Minimal-access aortic and valvular operations, including the "J/j" incision

Abstract

Background: We compared five current minimal-access approaches, namely, parasternal incision, transverse sternotomy, manubrial inverted "T" incision, incomplete mediastinotomy, and our "J/j" incision, to operations in matched patients, including aortic operations.

Methods: In a case-control study of 74 patients, 37 individuals consecutively underwent minimal-access operations (aortic valve, 18, including one mitral valve operation; composite valve graft, six, including one arch and one transaortic mitral valve operation for a patient with Marfan's syndrome; ascending aorta operation, two; root repair/reconstruction, three; mitral valve repair/replacement, seven, including one maze operation; and atrioseptal defect repair, one). The patients were matched by sex, age, surgeon, and operation with 37 control patients who had standard incisions. Patients having the "J/j" incision (n=25) had sternotomies from the first right intercostal space, or sternal notch, to the third to fifth right intercostal space.

Results: Minimal-access patients had a shorter postoperative hospital stay than standard incision patients (6.2 versus 8.2 days; p=0.0055), and required similar volumes of blood (0.86 versus 1.03 units; p=0.7243), postoperative morphine dosages (28 mg versus 40 mg, p=0.0643), and oral narcotics (8.1 versus 10.0 doses; p=0.3562). "J/j" incision patients, however, required less morphine (20.6 mg versus 40.9 mg; p=0.0028), but not fewer doses of oral narcotics (7.5 versus 9.9 doses; p=0.2640) and had the shortest postoperative stay (5.1 versus 8.1 days; p < 0.0001). No stroke or clinically noted neurocognitive deficit developed. One minimal-access patient (1/37, 2.7%) with severe preoperative pulmonary morbidity died of adult respiratory distress syndrome. Sternal nonunion developed in 1 patient with an inverted "T" manubrial incision. In a further seven patients, the "J/j" incision was used without a problem, for a total of 32 patients. This compared with a consecutive series of 125 aortic valve replacement operations without a death and 181 patients undergoing ascending arch operations with two 30-day hospital deaths (1.1%) and two strokes (1.1%).

Conclusions: Minimal-access incisions are associated with shorter hospital stays. For the "J/j" incision, even if used for more extensive double-valve, ascending aortic arch, or composite valve operations, postoperative pain appears to be less and patients are discharged even earlier.