Minimally Invasive Valve Surgery and Single Vessel Coronary Artery Bypass via Limited Anterior Right Thoracotomy

Masood A Shariff; Laura Klingbeil; Daniel Martingano; Robert F Carlucci; Rami Michael; Jonathan Davila; Scott M Sadel; John P Nabagiez; Joseph T McGinn Jr.

doi:10.1532/hsf.1319

Authors

Masood A Shariff Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York
Laura Klingbeil Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York
Daniel Martingano NYU Lutheran Medical Center, Brooklyn, New York, New York
Robert F Carlucci Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York
Rami Michael Department of Surgery, Greenville Hospital System, Greenville, South Carolina
Jonathan Davila Staten Island University Hospital Downstate Medical Center, Brooklyn, New York
Scott M Sadel Department of Cardiac Anesthesiology, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York
John P Nabagiez Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York
Joseph T McGinn Jr. Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York

DOI:

https://doi.org/10.1532/hsf.1319

Abstract

Background: Coronary artery bypass grafting with aortic valve replacement (AVR) or mitral valve replacement (MVR) is traditionally performed via sternotomy. Minimally invasive coronary surgery (MICS) and minimally invasive valve surgery have been successfully performed independently. Patients with critical right coronary artery (RCA) stenosis not amenable to percutaneous intervention are candidates for valve replacement and single vessel coronary artery bypass. We present our series of six patients who underwent a concomitant valve and single vessel intervention via right thoracotomy.
Methods: Between January 2011 and June 2013, six patients underwent right thoracotomy with valve replacement and single vessel bypass. Four aortic and two mitral valves were replaced and all received single vessel RCA bypass using reversed saphenous vein graft. Thoracotomy was via right anterior approach for AVR and right lateral for MVR. The patients were assessed postoperatively for overall outcomes.
Results: The average age was 74 years (range 69-81); two patients were elective (AVR-1; MVR-1) and four were urgent (AVR-3; MVR-1). For MICS AVR and MICS MVR, the average cardiopulmonary bypass time was 171 ± 30 and 169 ± 7 minutes and the average aortic cross-clamp time was 122 ± 36 and 112 ± 2 minutes, respectively. Three patients were discharged home, one patient to a nursing home, and two to rehab. No patients required conversion to sternotomy; one patient developed atrial fibrillation, and one sepsis.
Conclusion: Concomitant valve replacement and single bypass grafting via right anterior mini-thoracotomy is a viable option for select patients, particularly in non-stentable RCA stenosis. In the appropriate patient population, combined coronary artery bypass grafting and valve surgery can be safely performed via right thoracotomy.

Author Biographies

Masood A Shariff, Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York

Research Fellow

Robert F Carlucci, Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York

Cardiothoracic Surgery,

Chief Physician Assistant

Rami Michael, Department of Surgery, Greenville Hospital System, Greenville, South Carolina

Department of Surgery

Joseph T McGinn Jr., Department of Cardiothoracic Surgery, Staten Island University Hospital, North Shore-LIJ Medical Center, Staten Island, New York

Department of Cardiothoracic Surgery and General Surgery,

Chairman Dept. of SurgeryDirector of Cardiothoracic Surgery

References

Bouma W, Wijdh-den Hamer IJ, Klinkenberg TJ, et al. 2013. Mitral valve repair for post-myocardial infarction papillary muscle rupture. Eur J Cardiothorac Surg 44:1063-9.

Brinster DR, Byrne M, Rogers CD, et al. 2006. Effectiveness of same day percutaneous coronary intervention followed by minimally invasive aortic valve replacement for aortic stenosis and moderate coronary disease (“hybrid approach”). Am J Cardiol 98:1501-3.

George I, Nazif TM, Kalesan B, et al. 2015. Feasibility and early safety of single-stage hybrid coronary intervention and valvular cardiac surgery. Ann Thorac Surg doi: 10.1016/j.athoracsur.2015.01.028. [Epub ahead of print].

Grossi EA, Galloway AC, Ribakove GH, et al. 1999. Minimally invasive port access surgery reduces operative morbidity for valve replacement in the elderly. Heart Surg Forum 2:212-15.

Ilia R, Cafri C, Wolak A, Weinstein JM. 2013. Isolated nondominant right coronary stenosis: clinical presentation and management. Angiology 64:512-4.

