title: Minimally invasive right lateral thoracotomy without aortic cross-clamping: an attractive alternative to repeat sternotomy for reoperative mitral valve surgery.
abstract: OBJECTIVE
  The study aim was to determine the safety and benefits of minimally invasive mitral valve surgery without aortic cross-clamping for mitral valve surgery after previous cardiac surgery.
  
  
  METHODS
  Between January 2006 and August 2008, a total of 90 consecutive patients (38 females, 52 males; mean age 66 +/- 9 years) underwent minimally invasive mitral valve surgery after having undergone previous cardiac surgery. Of these patients, 80 (89%) underwent mitral valve replacement and 10 (11%) mitral valve repair utilizing a small (5 cm) right lateral thoracotomy along the 4th or 5th intercostal space under fibrillatory arrest (mean temperature 28 +/- 2 degrees C). The predicted mortality, calculated using the Society of Thoracic Surgeons (STS) algorithm, was compared to the observed mortality.
  
  
  RESULTS
  The mean ejection fraction was 45 +/- 13%, mean NYHA class 3 +/- 1, while 66 patients (73%) had previous coronary artery bypass grafting and 37 (41%) had previous valve surgery. Twenty-six patients (29%) underwent non-elective surgery. Cardiopulmonary bypass was instituted through axillary (n = 19), femoral (n = 70) or direct use aortic (n = 1) cannulation. Operative mortality was 2% (2/90), lower than the STS-predicted mortality of 7%. Three patients (3%) developed acute renal failure postoperatively, one patient (1%) required new-onset hemodialysis, and one (1%) developed postoperative stroke. No patients developed postoperative myocardial infarction. The mean postoperative packed red blood cell transfusion requirement at 48 h was 2 +/- 3 units.
  
  
  CONCLUSIONS
  Minimally invasive right thoracotomy without aortic cross-clamping is an excellent alternative to conventional redo-sternotomy for reoperative mitral valve surgery. The present study confirmed that this technique is safe and effective in reducing operative mortality in high-risk patients undergoing reoperative cardiac surgery.
authors.affiliation: Vanderbilt Heart and Vascular Institute, Nashville, Tennessee, USA.
authors.forename: Ramanan
authors.initials: R
authors.lastname: Umakanthan
authors.forename: Michael R
authors.initials: MR
authors.lastname: Petracek
authors.forename: Marzia
authors.initials: M
authors.lastname: Leacche
authors.forename: Nataliya V
authors.initials: NV
authors.lastname: Solenkova
authors.forename: Susan S
authors.initials: SS
authors.lastname: Eagle
authors.forename: Annemarie
authors.initials: A
authors.lastname: Thompson
authors.forename: Rashid M
authors.initials: RM
authors.lastname: Ahmad
authors.forename: James P
authors.initials: JP
authors.lastname: Greelish
authors.forename: Stephen K
authors.initials: SK
authors.lastname: Ball
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Hoff
authors.forename: Tarek S
authors.initials: TS
authors.lastname: Absi
authors.forename: Jorge M
authors.initials: JM
authors.lastname: Balaguer
authors.forename: John G
authors.initials: JG
authors.lastname: Byrne
mesh_terms: D000368:Aged; D001011:Aorta / Q000502:physiology; D006348:Cardiac Surgical Procedures; D003250:Constriction; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D008943:Mitral Valve / Q000601:surgery*; D011183:Postoperative Complications; D012086:Reoperation; D056346:Sternotomy; D013908:Thoracotomy