CASE REPORT
Mitral Valve Repair via a Minithoracotomy in a Patient With Pectus Excavatum Hidenobu Takaki, MD,* Kazuma Okamoto, MD, PhD,Þ Mikihiko Kudo, MD, PhD,Þ Ryohei Yozu, MD, PhD,Þ and Hideyuki Shimizu, MD, PhDÞ
Abstract: Cardiac surgery in patients with pectus excavatum is challenging because of the difficulty associated with achieving optimal surgical exposure and postoperative sternal fixation by using standard instruments. To solve these problems, mitral valve repair was performed via a right minithoracotomy in a 48-year-old man with severe mitral valve regurgitation and pectus excavatum. With the use of conventional median sternotomy, an optimal surgical field was difficult to achieve because of his thoracic deformity. Therefore, surgical fixation via right minithoracotomy using particular equipment was performed. Using right minithoracotomy, we could obtain an optimal surgical field better than that with median sternotomy, and the patient’s mitral valve regurgitation was fixed properly. This approach provides mitral valve exposure advantages as well as cosmetic satisfaction. Key Words: Pectus excavatum, Funnel chest, Minithoracotomy, Mitral valve repair, Minimally invasive cardiac surgery. (Innovations 2016;11:67Y69)
CASE REPORT A 48-year-old man, with a history of chronic atrial fibrillation that developed when he was in his 20s, was referred for surgery to correct severe mitral regurgitation that had caused the recent emergence of shortness of breath. The patient was 199 cm tall, weighed 91 kg, and displayed prominent pectus excavatum (Fig. 1). The rest of his physical findings, however, were consistent with a diagnosis of Marfan syndrome. Echocardiography demonstrated dilation of the left ventricle (70 mm at end diastole, 40 mm at end systole), with poor left ventricular function (ejection fraction, 45%) and an enlarged left atrium (54 mm) with moderate pulmonary hypertension
Accepted for publication May 20, 2015. From the *Department of Cardiovascular Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba; and †Department of Cardiovascular Surgery, Keio University of Medicine, Tokyo, Japan. Disclosure: The authors declare no conflicts of interest. Address correspondence and reprint requests to Kazuma Okamoto, MD, PhD, Department of Cardiovascular Surgery, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 1608582 Japan. E-mail: [email protected]. Copyright * 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/16/1101-0067
Innovations & Volume 11, Number 1, January/February 2016
(54 mm Hg during systole). Transesophageal echocardiography showed flail P2 leaflets due to chordal rupture. For this patient, median sternotomy would not have ensured an optimal direct view of the surgical site because of his pectus excavatum. However, right minithoracotomy using an endoscope was expected to be helpful. We offered this approach to the patient and obtained his consent for a right minithoracotomy approach. For surgery, the patient was set in supine position, with a slightly elevated right side, as routinely used during the right minithoracotomy approach for mitral valve repair.1 To establish cardiopulmonary bypass (CPB), while avoiding aortic dissection due to high perfusion pressure, both femoral arteries were cannulated because of his large body surface area (2.4 m2). The right femoral and right jugular veins were cannulated to provide good venous drainage. A right anterolateral minithoracotomy was created through the fourth intercostal space, and an endoscope port was made in the lateral side of the wound, along the same intercostal space. The fourth costal bone was cut, to break the continuity between the sternum and the costal bone and to afford a broad surgical field. A sternum-lifting hook system for mammary artery harvesting (IMA retractor 4100-IMR-41; Pemco, Cleveland, OH USA) was applied to lift the caudal part of the sternum. After CPB was established, the pericardium was opened, and the heart was arrested with antegrade cold cardioplegia. The mitral valve was exposed using the Unitrac air-driven retraction and holding system (Aesculap, Center Valley, PA USA) assisted with endoscope (5-mm size with a view of 30-degree angle; Olympus, Tokyo, Japan) (Fig. 2). The posterior wall of the left atrium was pushed down using the spatula connected to the Adams-Yozu Mini-Valve System (Geister, Tuttlingen, Germany)1 (Fig. 3). The papillary muscles were normal. The mitral valve was repaired with seven Gore-Tex (W. L. Gore & Associates, Newark, DE USA) artificial chordae fixed to the anterolateral and the posteromedial papillary muscle, using a ‘‘loop-in-loop technique,’’2 without resection of the posterior leaflet. Mitral annuloplasty, using a Physio Annuloplasty Ring (size 40; Edwards Lifesciences, Irvine, CA USA), was also performed. The cut fourth costal bone was repaired with a hydroxyapatitepoly-L-lactide plate (Osteotrans MX; Takiron Co Ltd, Osaka, Japan) to prevent pseudoarthrosis. Cardiopulmonary bypass time was 450 minutes, and aortic cross-clamp time was 195 minutes. The patient’s postoperative course was uneventful. Echocardiography, performed 6 days after the operation, revealed normal leaflet motion and trivial mitral valve regurgitation; mitral valve stenosis was not
