Less invasive intracardiac surgery performed without aortic clamping

Background. Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures through a right minithoracotomy. Recent publications have shown excellent patient outcomes after mitral valve (MV) procedures undertaken through thoracotomy on the fibrillating heart. We reviewed our experience with this approach. Methods. From March 2000 to September 2006, 100 patients underwent MV repair (n=42), MV annuloplasty (n=28), MV replacement (n=18), atrial septal defect closure (n=10), tricuspid valve repair (n=1), and left atrial myxoma excision (n=1). A modified maze procedure (n=4) or left minimally invasive direct coronary bypass grafting (MIDCABG) (n=2) was combined in six cases. The mean age was 57 +/- 11 years (range, 22 to 89); 27 patients were in New York Heart Association (NYHA) class III or IV; 24 cases were first or second time reoperations; 20 patients had a left ventricular ejection fraction of less than 0.3. All the operations were carried out on the fibrillating heart without crossclamping the aorta through a right minithoracotomy using peripheral cannulation. Results. Mean fibrillation time was 73 +/- 31 minutes (range, 10 to 198 minutes). There was no conversion to sternotomy. Postoperative inotropic support was needed in 20 cases. One patient who underwent a third time reoperation died within 30 days of mesenteric ischemia (hospital mortality = 1%). Complications were the following: four reoperations for bleeding (4%); two strokes (2%). Postoperative median hospital length of stay was five days (range, 2 to 58 days). None of the patients has required MV reoperation after hospital discharge. Follow-up was complete. All survivors were in NYHA class I or II. Conclusions. Ventricular fibrillation simplifies less invasive intracardiac procedures and carries lower complication rates and perioperative mortality compared with conventional surgery.