Minimally Invasive Cardiac Surgery For Aortic Valve Replacement

Case Scenario

A 51-year-old- man presented to the outpatient department of Apollo Hospital, B. G. Road, Bengaluru, with dyspnea on exertion and recurrent chest pain. The senior consultant of the Cardiothoracic & Vascular Surgery department examined the patient and diagnosed severe calcific aortic valve stenosis with mild aortic regurgitation. The patient also had unstable angina due to distal left circumflex artery disease. The patient also had a history of diabetes mellitus and hypothyroidism.

The patient was evaluated and prepared for surgery. The Senior Cardiothoracic Surgeon at Apollo Hospitals, B.G Road Bengaluru, decided to initially replace the aortic valve of the patient and later perform a coronary angioplasty for the ischemic heart disease. The chest wall was opened by a hemi-sternotomy, and the aortic valve was replaced. The procedure involved a small incision and minimal dissection. Minimally invasive surgery for aortic valve replacement is also known as mini aortic valve replacement. Since the patient had 95% blockage of the left circumflex artery, a coronary angioplasty was also performed on the patient, 2 days after the mini aortic valve replacement.

Minimally Invasive Cardiac Surgery

Traditionally, most surgical procedures on the heart are performed by a median sternotomy. Minimally invasive cardiac surgeries (MICS) provide access to the operating field without the need for a sternotomy. These surgeries require a skilled cardiac surgeon and well- equipped cardiac centers.

MICS was initially used for grafting of left internal mammary artery to left anterior descending artery. Currently, minimally invasive procedures are also performed for valve repair or replacement and closure of septal defects.

Cosgrove and Cohn pioneered aortic valve replacement by minimally invasive cardiac surgery. These procedures require advanced technical expertise and prolonged cardiopulmonary bypass time. The surgeon approaches the heart through a 5 cm incision with minimal dissection and preservation of sternal integrity. Standard approaches include upper hemi-sternotomy, right anterior thoracotomy, and parasternal and infra-axillary incisions.

The surgery causes minimal bleeding and better lung function. The main advantage of MICS is the absence of permanent instability of sternum and less postoperative wound infections. Other benefits of the surgery include smaller incisions, the lesser requirement of blood transfusions, minimal pain, early postoperative extubation and faster mobilization and rehabilitation compared to traditional open heart surgery.

Minimally invasive aortic valve replacement is preferred in elderly, re-operative surgery, and in patients with poor lung function, pulmonary hypertension, renal dysfunction and poor left-ventricular function. Most patients today are aware of minimally invasive procedures and prefer the option of heart surgery with intact sternum. Moreover, they are better satisfied due to the lower cost and shorter hospital stay.

Worldwide Scenario

Studies in western countries have shown that patients undergoing MICS have shorter hospital stays and faster recovery rates. Minimally invasive procedures are widely used for aortic and mitral valve replacement. Most cardiac centers prefer MICS to traditional open heart surgery.

Expertise at Apollo Hospitals

Expertise at Apollo Hospitals can be proven by the low rates of hemorrhages and revision thoracotomies following the surgery. A collaborative team of cardiothoracic surgeons and interventional cardiologists ensure that the procedure is performed with proficiency. The Cardiothoracic and Vascular Surgery departments of Apollo Hospitals are well equipped with facilities required for MICS.

The Outcome of the Current Patient

The patient had a severe form of aortic valve disease along with coronary artery stenosis. Surgical management was the ideal option due to the younger age of the patient. This patient recovered quickly due to the minimally invasive surgery performed at Apollo Hospital. He was discharged within two days after the second surgery. On follow up, there were no complications and the patient had complete relief from breathlessness.