67
Copyright © 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Innovations & Volume 11, Number 1, January/February 2016
Takaki et al
DISCUSSION The benefits of minimally invasive mitral valve surgery have been previously reported.3,4 Despite longer CPB and crossclamping times, the perioperative mortality rates are equivalent to those observed after conventional mitral surgery, and the minimally invasive method reduced the need for reexploration due to bleeding and showed a trend toward shorter hospital stays. Right minithoracotomy is also useful for the patients who are supposed to be difficult to approach with a median sternotomy.5 Especially in patients with pectus excavatum, it is difficult to use the rib spreader of median sternotomy, and we have a limited working space because of the deep concave sternum. In addition, a median approach would afford us of narrow surgical sight because of the steep angle of thoracic deformity. However, lateral thoracotomy assisted with endoscope can deal with the disadvantage of angle and make it easier to get a better surgical sight. Bernhardt et al6 reported good results in performing mitral valve repair for patients with Marfan syndrome with lateral thoracotomy. The indications for minimally invasive cardiac surgery are expanding, and pectus
FIGURE 1. Computed tomographic images show the extent of the pectus excavatum and the left deviation of the patient’s heart.
observed. The length of the surgical wound was approximately 12 cm (Fig. 4). The patient was discharged on postoperative day 7 in a stable, satisfactory clinical condition, and the length of hospital stay was 16 days.
FIGURE 2. Endoscopic view of the mitral valve.
68
FIGURE 3. A, An IMA retractor 4100-IMR-41 (Pemco, Cleveland, OH USA) lifts the sternum. B, The mitral valve is exposed using the Unitrac air-driven retraction and holding system (Aesculap, Center Valley, PA USA). C, An Adams-Yozu Mini-Valve System (Geister, Tuttlingen, Germany) helps to achieve an optimal view of the mitral valve.
Copyright * 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery
Copyright © 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Innovations & Volume 11, Number 1, January/February 2016
Mitral Valve Repair in Pectus Excavatum
complain of postoperative pain. To deal with this problem, we perform an intercostal nerve blockade using 0.75% ropibacaine at the end of surgery and use intravenous patient-controlled analgesia (fentanyl and droperidol) after surgery. Although these methods were used, it would be very difficult for the patient whose left atrium is located at the totally left side of the concave sternum, indicated on a preoperative computed tomography, because of the distance from the surgical wound to the mitral valve and the quite narrow working space. In the given circumstances, we would not use this approach, and we would adopt median sternotomy or left thoracotomy. The loop technique is also useful in narrow working spaces associated with minithoracotomy. Kuntze et al8 reported excellent mitral valve repair outcomes using premeasured Gore-Tex loop sets during minithoracotomy. This has also been our routine technique for mitral valve repair. In 2011, this technique evolved to become the ‘‘loop-in-loop technique,’’ which involves the primary loop set being fixed to the papillary muscle and the secondary loop being fixed to the prolapsed leaflet. The present patient had annuloaortic ectasia, which meant that the aorta diameter was smaller than that indicated for the surgery. Considering future reentries into the mediastinum, a sternotomy in a patient with a history of cardiac surgery via minithoracotomy is safer than that after a previous sternotomy. In conclusion, mitral valve surgery via right minithoracotomy for the patients with pectus excavatum is a feasible approach, under appropriate conditions including the use of proper devices and equipment. The procedure also provides a satisfactory postoperative course and acceptable cosmesis. FIGURE 4. Postoperative surgical wound.
