Mini Thoracotomy v. Mini Sternotomy

[jpattillo]

This is the biggest choice I will have to make. Each surgeon suggests the approach he prefers. Both are sufficiently experienced in the incision they recommend. One is at a teaching hospital. The other is at a not-for-profit. Any thoughts, input, and experience would be great. I'm a 38 year old male with 3 kids (6, 4, and 2) and a wonderful wife who has a very tough time with all this because of a medical phobia that goes back to childhood.

 

[jpattillo]

PS this is for an aortic valve replacement most likely with the on-x valve.

 

[ElectLive]

Unfortunately, any given procedure type isn't necessarily better or worse globally, it just all depends on the experience, skill, and even judgment, of the individual surgeon. In fact, many leading surgeons, such as mine, still prefer a full sternotomy, even after experience performing minimally invasive procedures. His reasoning was that the advantages of minimally invasive (such as reduction in blood loss, trauma, infection, and length of hospital stay) were still not a fair trade off, in his eyes, for some of the potential compromises to the operation itself. For instance, he mentioned that national data have actually shown double the surgical stroke rate. Now, on the other hand, for isolated AVR, a mini sternotomy is pretty much standard at places like the Cleveland Clinic. I don't know, but I would assume, that they may have their own data refuting my surgeon's argument, given the high level of experience and skill of their surgeons, which is certainly known to be well above the national average.

Anyway, I'm sorry I'm not answering your question more directly, but I would just recommend, if you haven't already done so, that you ask both surgeons to be absolutely specific (including rates of all possible complications) about the pros and cons of their approach in comparison to not only the other, but also to a full sternotomy. They obviously wouldn't be doing it without very good reason, and maybe hearing their full reasoning and clinical evaluation will help you better decide.

If you're still not sure, I guess maybe one way to look at would be this: which surgeon do you otherwise have the most confidence in? When it gets down to it, there are probably lots of much more minor surgical details that we never bother considering, but which individual surgeons do somewhat differently. At least in my view, I think choosing a surgeon inevitably involves trusting them to make the right decisions, those we are aware of and those we are not.

Medical phobia or not, in many ways this is all toughest for our spouses. I was 35 at the time of surgery, and have young children as well, so let me reassure you that once you're in recovery, smiling and laughing, everyone is going to be just fine. Kids probably help more than anything keeping everyone's spirits up through it all. Best wishes.

 

[TheGymGuy]

I second EL, pick the surgeon you have the most faith/trust in. To give you my own perspective, I chose the surgeon that could do both, mini and full-sternotomy. He told me he can do mini, but would prefer to do full for ease of access to things. In all honesty, my thinking is as follows, if the surgeon has more access to things and it is easier for them, in the end you benefit more. For younger people, most who are under 60, recovery from full-sternotomy is pretty routine. I think mini- versions are for older folks where there are lots of co-mortalities and co-morbidities and where minimizing bleeding and trauma is very important and prudent for their post-surgical recovery and survival.

It is probably very very very freaking scarry right now. I know, I was there just 2-month back. Things are all going to work out. Read up on these procedures here, read people's recovery stories. Your biggest worry should not be coming out alive from this 6 hour procedure where only 2 hours is the surgery itself, you will come out just fine, you should concentrate on making the plan for recovery, arranging things for the wife and kids so that they and you can get some help once you are home recovering. I'd say first month your house will have your wife, 3 kids, and 1 older kid that needs lots of help with lots of things

We are here for you for any and all questions you have. Also, me and RTZDad have some books we can share so long as you share them with the next person too

PS SInce you have BAV, also try to find out before hand if your aorta or aortic root need any work. Cardiac MRI or CT Scan can confirm these. It would be better to get it all done together VS waiting for x years and doing it again.

 

[Mom2izzy]

I agree with others that I would pick the surgeon and facility you feel most comfortable with, and let them use the approach they are most comfortable with, but for what it's worth, here's my story...

My surgeon gave me either option, and I chose mini-sternotomy over the mini-thoracotomy. FOR ME, I felt this was the best choice because I was told that the thoracotomy was more painful because they cut through muscle which moves with every breath. I have never been able to tolerate pain meds well, so I chose the sternotomy. Most normal movements do not put stress on the sternal area, so it is supposed to be less painful. To me the only advantage to the thoracotomy was a hidden scar, but that wasn't enough to change my mind (even as a woman who has too many v-neck shirts ).

I can tell you that in my experience with the mini sternotomy (which in my opinion doesn't seem very mini...6 inches), I did not have much sternum pain...actually, I never took any pain meds stronger than Extra strength Tylenol and/or Ibuprofen after leaving the ICU on day 4 (longer than normal ICU stay was due to no beds on the regular floor). My back and shoulders were a different story...they caused me more pain than anything else. I'm not sure if the thoracotomy causes the same type of back issues as the rib spreading they do with the sternotomy. At 8 weeks post surgery, I still have discomfort in my back (behind my shoulder blade)...Nothing bad enough to require frequent pain meds...I occasionally take 400mg ibuprofen, buy usually a good walk or a good massage loosens it up.

