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Research Article | Volume 30 Issue 1 (Jan -Jun, 2025) | Pages 1 - 5
Outcomes of Minimally Invasive Triple Valve Surgery Through the Right Anterior Thoracotomy Approach
1
Additional Prof, CVTS Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P., India
Under a Creative Commons license
Open Access
Received
Nov. 25, 2024
Revised
Dec. 15, 2024
Accepted
Dec. 30, 2024
Published
Jan. 15, 2025
Abstract

Background Minimally invasive cardiac surgery has gained popularity as an alternative to conventional sternotomy due to reduced surgical trauma, faster recovery, and improved cosmetic outcomes. Triple valve surgery, involving the mitral, aortic, and tricuspid valves, poses significant challenges. This study evaluates the clinical outcomes of minimally invasive triple valve surgery performed through the right anterior thoracotomy approach. Materials and Methods A prospective cohort study was conducted on 50 patients undergoing triple valve surgery through the right anterior thoracotomy approach at a tertiary care center. The patients, aged 35–70 years, had indications for mitral valve replacement, aortic valve replacement, and tricuspid valve repair or replacement. Preoperative, intraoperative, and postoperative data were collected, including cardiopulmonary bypass (CPB) time, aortic cross-clamp time, intensive care unit (ICU) stay, and hospital length of stay. Postoperative outcomes, such as mortality, complications, and echocardiographic findings, were analyzed over a 6-month follow-up period. Results The mean CPB and aortic cross-clamp times were 180 ± 20 minutes and 110 ± 15 minutes, respectively. The average ICU stay was 2.5 ± 0.5 days, and the mean hospital stay was 7 ± 1.5 days. Postoperative complications included arrhythmias in 10% of patients, wound infection in 4%, and transient renal dysfunction in 6%. No cases of stroke or reoperation for bleeding were reported. The 6-month survival rate was 96%, with significant improvement in New York Heart Association (NYHA) functional class (preoperative mean: 3.5 ± 0.3 vs. postoperative mean: 1.8 ± 0.4, p < 0.001). Conclusion The right anterior thoracotomy approach for minimally invasive triple valve surgery is a safe and effective technique, offering favorable clinical outcomes, shorter recovery times, and enhanced patient satisfaction. It represents a viable alternative to conventional sternotomy for selected patients requiring multiple valve interventions.

Keywords
INTRODUCTION

Minimally invasive cardiac surgery has emerged as an important alternative to conventional sternotomy, driven by advancements in surgical techniques and equipment. This approach has gained attention due to its potential benefits, including reduced surgical trauma, shorter recovery periods, and improved cosmetic results, which are particularly relevant in patients undergoing complex procedures such as triple valve surgery (1,2). Triple valve surgery, involving intervention on the mitral, aortic, and tricuspid valves, is often indicated in patients with multivalvular disease due to rheumatic heart disease, infective endocarditis, or degenerative conditions (3).

 

Traditionally, these surgeries have been performed through a median sternotomy, providing excellent surgical exposure but associated with significant morbidity, such as prolonged hospital stays, risk of sternal infections, and impaired postoperative quality of life (4,5). The right anterior thoracotomy approach has been increasingly adopted as a minimally invasive technique, allowing for similar surgical outcomes with the added advantages of smaller incisions, reduced pain, and faster rehabilitation (6).

 

However, the application of this approach to triple valve surgery poses unique challenges, including prolonged operative times, the need for advanced surgical expertise, and potential complications such as air embolism or inadequate valve exposure (7). Despite these challenges, recent studies suggest that minimally invasive techniques can yield outcomes comparable to or better than traditional methods in terms of mortality, morbidity, and functional recovery (8,9).

 

This study aims to evaluate the outcomes of triple valve surgery performed via the right anterior thoracotomy approach, focusing on perioperative and postoperative metrics, as well as medium-term clinical outcomes. By exploring this approach, we seek to provide evidence on its feasibility and effectiveness in managing patients with complex multivalvular disease.

MATERIALS AND METHODS

Study Design and Population

This prospective observational study was conducted at a tertiary care cardiac center over a period of 18 months. Fifty patients with multivalvular disease requiring triple valve surgery were included in the study. Inclusion criteria were patients aged 35–70 years with indications for mitral valve replacement, aortic valve replacement, and tricuspid valve repair or replacement. Exclusion criteria included prior cardiac surgery, severe left ventricular dysfunction (ejection fraction <30%), and active infective endocarditis.

 

Surgical Technique

All surgeries were performed through a right anterior thoracotomy approach. Patients were positioned supine with the right chest elevated. A 5–7 cm incision was made in the fourth or fifth intercostal space, and cardiopulmonary bypass (CPB) was established using femoral arterial and venous cannulation. Cardiac arrest was achieved with cold blood cardioplegia, and surgical access to the mitral, aortic, and tricuspid valves was obtained sequentially. Mitral and aortic valves were replaced with mechanical or bioprosthetic valves, and tricuspid valve repair was performed using a De Vega annuloplasty technique or a prosthetic ring as required.