excavatum is not a contraindication for a minithoracotomy approach anymore.7 However, to perform surgery for the patients with pectus excavatum via minithoracotomy, it demands some alternative methods using appropriate instruments and surgical settings. The left atrial retractor connected to the Unitrac system, which can be fixed in any favorable position to realize optimal exposure of the mitral valve, is effective for mitral valve repairs performed via minithoracotomy, especially in patients with thoracic deformities. In addition, the use of a sternum-lifting hook system for mammary artery harvesting is effective for keeping the surgical field open while lifting the sternum. Basically, we perform right minithoracotomy without cutting costal bones. It reduces postoperative pain and encourages rehabilitation of patients. However, in this case, we prioritized getting the feasible surgical site. Compared with patients who underwent median sternotomy, patients who received right minithoracotomy by cutting a costal bone tend to
REFERENCES 1. Yozu R, Okamoto K, Kudo M, Nonaka H, Adams DH. New innovative instruments facilitate both direct-vision and endoscopic-assisted mini-mitral valve surgery. J Thorac Cardiovasc Surg. 2012;143(suppl 4):S82YS85. 2. Okamoto K, Yozu R, Kudo M. Loop-in-loop technique in mitral valve repair via minithoracotomy. Ann Thorac Surg. 2012;93:1329Y1330. 3. Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J. 2010;31:1958Y1966. 4. Modi P, Rodriguez E, Hargrove WC III, Hassan A, Szeto WY, Chitwood WR Jr. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg. 2009;137: 1481Y1487. 5. Byrne JG, Aranki SF, Adams DH, Rizzo RJ, Couper GS, Cohn LH. Mitral valve surgery after previous CABG with functioning IMA grafts. Ann Thorac Surg. 1999;68:2243Y2247. 6. Bernhardt AM, Treede H, Detter C, et al. Results of modern mitral valve repair in patients with Marfan syndrome. Thorac Cardiovasc Surg. 2014; 62:35Y41. 7. Misfeld M, Borger M, Byrne JG, et al. Cross-sectional survey on minimally invasive mitral valve surgery. Ann Thorac Cardiovasc Surg. 2013;2:733Y738. 8. Kuntze T, Borger MA, Falk V, et al. Early and mid-term results of mitral valve repair using premeasured Gore-Tex loops (‘loop technique’). Eur J Cardiothorac Surg. 2008;33:566Y572.
Copyright * 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery
69
Copyright © 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Mitral Valve Repair via a Minithoracotomy in a Patient With Pectus Excavatum Hidenobu Takaki, MD,* Kazuma Okamoto, MD, PhD,Þ Mikihiko Kudo, MD, PhD,Þ Ryohei Yozu, MD, PhD,Þ and Hideyuki Shimizu, MD, PhDÞ
Abstract: Cardiac surgery in patients with pectus excavatum is challenging because of the difficulty associated with achieving optimal surgical exposure and postoperative sternal fixation by using standard instruments. To solve these problems, mitral valve repair was performed via a right minithoracotomy in a 48-year-old man with severe mitral valve regurgitation and pectus excavatum. With the use of conventional median sternotomy, an optimal surgical field was difficult to achieve because of his thoracic deformity. Therefore, surgical fixation via right minithoracotomy using particular equipment was performed. Using right minithoracotomy, we could obtain an optimal surgical field better than that with median sternotomy, and the patient’s mitral valve regurgitation was fixed properly. This approach provides mitral valve exposure advantages as well as cosmetic satisfaction. Key Words: Pectus excavatum, Funnel chest, Minithoracotomy, Mitral valve repair, Minimally invasive cardiac surgery. (Innovations 2016;11:67Y69)
CASE REPORT A 48-year-old man, with a history of chronic atrial fibrillation that developed when he was in his 20s, was referred for surgery to correct severe mitral regurgitation that had caused the recent emergence of shortness of breath. The patient was 199 cm tall, weighed 91 kg, and displayed prominent pectus excavatum (Fig. 1). The rest of his physical findings, however, were consistent with a diagnosis of Marfan syndrome. Echocardiography demonstrated dilation of the left ventricle (70 mm at end diastole, 40 mm at end systole), with poor left ventricular function (ejection fraction, 45%) and an enlarged left atrium (54 mm) with moderate pulmonary hypertension
Accepted for publication May 20, 2015. From the *Department of Cardiovascular Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba; and †Department of Cardiovascular Surgery, Keio University of Medicine, Tokyo, Japan. Disclosure: The authors declare no conflicts of interest. Address correspondence and reprint requests to Kazuma Okamoto, MD, PhD, Department of Cardiovascular Surgery, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 1608582 Japan. E-mail: [email protected]. Copyright * 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/16/1101-0067