 

[dwhist]

I went into surgery with the doctor saying he felt he could do a mini stenotomy. When I woke up he said when they got in they found the heart was larger than they thought and he ended up doing a full. He felt it was safer and I felt since he was doing it, I trusted him to do right thing. He said the difference would not be apparent after 3 months. I assume he meant in recovery. At 6 months I have not had any problems with the healing process of the sternam.

So, I am on the side of picking the one you like and trust the most and going their preferred route.

 

[jpattillo]

All great thoughts! Thanks everyone. The mini-stern doc is at a teaching hospital (UAB - McGiffin). The mini -thor guy is Clifton Lewis at St. Vincent's in Birmingham. See www.drcliftonlewis.com. I'm leaning towards Lewis but I have not met with him yet.

 

[jpattillo]

I'm also leaning towards an On-x valve. Can't wait for the results of the PROACT trial! I'm a runner/marathoner and I do have a question about reduced valve opening size for mechanicals v tissue. Of course we may discuss repair too.

 

[ElectLive]

Replacement valve options are of varying designs, with varying effective openings, so definitely a good idea to bring to the attention and discuss with the surgeons. There are good options for both mechanical and tissue. Of course, what "fits" you will be somewhat of a limiting factor, but if you've had a CT or MRI, a surgeon should be able to give you a good estimate of what size valve it will be. Any replacement valve will be smaller to a degree than the valve you were born with, but more often than not, this is not a big issue. For those with smaller valves (19 or 21 mm), though, it can be a concern.

I can certainly understand the hope for PROACT results, but it's going to be at least a few years before final results are in (data collection originally scheduled to complete in March of 2015) for the reduced INR group, and likely even longer for the low-risk non-Coumadin group since it's still recruiting. By the way, if you're not aware, the trial center and study Director (Dr. John Puskas) is here in Atlanta, at Emory.

 

[Lauratx22]

Hi! I had the min thorac when my daughter was 19 months. I chose the mini thorac because of the healing time...I could pick her up 3 weeks post op. I am a stay at home mom and couldn't chance if anything happening at home and hurting my incision if she really needed to be picked up. Best of luck to you

 

[jpattillo]

ElectLive, thanks! I was aware of the 2015 date. I was not aware that they are still recruiting for the non-coumadin group. What are the guidelines for participation?

 

[Luana]

With any smaller-incision surgery, the consent form will state that if needed, a sternotomy will be done.

 

[ElectLive]

Here's all the pertinent info, including inclusion and exclusion criteria, for the PROACT trial: http://clinicaltrials.gov/ct2/show/NCT00291525?term=proact&rank=7.

Let me just say, though, that I mentioned the Emory connection not to encourage participation in the trial, but just so you were aware that there is a good PROACT resource (not just an On-X rep but the surgeon lead investigator) somewhat nearby in case you were in any way basing your valve decision on this and wanted to learn a lot more of the specifics to your unique valve situation and risk profile.

In any case, should you ever have any specific interest, I think there is a member here who volunteered for the study arm still recruiting, but may have actually ended up getting randomized to the control group instead. I wish I could remember more of the specifics, such as the member's name...but cannot. You might be able to find with a search on PROACT here as well.

I only got a snapshot overview of PROACT when meeting with my own surgeon at Emory. I wasn't interested in participating, and then ended up getting a tissue valve anyway.

 

[DebbyA]

My surgeon offered those two choices, so I wasn't choosing a surgeon as well as incision, but I asked my cardiologist her opinion, reasoning that she sees an individual patient over a longer period after surgery and might have gotten some feedback. What really happened is that she talked to the surgeon, and told me there was greater possibility of nerve and muscle involvement with the thoracotomy. The most important healing is in your heart--don't let 'mini-' terminology lead you into minimizing the surgery...

 

[jpattillo]

Debby, you framed the issue really well. The issue for me is whether the mini-thoracotomy produces the same statistical outcomes as the mini-sternotomy or the full sternotomy. The thoracotomy is more painful but faster recover by all accounts. The medical literature I've found seems to support similar rates of complication and reoperation. But I'm still going with my gut if it tells me to not do it.

 

[Boston Tiger]

My surgeon told me that he preferred the mini-stern, since that could most easily be converted to a full blown stern if the situation required it. This was at a teaching hospital that offered three types of minimally invasive procedures, but the surgeon said that recovery from any time of OHS was tough.

 

[Bill B]

From many reports, it seems the minis are often just as painful post-op as the full. For what it is worth, I never had an ounce of pain after my full sternotomy. In my case, with my aortic arch work, a mini was not a good option. Even the Cleveland Clinic agrees with that (they said it could be done, but results have been better with a full sternotomy). And sometimes it is not clear pre-op whether the arch is diseased enough in BAV to require repair or the extent of the repair required.

 

[jpattillo]

Bill, I think you are right. and the mini-thoracotomy is sometimes more painful than the mini-sternotomy. However, the recovery is quicker. But my main reason for choosing the mini-thoracotomy is to reduce the risk of bleeding, transfusion and infection. The smaller incision gives you that. Plus, if I ever have to have a sternotomy, it's much easier to have one the first time than the second. There is a small chance I'd have to have a root replacement someday. If I do, that surgeon will get the first "criack" at my chest and not the second (pun intended).