Outcome of reoperative valve surgery via right thoracotomy

The rate of patients being referred for mitral or tricuspid valve surgery after previous cardiac surgery is expected to increase. Reoperative median sternotomy has known risks, including injury to or embolism from prior grafts, sternal dehiscence, phrenic nerve injury, excessive hemorrhage, and inadvertent cardiac injury leading to morbidity and mortality.

To avoid these problems, the right thoracotomy approach for reoperative mitral or tricuspid valve surgery was used in 62 patients from January 1990 to September 1995. Average patient age was 66 +/- 12 years. Previous operations included: coronary artery bypass graft, 31; mitral valve surgery, 26 (repair, 12, replacement, 14); and aortic valve surgery, 10. Patients were cannulated via the ascending aorta or common femoral artery with bicaval venous drainage. Systemic cooling and fibrillatory arrest were used. Operations performed included mitral valve repair in 27 patients; mitral valve replacement in 18; prosthetic mitral valve replacement in 14; repair of prosthetic mitral valve leak in 2; and tricuspid valve repair in 5. There was 1 intraoperative death and 4 other hospital deaths; 30-day hospital mortality was 6.4%. Complications were uncommon; only 1 patient required reexploration for bleeding. There have been 4 late deaths, and at a mean follow-up of 27 months (range, 1 to 69 months), survivors are in New York Heart Association class I or II.

Right thoracotomy is a safe, feasible alternative to median sternotomy for selected reoperative mitral valve patients and should be considered whenever repeat sternotomy could prove hazardous.