Innovations & Volume 11, Number 1, January/February 2016
(54 mm Hg during systole). Transesophageal echocardiography showed flail P2 leaflets due to chordal rupture. For this patient, median sternotomy would not have ensured an optimal direct view of the surgical site because of his pectus excavatum. However, right minithoracotomy using an endoscope was expected to be helpful. We offered this approach to the patient and obtained his consent for a right minithoracotomy approach. For surgery, the patient was set in supine position, with a slightly elevated right side, as routinely used during the right minithoracotomy approach for mitral valve repair.1 To establish cardiopulmonary bypass (CPB), while avoiding aortic dissection due to high perfusion pressure, both femoral arteries were cannulated because of his large body surface area (2.4 m2). The right femoral and right jugular veins were cannulated to provide good venous drainage. A right anterolateral minithoracotomy was created through the fourth intercostal space, and an endoscope port was made in the lateral side of the wound, along the same intercostal space. The fourth costal bone was cut, to break the continuity between the sternum and the costal bone and to afford a broad surgical field. A sternum-lifting hook system for mammary artery harvesting (IMA retractor 4100-IMR-41; Pemco, Cleveland, OH USA) was applied to lift the caudal part of the sternum. After CPB was established, the pericardium was opened, and the heart was arrested with antegrade cold cardioplegia. The mitral valve was exposed using the Unitrac air-driven retraction and holding system (Aesculap, Center Valley, PA USA) assisted with endoscope (5-mm size with a view of 30-degree angle; Olympus, Tokyo, Japan) (Fig. 2). The posterior wall of the left atrium was pushed down using the spatula connected to the Adams-Yozu Mini-Valve System (Geister, Tuttlingen, Germany)1 (Fig. 3). The papillary muscles were normal. The mitral valve was repaired with seven Gore-Tex (W. L. Gore & Associates, Newark, DE USA) artificial chordae fixed to the anterolateral and the posteromedial papillary muscle, using a ‘‘loop-in-loop technique,’’2 without resection of the posterior leaflet. Mitral annuloplasty, using a Physio Annuloplasty Ring (size 40; Edwards Lifesciences, Irvine, CA USA), was also performed. The cut fourth costal bone was repaired with a hydroxyapatitepoly-L-lactide plate (Osteotrans MX; Takiron Co Ltd, Osaka, Japan) to prevent pseudoarthrosis. Cardiopulmonary bypass time was 450 minutes, and aortic cross-clamp time was 195 minutes. The patient’s postoperative course was uneventful. Echocardiography, performed 6 days after the operation, revealed normal leaflet motion and trivial mitral valve regurgitation; mitral valve stenosis was not
67
Copyright © 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Innovations & Volume 11, Number 1, January/February 2016
Takaki et al
DISCUSSION The benefits of minimally invasive mitral valve surgery have been previously reported.3,4 Despite longer CPB and crossclamping times, the perioperative mortality rates are equivalent to those observed after conventional mitral surgery, and the minimally invasive method reduced the need for reexploration due to bleeding and showed a trend toward shorter hospital stays. Right minithoracotomy is also useful for the patients who are supposed to be difficult to approach with a median sternotomy.5 Especially in patients with pectus excavatum, it is difficult to use the rib spreader of median sternotomy, and we have a limited working space because of the deep concave sternum. In addition, a median approach would afford us of narrow surgical sight because of the steep angle of thoracic deformity. However, lateral thoracotomy assisted with endoscope can deal with the disadvantage of angle and make it easier to get a better surgical sight. Bernhardt et al6 reported good results in performing mitral valve repair for patients with Marfan syndrome with lateral thoracotomy. The indications for minimally invasive cardiac surgery are expanding, and pectus
FIGURE 1. Computed tomographic images show the extent of the pectus excavatum and the left deviation of the patient’s heart.
observed. The length of the surgical wound was approximately 12 cm (Fig. 4). The patient was discharged on postoperative day 7 in a stable, satisfactory clinical condition, and the length of hospital stay was 16 days.
FIGURE 2. Endoscopic view of the mitral valve.
