title: Reoperative mitral valve surgery by the port access minithoracotomy approach is safe and effective.
abstract: BACKGROUND
  Reoperative mitral valve (MV) surgery through sternotomy can be technically challenging. Limited exposure and injury to the right ventricle or patent grafts (previous coronary artery bypass graft surgery [CABG]) are potential complications upon sternal reentry. The purpose of this study was to examine the results of port access MV surgery through right minithoracotomy in patients with previous cardiac surgery performed through median sternotomy.
  
  
  METHODS
  From 1998 through July 2007, 651 port access MV procedures were performed. In 107 patients (16.4%), previous cardiac surgery had been performed through midline sternotomy. Mean age was 67.5 +/- 11.2 years, and 60.7% (n = 65) were male. Previous surgery included CABG (n = 45, 42.1%), aortic valve replacement (n = 9, 8.4%), aortic valve replacement/MV repair (n = 2, 1.9%), MV repair (n = 21, 19.6%), MV replacement (n = 5, 4.7%), CABG/MV replacement (n = 1, 0.9%), CABG/MV repair (n = 8, 7.5%), CABG/aortic valve replacement (n = 2, 1.9%), and others (n = 14, 13.1%). New York Heart Association functional classes were I (n = 2, 1.9%), II (n = 28, 26.2%), III (n = 50, 46.7%), and IV (n = 27, 25.2%). The endoaortic balloon was used in 75 patients (70.1%) and the Chitwood clamp in 11 patients (10.2%). In the remaining patients (n = 21, 19.6%), fibrillatory arrest was employed.
  
  
  RESULTS
  Mitral valve repair and MV replacement were performed in 60 patients (56.1%) and 47 patients (43.9%), respectively. The 30-day mortality was 4.7% (n = 5). The mean cardiopulmonary bypass and aortic cross-clamp times were 140.8 +/- 43.7 minutes and 77.0 +/- 49.7 minutes, respectively. Complications included 6 reoperations for bleeding (5.6%), 1 stroke (0.9%), and 2 wound infections (1.9%). Conversion to sternotomy was required in 1 patient (0.9%) because of an acute type A dissection secondary to aortic occlusion with Chitwood clamp. The mean hospital stay was 9.6 days. During follow-up, reoperation for failure of MV repair was performed in 4 patients (3.7%).
  
  
  CONCLUSIONS
  Reoperative port access MV surgery can be performed with minimal morbidity and mortality. This approach may be the preferred technique for patients who require MV procedures after previous cardiac surgery performed through median sternotomy.
authors.affiliation: Division of Cardiovascular Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania 19104, USA.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Meyer
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.forename: John G T
authors.initials: JG
authors.lastname: Augoustides
authors.forename: Rohinton J
authors.initials: RJ
authors.lastname: Morris
authors.forename: William J
authors.initials: WJ
authors.lastname: Vernick
authors.forename: Deborah
authors.initials: D
authors.lastname: Paschal
authors.forename: Jeanne
authors.initials: J
authors.lastname: Fox
authors.forename: W Clark
authors.initials: WC
authors.lastname: Hargrove
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery; D006348:Cardiac Surgical Procedures / Q000379:methods / Q000401:mortality; D001026:Coronary Artery Bypass; D005260:Female; D006331:Heart Diseases / Q000145:classification / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D012086:Reoperation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012449:Safety; D013249:Sternum / Q000601:surgery