Marc Gillinov MD

Staff Cardiothoracic Surgery

The Cleveland Clinic Foundation Cleveland, Ohio

Thousands of people benefit from heart valve repair or replacement every year. Heart valves require surgical correction when they become narrowed (stenotic) or when they begin to leak (become regurgitant). Although there are four heart valves, surgery is most often necessary for diseases of the mitral valve and the aortic valve. When these two valves become severely dysfunctional and cause symptoms, valve repair or replacement is indicated; there are no effective nonsurgical treatments.

Traditionally, during heart valve surgery with the heart-lung machine, the heart was approached through a long incision down the middle of the chest. The breastbone, or sternum, was split in two, allowing access to the entire heart and the great vessels. This incision is called a median sternotomy. Recently, however, it has become apparent that heart valve surgery can be accomplished through a far smaller incision.

When a patient needs valvular heart surgery and does not require a coronary artery bypass graft, a variety of smaller incisions allow the mitral and aortic valves to be seen. These incisions generally fall into two categories: thoracotomy, or an incision in the side of the chest between the ribs, and partial sternotomy, or an incision in the middle of the chest that divides only a portion of the sternum. Using these smaller incisions to accomplish heart valve surgery is called minimally invasive heart valve surgery. At the Cleveland Clinic Foundation, heart valve surgery is performed through a 2.5-inch to 3.5-inch skin incision and a partial upper sternotomy. A large portion of the sternum is left intact, decreasing postoperative pain and hastening healing.

Since 1996, we have performed more than one thousand heart valve operations using this incision. The average patient age was fifty-six years, and the oldest patient was eighty-four years old. More than six hundred patients had mitral valve surgery, and nearly 90 percent of these patients had mitral valve repair. Three hundred patients had aortic valve procedures, including valve replacements with a variety of artificial valves and a considerable number of aortic valve repairs.

Overall, operative mortality was less than 1 percent, and wound infections occurred in only 0.3 percent of patients.

The average length of stay in intensive care was one day, and the average hospital stay was six days.

These results demonstrate that minimally invasive heart valve surgery can be performed very safely with a low risk of complications. There are many advantages to minimally invasive heart valve surgery. There is less blood loss, and patients generally report less postoperative discomfort.

Less time is spent in the intensive care unit and in the hospital, and recovery at home tends to be rapid.

The next decade is likely to bring even more ingenious approaches, including robotically assisted cardiac valve surgery. These advances promise refinements to minimally invasive heart valve surgery, further reducing hospital stays and increasing patient satisfaction.

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