Ministernotomy for Aortic Valve Replacement

Fernando Barbosa

doi:doi:10.25373/ctsnet.9770438

Wednesday, September 11, 2019

By

Fernando Barbosa

Claudio Moyano

Andres Otero

Diego Colichelli

Barbosa F, Moyano C, Otero A, et al.. Ministernotomy for Aortic Valve Replacement. September 2019. doi:10.25373/ctsnet.9770438.

The upper sternotomy or ministernotomy has been a well-known technique for many years, but it is not a common surgery. It has few pitfalls and not many secrets, but many benefits. Despite these factors, a minimally invasive approach is not routinely adopted. The ministernotomy finished at the third or fourth right Intercostal spaces can result in one of the pitfalls at the right mammary artery. The authors prefer to clip and section the artery. Some others prefer to respect the mammary. The point of this technique is that one must open the right pleura, and if the mammary bleeds, it can result in some blood loss. One of the tips is to put in the venous cannula as a chest tube. This can expand the operating field with less cannulae in the area, and remove the right atrium from the aortic root.

References

Aris A, Cámara ML, Montiel J, Delgado LJ, Galán J, Litvan H. Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study. Ann Thorac Surg. 1999; 67:1583-1587.
Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg. 2002; 73:460-465.
Filip G, Bryndza MA , et al. Ministernotomy or sternotomy in isolated aortic valve replacement? Early results. Kardiochir Torakochirurgia Pol. 2018 Dec;15(4):213-218.

Comments

Submitted by Germán Fortunato on Thu, 2019-09-12 19:15

Nice and well-documented case, congrats! As I can see is a fat woman, so reducing full sternotomy with this approach is great. I love the idea of using the same incision of the chest tube and the venous cannula. Just a couple of questions: 1. Some people believe that blood cardioplegia is the best option for several good reasons. However, other people think that this technique can be simplified with Del Nido or Bretschneider cardioplegia. Which cardioplegia do you think is better in these cases? 2. In order to improve your mediastinal visualization, It is possible to place the venous cannula through the femoral vein? Placing the wires before decanulation is clever, it could be tough to place it with the beating heart in a minimally invasive approach. Congratulations again and thank you for sharing this video.

Submitted by Fernando Barbosa on Fri, 2019-09-13 06:00

Thanks Dr Fortunato. The first answer is that in our institution we use Del Nido Cardioplegia for the On Pump Surgeries, and for this cases, is the best one, because in 90 minutes you can perform the surgery wothout problems. The second quiestion, one of the tips of this technique is thet when you plase the venus canula like we use, it is really helpphull tp remove the right atrium form the aortic root. I have just see you Ctsnet video, https://www.ctsnet.org/article/how-perform-midcab-procedure-step-step-single-vessel-disease. Great Job, congratulations too.

Submitted by George Tolis, Jr. on Thu, 2019-09-19 17:32

This is a very nicely executed operation. I have two questions : 1) In my experience, if you do an upper hemisternotomy, the incision is smaller than a full sternotomy but it is higher up toward the neck and more visible if the patient wants to wear an open shirt. With a full sternotomy incision, you can start the skin incision much lower but you have to extend it more caudad. Most people that worry about cosmesis are more concerned about a scar showing when they wear an open shirt and much less about their careers as a xiphoid model. In other words, I find the "full"sternotomy cosmetically more appealing than the "mini" sternotomy. 2) A hemisternotomy hurts more than a full sternotomy, at least in my personal experience. That's why I have stopped offering this option to patients. Having said that, this is a nice video and a very nicely executed operation.

Submitted by Fernando Barbosa on Sat, 2019-09-28 21:31

Dr Tolis, thanks for you questions, first, we perform the mini sternotomi 3 centimeters below the full sternotomy incisions as you could see in the video. The second, our patients doesnt reffer more painfully than the full sternotomy. One thing that we observ is that the skin need more time to heal, may be because it is more traumatic for the skin this technique. Once again, thanks for your questions.

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