Minimally Invasive Heart Valve Surgery Decreases Recovery Time
R. Eric Lilly, MDMedical College of Wisconsin Cardiothoracic Surgeon
Heart surgery traditionally has been an invasive procedure: to access the heart, doctors cut the breastbone and opened the chest. Minimally invasive heart valve surgery is just that: minimally invasive. Instead of splitting open the chest, doctors work through two small incisions. R. Eric Lilly, MD, describes the many advantages of minimally invasive heart valve surgery.
Q. What is minimally invasive heart surgery?Minimally invasive heart surgery is the same as conventional surgery but performed through smaller incisions. What’s done inside of the heart with the minimally invasive option is the same as it would be with conventional heart surgery. Typically the surgery doesn’t involve cutting the sternum. It’s been found that cutting the sternum negatively impacts people. It affects their ability to get back into their normal activities. If you can leave the sternum intact, you can help them get better sooner.
With minimally invasive heart valve surgery, there is a five- to seven-centimeter incision made underneath the right breast, in the contour of the breast. There is also a second, approximately two-and-a-half- to three-centimeter incision in the right groin. We can do a lot of things through that combination of small incisions.
Q. What medical indications is it appropriate for?Minimally invasive surgery is appropriate for all problems associated with the mitral valve or tumors that can exist within the heart, such as atrial myxomas. It’s also appropriate for closure of atrial-septal defects or patent foramen ovale, closures of holes within the atrial-septum. And through a similar incision, we can also do aortic valve surgery.
Q. What are the outcomes?If you look at mitral valve repairs, minimally invasive procedures offer exactly the same results, and there is data in the literature to support that. The good news is that people tend to go to work sooner and if they are athletic, they tend to get back to their sport of choice sooner. It makes a difference in terms of quality of life in the short-term, because the sternum remains intact. It also erases the risk of sternal wound infections. There’s a defined incidence of infection of the sternum when you open it up that doesn’t exist when you go through smaller incisions in the chest. So there are defined benefits. Minimally invasive surgery is certainly a little more difficult, and it adds a little more time in the operating room. But the outcomes for patients are exactly the same in terms of survival and quality of the operation.
Q. What are the risks and recovery times versus more traditional surgery?The risks are associated with inserting a cannula – a small tube – into the vessels in the groin. Certainly, it can be done safely with modern cannulae, and we use echo guidance to minimize the risk. Risks include perforation or injury to the groin vessels, possibly causing long-term complications with the leg.
People who have a lot of athlerosclerotic disease, or plaque, in their aorta really aren’t candidates for this kind of an approach, because as you’re cannulating the vessel in the groin, patients are on the heart-lung machine. You don’t want to blow debris that might be there back into the brain and cause problems like stroke or organ dysfunction.
In terms of recovery time, the hospital stay is about the same. Patients are in the hospital three to seven days after this operation. But the data in the literature reports people tend to get back to work or their usual physical activities 15 to 20 days before they would with another type of procedure. So, there is a defined improvement in terms of quality of life. They can jog and do some resistance training, which we wouldn’t want them to do if the sternum was fractured.
A real advantage that shouldn’t be overlooked is the cosmetic advantage. We can usually keep chest incisions so low that women, for example, could wear a lower cut top, but with this technique, they could wear a bikini and no one knows they’ve had a heart operation.
Q. When is this a viable alternative?This is a good alternative for anybody who has isolated aortic or mitral valve disease, tumors within the heart or an atrial-septal defect or patent foramen ovale and who does not want a big sternal incision.
Q. Am I a candidate?Almost everybody who has isolated valve problems is a candidate, particularly young women with isolated mitral disease. Younger people who haven’t athlerosclerotic disease are certainly candidates. Patients who have a lot of plaque in the descending aorta or in the vessels in the groin are not candidates.
Just a couple of screening tests will tell us whether that’s the case or not. If a patient comes to me and wants this operation, we’ll get a CT scan without contrast to make sure the vessels all look good.
Source: Every Day, Interview with R. Eric Lilly, MD
Date: Aug - Dec 2006