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Beating Heart Surgery via Right Thoracotomy for Reoperative Mitral Valve Surgery: A Safe and Effective Operative Alternative
Study Questions:
What are the feasibility and the safety of reoperative mitral valve surgery using a right thoracotomy approach and a beating heart technique?
Methods:
The outcomes were reviewed of 450 patients who underwent redo mitral valve surgery via a right thoracotomy from 1996 to 2011 at a large academic medical center. Of these, 134 patients underwent redo mitral valve surgery with ventricular fibrillation, and 316 patients underwent beating heart surgery. Although operative eras were consecutive rather than simultaneous, patients’ age, risk factors, New York Heart Association functional classification, and preoperative left ventricular ejection fraction were not significantly different. Core temperature on cardiopulmonary bypass for beating heart surgery was 32°C versus 26°C for ventricular fibrillation.
Results:
Compared to patients undergoing redo surgery via right thoracotomy with ventricular fibrillation, patients undergoing beating heart surgery had shorter periods of cardiopulmonary bypass (81 ± 9 minutes vs. 113 ± 36 minutes). Beating heart surgery required less blood products than ventricular fibrillation (1.65 ± 2 units vs. 3.8 ± 5 units packed red blood cells, 0.6 ± 1.2 units vs. 1.8 ± 4 units fresh-frozen plasma, and 1.02 ± 4 vs. 7.5 ± 17 platelet packs [all p < 0.01]). Conversely, patients undergoing surgery with ventricular fibrillation required longer postoperative ventilation (34 ± 101 hours vs. 15.5 ± 27 hours [p < 0.01]). The 30-day mortality was similar for both (6.5% for beating heart and 7.4% for ventricular fibrillation), and postoperative length of stay was the same at 7 days. Stroke rate was 2.6% for patients undergoing beating heart surgery and 3% for patients receiving ventricular fibrillation. Significant operative complications were uncommon; there was no catastrophic hemorrhage, and only two patients undergoing surgery with ventricular fibrillation and two patients undergoing beating heart surgery required re-exploration.
Conclusions:
As an operative alternative to right thoracotomy with ventricular fibrillation, redo right thoracotomy mitral valve surgery on the beating heart is associated with shorter bypass time, less transfusion requirements, shorter postoperative ventilation, and lower mortality. The authors recommend that this approach should be considered for this complex operation.
Perspective:
As reoperative cardiac surgery continues to become more common, techniques should be adopted that safely facilitate operation while improving outcome. Right thoracotomy using ventricular fibrillation with cooling has been used for redo mitral valve surgery, avoiding complications of redo sternotomy including injury to prior coronary bypass grafts and reducing the risk of major hemorrhage. This report from a group of cardiac surgeons at a single high-volume medical center suggests that outcomes for this complex operation can be improved upon using a beating heart technique rather than reoperation on a fibrillating heart.
Keywords: Sternotomy, Ventricular Function, Left, Mitral Valve Insufficiency, Ventricular Fibrillation, Cardiovascular Physiological Phenomena, Risk Factors, New York, Postoperative Period, Thoracotomy, Reoperation, Heart Valve Diseases, Stroke Volume, Cardiopulmonary Bypass, Coronary Artery Bypass, Myocardial Contraction
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