Clinician-to-Clinician Update Clinician-to-Clinician Update

Minimally Invasive Approach after Prior Bypass Surgery Produces Excellent Outcome

November 2015

Contributed by Kenneth Liao, MD

As the population ages, the cardiac surgeon is increasingly presented with patients with a history of cardiac surgery via sternotomy who require surgical valve repair or replacement. Repeat median sternotomies present wellknown risks, including excessive bleeding, mediastinitis, cardiac tamponade, dehiscence, sternal osteomyelitis, and injury to cardiac structures and/or patent coronary grafts.1

Here we describe an elderly, active man with a history of prior coronary artery bypass surgery who successfully underwent minimally invasive mitral valve surgery (MIMVS) at a University of Minnesota Heart Care Center with an excellent long-term outcome.

Patient

A 76-year-old man was referred to a University of Minnesota Heart Care location for evaluation of severe mitral valve regurgitation due to diffuse degenerative changes. He had severe congestive heart failure symptoms of fatigue, shortness of breath, and lower limb edema. He had undergone a coronary artery bypass surgery via sternotomy previously at age 66 years. Repeat angiogram showed all bypass grafts were patent.

Figure-1-case-study-CV-Consult-Nov2015
— Figure 1. Surgical incision mark from MIMVS; prior sternotomy scar also visible.

Management and Outcome

Because the patient had a job as a delivery truck driver and was the owner of his delivery business, he requested a procedure that would allow for the fastest possible return to work. He was hesitant to undergo a repeat sternotomy. Because of these factors and in order to avoid injury to the patent bypass grafts, we offered him MIMVS with a tissue valve, and he agreed.

The patient underwent MIMVS via a 3-inch incision between ribs and tolerated the procedure well, recovering without sequelae. The patient completed rehabilitation and was able to return to work at 4 weeks postsurgery. He was pleased with the outcome and cosmetic appearance of his surgical incision (Figure 1). The fatigue, shortness of breath, and lower limb edema resolved, and the patient continues to feel well at 1-year follow-up.

Discussion

Studies have reported very good perioperative outcomes among MIMVS patients who had a prior sternotomy. One such study examined outcomes of a cohort of 181 patients with a mean age of 64.5 years who had undergone MIMVS after prior coronary bypass grafting (42%), isolated valve operation, 55 (30%), or other cardiac operation (28%) conducted via sternotomy.2 MIMVS was performed for valve repair in 60% of the patients and for replacement in 40%. Among these patients, the 30-day mortality rate was lower than it is with the conventional redo sternotomy approach, and early echocardiographic follow-up revealed excellent valve function in most patients. As these findings suggest, MIMVS is a useful alternative surgical strategy for patients with previous coronary bypass grafting who require mitral valve repair or replacement.

References

1. Morales D, Williams E, John R. Is resternotomy in cardiac surgery still a problem? Interact Cardiovasc Thorac Surg. 2010;11:277-286.

2. Seeburger J, Borger MA, Falk V, et al. Minimally invasive mitral valve surgery after previous sternotomy: experience in 181 patients. Ann Thorac Surg. 2009;87:709-714.

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