 

Data Collection

Preoperative data, including patient demographics, comorbidities, and echocardiographic findings, were recorded. Intraoperative parameters such as CPB time, aortic cross-clamp time, and total operative duration were documented. Postoperative outcomes, including ICU stay, hospital length of stay, complications (arrhythmias, infections, renal dysfunction), and mortality, were recorded. Patients were followed up for six months to assess clinical and echocardiographic outcomes.

 

Outcome Measures

Primary outcomes included operative mortality, postoperative complications, and changes in functional status as measured by the New York Heart Association (NYHA) classification. Secondary outcomes were hospital length of stay, ICU stay, and 6-month survival rates. Echocardiographic parameters were evaluated preoperatively and at follow-up to assess valve function and cardiac performance.

 

Statistical Analysis

Data were analyzed using statistical software SPSS 23. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Paired t-tests were used to compare preoperative and postoperative parameters. A p-value of <0.05 was considered statistically significant

RESULTS

Patient Demographics and Preoperative Characteristics

The study included 50 patients, with a mean age of 58 ± 9 years, and 60% were male. Common comorbidities included hypertension (40%), diabetes mellitus (30%), and chronic obstructive pulmonary disease (10%). The majority of patients (80%) presented with NYHA Class III or IV symptoms. Preoperative echocardiographic findings revealed a mean left ventricular ejection fraction (LVEF) of 50 ± 5% and severe mitral regurgitation in 90% of cases (Table 1).

 

Table 1: Patient Demographics and Preoperative Characteristics

Parameter

Value (n = 50)

Mean Age (years)

58 ± 9

Male (%)

60%

Hypertension (%)

40%

Diabetes Mellitus (%)

30%

COPD (%)

10%

NYHA Class III or IV (%)

80%

Mean LVEF (%)

50 ± 5

Severe Mitral Regurgitation (%)

90%

 

Intraoperative Data

The mean cardiopulmonary bypass (CPB) time was 180 ± 20 minutes, and the mean aortic cross-clamp time was 110 ± 15 minutes. Mechanical valves were used in 70% of mitral and aortic valve replacements, while 30% received bioprosthetic valves. Tricuspid valve repair was performed using a De Vega annuloplasty technique in 80% of cases and prosthetic ring annuloplasty in the remaining 20%. No significant intraoperative complications were noted (Table 2).

 

Table 2: Intraoperative Data

Parameter

Value

Mean CPB Time (minutes)

180 ± 20

Mean Cross-Clamp Time (minutes)

110 ± 15

Mechanical Valves (%)

70%

Bioprosthetic Valves (%)

30%

De Vega Annuloplasty (%)

80%

Prosthetic Ring Annuloplasty (%)

20%

 

Postoperative Outcomes

The mean ICU stay was 2.5 ± 0.5 days, and the mean hospital stay was 7 ± 1.5 days. Postoperative complications included arrhythmias in 10% of patients, transient renal dysfunction in 6%, and wound infections in 4%. No cases of stroke or reoperation for bleeding were observed. The 30-day mortality rate was 2%, and the 6-month survival rate was 96%. NYHA functional status improved significantly, with 90% of patients achieving Class I or II status at follow-up (p < 0.001, Table 3).

 

Table 3: Postoperative Outcomes

Parameter

Value

Mean ICU Stay (days)

2.5 ± 0.5

Mean Hospital Stay (days)

7 ± 1.5

Arrhythmias (%)

10%

Transient Renal Dysfunction (%)

6%

Wound Infections (%)

4%

30-Day Mortality (%)

2%

6-Month Survival (%)

96%

 

Echocardiographic Outcomes

Postoperative echocardiographic evaluation showed significant improvements in valve function. The mean mitral valve gradient decreased from 8 ± 3 mmHg preoperatively to 3 ± 1 mmHg postoperatively (p < 0.01). Aortic valve gradients improved from 45 ± 10 mmHg to 15 ± 5 mmHg (p < 0.001). Tricuspid regurgitation was reduced from severe in 70% of cases to mild or none in 85% of cases at 6 months (Table 4).

 

Table 4: Echocardiographic Outcomes

Parameter

Preoperative Value

Postoperative Value

p-Value

Mitral Valve Gradient (mmHg)

8 ± 3

3 ± 1

<0.01

Aortic Valve Gradient (mmHg)

45 ± 10

15 ± 5

<0.001

Severe Tricuspid Regurgitation (%)

70%

15%

<0.001

DISCUSSION

Minimally invasive triple valve surgery through the right anterior thoracotomy approach offers a promising alternative to traditional sternotomy, demonstrating favorable clinical outcomes in selected patients. This study evaluated the feasibility, safety, and outcomes of this technique and found results comparable to or better than those reported in previous studies.

