an "L" incision into the left chest, the left internal mammary artery can be dissected down without much difficulty and coronary bypass grafts to the left anterior descending, diagonal, and proximal right coronary arteries can be performed on cardiopulmonary bypass through this incision. The appropriate use of the "J" and "L" incisions should increase the surgeon's armamentarium in tailoring minimal-access exposures for specific operative sites. I am most grateful to Delos M. Cosgrove III, MD, for the opportunity of learning from him his innovative minimal-access approaches for aortic and mitral valve operations. The applications of his techniques for valvular operations form the basis for the development of this "J" or "j" incision approach, which he also has found to be useful.