Kay PH, Nunley DL, Grunkemeier GL, Pinson CW, Starr A. 1985. Late results of combined mitral valve replacement and coronary bypass surgery. J Am Coll Cardiol 5:29-33.

Kieser TM, Curran HJ, Rose MS, Norris CM, Graham MM. 2014. Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts. J Thorac Cardiovasc Surg 147:75-83.

Kumpuris AG, Quinones MA, Kuaon D, Miller RR. 1980. Isolated stenosis of left anterior descending or right coronary artery; relation between site of stenosis and ventricular dysfunction and therapeutic implications. Am J Cardiol 46:13.

Lamelas J, Sarria A, Santana O, Pineda AM, Lamas GA. 2011. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg 91:79-84.

Mihos CG, Santana O, Pineda AM, La Pietra A, Lamelas J. 2014. Aortic valve replacement and concomitant right coronary artery bypass grafting performed via a right minithoracotomy approach. Innovations (Phila). 9:302-5.

Onnasch JF, Schneider F, Falk V, Walther T, Gummert J, Mohr FW. 2002. Minimally invasive approach for redo mitral valve surgery: a true benefit for the patient. J Card Surg 17:14-19.

Pineda AM, Santana O, Reyna J, Sarria A, Lamas GA, Lamelas J. 2013. Outcomes of reoperative aortic valve replacement via right mini-thoracotomy versus median sternotomy. J Heart Valve Dis 22:50-5.

Santana O, Funk M, Zamora C, Escolar E, Lamas GA, Lamelas J. 2012. Staged percutaneous coronary intervention and minimally invasive valve surgery: results of a hybrid approach to concomitant coronary and valvular disease. J Thorac Cardiovasc Surg 144:634-9.

Santana O, Pineda AM, Cortes-Bergoderi M, et al. 2014. Hybrid approach of percutaneous coronary intervention followed by minimally invasive valve operations. Ann Thorac Surg 97:2049-55.

Schaff HV, Dearani JA, Daly RC, Orszulak TA, Danielson GK. 2000. Cox-Maze procedure for atrial fibrillation: Mayo Clinic experience. Semin Thorac Cardiovasc Surg 12:30-7.

Seeburger J, Borger MA, Falk V, et al. 2009. Minimally invasive mitral valve surgery after previous sternotomy: experience in 181 patients. Ann Thorac Surg 87:709-14.

Serruys PW, Onuma Y, Garg S, et al. 2010. 5-year clinical outcomes of the ARTS II (Arterial Revascularization Therapies Study II) of the sirolimus-eluting stent in the treatment of patients with multivessel de novo coronary artery lesions. J Am Coll Cardiol 55:1093-101.

Sharony R, Grossi EA, Saunders PC, et al. 2006. Minimally invasive reoperative isolated valve surgery: early and mid-term results. J Card Surg 21:240-4.

Smit PJ, Shariff MA, Nabagiez JP, Khan MA, Sadel SM, McGinn JT Jr. 2013. Experience with a minimally invasive approach to combined valve surgery and coronary artery bypass grafting through bilateral thoracotomies. Heart Surg Forum 16:E125-31.

Srivastava SP, Patel KN, Skantharaja R, Barrera R, Nanayakkara D, Srivastava V. 2003. Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB): the first 200 cases. Ann Thorac Surg 76:46-9.

Stefanovski D, Walfisch A, Kedev S, Tager S. 2012. Isolated right coronary lesion and anterolateral papillary muscle rupture – case report and review of literature. J Cardiothorac Surg 7:75.

Tabata M, Umakanthan R, Cohn LH, et al. 2008. Early and late outcomes of 1000 minimally invasive aortic valve operations. Eur J Cardiothorac Surg 33:537-41.

Thourani VH, Weintraub WS, Craver JM, et al. 2000. Influence of concomitant CABG and urgent/emergent status on mitral valve replacement surgery. Ann Thorac Surg 70:778-84.

van der Bolt CL, Vermeersch PH, Plokker HW. 1996. Isolated acute occlusion of a large right ventricular branch of the right coronary artery following coronary balloon angioplasty: the only true model to study ECG changes in acute, isolated right ventricular infarction. European Heart J 17:247-50.