68
FIGURE 3. A, An IMA retractor 4100-IMR-41 (Pemco, Cleveland, OH USA) lifts the sternum. B, The mitral valve is exposed using the Unitrac air-driven retraction and holding system (Aesculap, Center Valley, PA USA). C, An Adams-Yozu Mini-Valve System (Geister, Tuttlingen, Germany) helps to achieve an optimal view of the mitral valve.
Copyright * 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery
Copyright © 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Innovations & Volume 11, Number 1, January/February 2016
Mitral Valve Repair in Pectus Excavatum
complain of postoperative pain. To deal with this problem, we perform an intercostal nerve blockade using 0.75% ropibacaine at the end of surgery and use intravenous patient-controlled analgesia (fentanyl and droperidol) after surgery. Although these methods were used, it would be very difficult for the patient whose left atrium is located at the totally left side of the concave sternum, indicated on a preoperative computed tomography, because of the distance from the surgical wound to the mitral valve and the quite narrow working space. In the given circumstances, we would not use this approach, and we would adopt median sternotomy or left thoracotomy. The loop technique is also useful in narrow working spaces associated with minithoracotomy. Kuntze et al8 reported excellent mitral valve repair outcomes using premeasured Gore-Tex loop sets during minithoracotomy. This has also been our routine technique for mitral valve repair. In 2011, this technique evolved to become the ‘‘loop-in-loop technique,’’ which involves the primary loop set being fixed to the papillary muscle and the secondary loop being fixed to the prolapsed leaflet. The present patient had annuloaortic ectasia, which meant that the aorta diameter was smaller than that indicated for the surgery. Considering future reentries into the mediastinum, a sternotomy in a patient with a history of cardiac surgery via minithoracotomy is safer than that after a previous sternotomy. In conclusion, mitral valve surgery via right minithoracotomy for the patients with pectus excavatum is a feasible approach, under appropriate conditions including the use of proper devices and equipment. The procedure also provides a satisfactory postoperative course and acceptable cosmesis. FIGURE 4. Postoperative surgical wound.
excavatum is not a contraindication for a minithoracotomy approach anymore.7 However, to perform surgery for the patients with pectus excavatum via minithoracotomy, it demands some alternative methods using appropriate instruments and surgical settings. The left atrial retractor connected to the Unitrac system, which can be fixed in any favorable position to realize optimal exposure of the mitral valve, is effective for mitral valve repairs performed via minithoracotomy, especially in patients with thoracic deformities. In addition, the use of a sternum-lifting hook system for mammary artery harvesting is effective for keeping the surgical field open while lifting the sternum. Basically, we perform right minithoracotomy without cutting costal bones. It reduces postoperative pain and encourages rehabilitation of patients. However, in this case, we prioritized getting the feasible surgical site. Compared with patients who underwent median sternotomy, patients who received right minithoracotomy by cutting a costal bone tend to
REFERENCES 1. Yozu R, Okamoto K, Kudo M, Nonaka H, Adams DH. New innovative instruments facilitate both direct-vision and endoscopic-assisted mini-mitral valve surgery. J Thorac Cardiovasc Surg. 2012;143(suppl 4):S82YS85. 2. Okamoto K, Yozu R, Kudo M. Loop-in-loop technique in mitral valve repair via minithoracotomy. Ann Thorac Surg. 2012;93:1329Y1330. 3. Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J. 2010;31:1958Y1966. 4. Modi P, Rodriguez E, Hargrove WC III, Hassan A, Szeto WY, Chitwood WR Jr. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg. 2009;137: 1481Y1487. 5. Byrne JG, Aranki SF, Adams DH, Rizzo RJ, Couper GS, Cohn LH. Mitral valve surgery after previous CABG with functioning IMA grafts. Ann Thorac Surg. 1999;68:2243Y2247. 6. Bernhardt AM, Treede H, Detter C, et al. Results of modern mitral valve repair in patients with Marfan syndrome. Thorac Cardiovasc Surg. 2014; 62:35Y41. 7. Misfeld M, Borger M, Byrne JG, et al. Cross-sectional survey on minimally invasive mitral valve surgery. Ann Thorac Cardiovasc Surg. 2013;2:733Y738. 8. Kuntze T, Borger MA, Falk V, et al. Early and mid-term results of mitral valve repair using premeasured Gore-Tex loops (‘loop technique’). Eur J Cardiothorac Surg. 2008;33:566Y572.
Copyright * 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery
69
Copyright © 2016 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