The mean cardiopulmonary bypass (CPB) time and aortic cross-clamp time in this study were similar to those reported in other minimally invasive series, despite the complexity of triple valve interventions (1,2). The use of femoral cannulation and specialized instruments facilitated adequate exposure and minimized intraoperative complications. These findings are consistent with previous studies highlighting the technical feasibility of the right anterior thoracotomy approach in multivalvular surgeries (3,4).

 

The low incidence of postoperative complications, including arrhythmias (10%) and renal dysfunction (6%), reflects the safety profile of this approach. These results align with studies showing reduced rates of major complications in minimally invasive cardiac surgery compared to sternotomy (5,6). Furthermore, the observed improvements in NYHA functional class and echocardiographic parameters support the effectiveness of this technique in restoring cardiac function (7,8).

 

The shorter ICU and hospital stays in our cohort, averaging 2.5 ± 0.5 days and 7 ± 1.5 days, respectively, are consistent with the benefits of minimally invasive surgery. Similar results have been reported in studies emphasizing faster recovery and earlier mobilization with thoracotomy-based approaches (9,10). The cosmetic advantage of a smaller incision also contributes to enhanced patient satisfaction and quality of life (11,12).

 

The 30-day mortality rate of 2% and the 6-month survival rate of 96% observed in this study compare favorably with rates reported for traditional sternotomy in complex valve surgeries (13). These outcomes highlight the potential of the minimally invasive approach to achieve excellent survival rates without compromising surgical quality. Improvements in mitral and aortic valve gradients, as well as reductions in tricuspid regurgitation, further confirm the durability of the surgical repairs (14,15).

 

Despite its advantages, this technique requires advanced surgical expertise and specialized equipment, limiting its widespread adoption. Additionally, the study's relatively small sample size and short follow-up period may not capture rare complications or long-term durability. Future research with larger cohorts and longer follow-ups is necessary to validate these findings.

CONCLUSION

Minimally invasive triple valve surgery through the right anterior thoracotomy approach is a safe and effective technique for managing complex multivalvular disease. It offers significant advantages in terms of reduced morbidity, faster recovery, and favorable clinical outcomes. With growing expertise and technological advancements, this approach has the potential to become a standard of care in carefully selected patients

REFERENCES
  1. Falk V, Cheng DC, Martin J, et al. Minimally invasive versus open valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2011;39(6):798-805.
  2. Yamada T, Ochiai Y, Takeda H, et al. Right thoracotomy approach for multivalve surgery. Ann Thorac Surg. 2010;89(3):818-823.
  3. Glauber M, Ferrarini M, Miceli A. Minimally invasive approach for multivalve surgery. Heart Lung Circ. 2015;24(3):310-315.
  4. Tabata M, Khalpey Z, Aranki SF, et al. Late outcomes of minimally invasive mitral valve repair: a propensity analysis. Ann Thorac Surg. 2013;96(1):98-105.
  5. Murzi M, Cerillo AG, Gasbarri T, et al. Right anterior thoracotomy for minimally invasive mitral valve surgery: impact on pain and quality of life. Eur J Cardiothorac Surg. 2013;43(6):e193-e197.
  6. Mazine A, Veiga C, Hassan A, et al. Long-term outcomes of sternotomy versus minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg. 2019;158(3):645-652.
  7. Iribarne A, Russo MJ, Easterwood R, et al. Minimally invasive multivalve surgery. Ann Thorac Surg. 2010;90(5):1460-1465.
  8. Seeburger J, Borger MA, Falk V, et al. Minimally invasive mitral valve repair: the Leipzig experience. Ann Cardiothorac Surg. 2013;2(6):744-750.
  9. Shah AM, Kang DH, Park SJ. Multivalvular heart disease in rheumatic fever. J Am Coll Cardiol. 2017;70(7):847-856.
  10. Byrne JG, Aranki SF, Couper GS, et al. Mitral valve surgery after previous cardiac operations. J Thorac Cardiovasc Surg. 2001;121(4):892-899.
  11. Mohr FW, Onnasch JF, Falk V, et al. The evolution of minimally invasive valve surgery—2 year experience. Eur J Cardiothorac Surg. 1999;15(3):233-238.
  12. Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997;226(4):421-428.
  13. Lamelas J. Minimally invasive approach for triple valve surgery. J Card Surg. 2020;35(10):2452-2458.
  14. Borger MA, Murzi M, Gatti G, et al. Minimally invasive mitral valve repair in Barlow's disease: early and long-term results. J Thorac Cardiovasc Surg. 2014;148(2):667-675.
  15. Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Eur J Cardiothorac Surg. 2008;33(4):523-528
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