MI – DVR(Minimally Invasive Double valve Repair)

Rajendra Vasaiya, Mch, Vihar Shah-MD(anesthesiologist)
Sunil vyas,M.Sc,PGDPT (perfusion technologist)

BACKGROUND: Minimally invasive double valve surgery is relatively lesser known in this part of the globe.. Here we are reporting a case of double valve surgery using minimally invasive approach.


METHODS: A 31yrs old female with post CMV(12yrs back), post MTP(22-days back) status with Hb%=7.3gm was admitted for DVR Gradient across aortic valve=55mm Hg with grade II -AR and MVA=0.8 cm. She had past H/O MTP twice due to her cardiac condition. . A 4 inch size skin incision is made. Sternum is cut with oscillating saw up to the 3rd ICS. Adhesion due to previous surgery were removed, adhesion from Aorta,,PA,&RA are also removed very carefully. Cannulation was carried .through femoral artery and two stage venous cannula in to RA Venous cannula was delivered out from the future drains tube site just below xyphoid. 1st cardioplegia was delivered antigrade in to the aortic root, rest were delivered directly in to the ostea . .Fusion between RCC & NCC up to the mid point was released, partial fusion between RCC & LCC also released. Annulus found to be dilated which was tackle later on after mitral valve correction. Mitral valve was approach through aortic aortic opening, LA was also incise. Complete MV was not seen even through this incision due to previous CMV. Through aortic opening and LA MV and its subvalver apparatus were inspected and decided to go for MV commisurotomy and release of chordal and papillary fusion.Valve is check for any leakage . Now aortic annular dilatation is dealt with reduction annuloplasty using 4-0 teflon pledgated prolien suture.t.
Immediate and late post operative period was smooth and uneventful. Ventilator was removed 3hrs after surgery.On day one blood loss was 120ML.Two units of blood was required post operatively.PCM was given as pain killer.Pnt was shifted to the ward on2nd POD ,and was discharged on 4th POD

REASULT: DVR can be carried out without much of the difficulty using minimally invasive approach. .In this particular patient post operative blood loss was significantly low. Requirement of post operative analgesia is also less. It gives patient a sense of INTACT CHEST.

CONCLUSION: Minimally invasive double valve surgery can be carried out without much difficulty with numerous advantages.

JOURNEY THROUGH MIDCAB (1997 to 2009)
TYRO TO VIRTUOSO (STUDY OF 159 MIDCAB)

BACKGROUND: - MIDCAB CABG in triple vessel disease is remained dream to many Cardiac surgeons. Difficulties and short comes exist. How to overcome and accomplish a complete and satisfactory revascularization is the most important goal of a Bypass surgery. Technical difficulties and its solution are described.

METHOD: - Since 1997, we started sternal sparing MIDCAB CABG. Till 2009 we have done 159 patients.70 patients were operated for SVD (58 CABG, 12 redo CADG), 32 cases for DVD (29 CABG, 3 redo CABG), 57 cases of TVD (55 CABG, 2 redo CABG). For initial two yrs. it was limited to SVD, mostly CTO of LAD. 1st case of redo CABG was carried out in 1999. Gradually field was expanded to DVD and since last 4 yrs. TVD cases are also incorporated. It also includes 10 cases of endarterectomy. One case with CMV and CABG. Patients’ age range between 32 – 92 yrs. LVEF = 25% (10 – 55%), 3 patients with EF of 10% were offered CABG with stem cells implantation. As much as 4 vessels were grafted. Patients overweight have no contra indication. Additional plural adhesion is also not a contra indication. Among TVD 20% had varying degree of left main disease (50 – 96%). 1 patient weighing 114 kg was also operated.

RESULT: - There was 1 mortality in a redo CABG group. The patient died on 6th POD due to VTVF. One case of TVD shows ST- elevation for 24 hrs, post operatively which subsided later on (peri operative MI). 1 patient required re-exploration due to bleeding from mammary bed. Average requirement of BT was 1.5 bottles per patient. Transfusion requirement usually depends upon pre operative HB level. Average hospital stay was 4 days (36 hrs to 6th POD). No major wound complication is seen. Average incision size is 3.5 inches (2.5- 4.2 in.). Conversion to mid sternotomy was required in 1 patient.

CONCLUSION: - Sternal sparing MIDCAB can be carried out in all but cardiogenic shock group of patients. We found it is particularly advantageous to old debilitating patient more so with farer sex group of patient. It can b learnt only by self indulgence. This method is not described anywhere in known literature. It is little time consuming and requires great deal of skill and patience on part of operator.