? re portal access procedure

[RANDYJEAN]

Hi, everyone...I'm new here. First, I want to thank everyone for the wealth of info that's been collected on this site. It's been very helpful to me. Now, I have a question for anyone who's had portal access surgery to replace a valve.

I'm a 56-year old female, diagnosed in October with severe aortic stenosis. Luckily, I'm not suffering any symptoms--the only reason I got checked at all was because of my family's history with heart disease. Mom died at 41, brother had bypass surgery at 38 and died at 61, niece had a heart attack at 32 and got three stents, and in August my nephew (while suffering NO SYMPTOMS) discovered he had SEVEN blocked arteries. Well, it turns out (yay!) my arteries are totally clear but that little heart murmur I've always had...well, you know the drill. Time for replacement.

In June, my 87-yr old father was diagnosed with multiple myeloma and began radiation treatments for tumors on his spine. Six days later, my brother died. This leaves me as the person responsible for looking after my dad's health and financial affairs plus running the family business alone now that my brother's gone.

When I learned I was facing heart surgery, I started doing research to see if there was ANY alternative to the traditional...and this is why I became so interested in the "less invasive" portal access (through the rib) procedure. Long story short, talked my insurance company into letting me see a surgeon who performs the procedure...but here's my problem: he'll DO it, but he kinda tried to talk me out of it. As have lots of friends.

I "GET" the argument: why not give your surgeon the best playing field possible? Make his job as easy as possible?

So my question is: to those of you who opted for this procedure, how did you justify it to yourself? I keep asking myself whether I should do the "smart" thing and go traditional. Am I taking a "gamble" by going for the alternative procedure?

Is it true that the post-op experience is shorter?? Is it true that the intubation time is shorter?

I've never been sick a day in my life. Never been through childbirth; never been in the hospital. The idea of OHS is SO DAUNTING to me; that's why the less invasive freaks me out so much less.

Anyway, I'm curious as to the thought process that led others to making their decision.

Thanks!

Randy

 

[drivetopless]

Nothing to offer, but I'm interested to see if you get any posts on this topic. It sounds like you've had a really tough time with family medical issues. Good luck!

 

[Nancy]

My husband had port access surgery for his third valve surgery to repair a leak around the mitral cuff. He did very well with it. It was his surgeon's first minimally invasive port access surgery, so he had a colleague in there with him. The early recovery was probably better than with regular sternum surgery, but only by a day or so. Long term recovery about the same as regular. He was much more mobile after this surgery. There was pain in the side lung area because they go through that area and there are numerous small incisions. I think pain-wise the recovery is about the same, just in different areas.

The reason the surgeon did this type for Joe's 3rd surgery was to spare him another sternum crack and try to avoid scar tissue problems from old surgeries.

I asked the surgeon whether he had ample room during surgery, and he told me it was fine.

This surgeon now specializes in minimally invasive heart surgeries.

 

[river-wear]

I'll see if I can find the person who posted just a couple of days ago about having her AVR done that way... she said recovery seemed to be quicker than for sternotomy patients. It stuck in my head because I didn't know it was possible.

Does anyone remember the recent post about this?

 

[lb151]

I have had 2 of those surgeries and would have to say,based on my experience,that the recovery time is shorter. My surgeon does this whenever possible. The second was a little more painfull due to scar tissue. I was able to come home alone and take care of myself with no problems. If you want more detail,feel free to contact me.

Lou

 

[ALCapshaw2]

My understanding is that the Mitral Valve may actually be more readily accessable using a Right Thoracotomy (through the ribs on the right side).

Dr. Petracek at Vanderbilt University Hospital in Nashville, TN specializes in Thoracotomy procedures. It might be worth calling his office for a second opinion.

There may be another solution using the conventional Sternotomy.

There was a recent thread about "Kryptonite Glue" which allows the sternum to be glued back together giving much greater rigidity from the 'get-go' that would allow the patient to do more without the severe weight lifting/pushing/pulling limitations that are required after the usual sternotomy. I'm thinking the sternum will still have to heal but at least you would be able to do more for yourself after the first couple of weeks.

Do a Search on VR.com for "Kryptonite" or just "glue" and you should be able to find that thread.

'AL Capshaw'

 

[Marcia58]

Mine was a mitral valve repair, but my surgeon seemed to have no qualms about doing the right port access/mini-thoracotomy approach For the record, I'm 5'3" and small-framed, while the doctor is over 6 feet, with hands in proportion to his height. They told me that they deflate the right lung for the surgery, so I'd assume that give quite a bit more room to work.

My surgery was on a Thursday, and I was out of the hospital the following Tuesday. I had a 15 pound lifting limit on the right side only, for only a couple weeks, and was not allowed to drive as long as I was on the "good stuff" (Tylenol 3, etc).

Hope this info helps, at least a little.

Marcia

 

[Ruth]

Greetings! Welcome to the Forum!

I had a right Thoracotomy, mostly for cosmetic reasons. Both my parents had scars from bypass surgery. Dunno, I was just sensitive about having a full sernotomy scar.

In any event, there was nothing "minimally invasive" about my MVR. I don't want to sound like a wet blanket here but OHS is a major deal no matter which way you cut it (pun intended).

The robotic heart port surgery may be less invasive with a shorter recovery time, there are plenty of good folks here who can chime in with their experiences.

On the positive note, I'm delighted with the cosmetic result (my scar under my right breast is barely noticeable) but the surgery, recovery etc. were every bit as "invasive" as the other approaches. For me, personally, I think the whole concept of "minimally invasive" is a bit of a misnomer. OHS is a big deal, plain and simple.

Surgery is daunting, and it is scary. But, it is also wonderful to live in a time and place where our hearts can be mended.

We all get through it, some hit fewer bumps, some it more. There are tough decisions to be made all around, I wish you well in yours. This forum is a great place to gather information, friends, and support.

Best Wishes,
Ruth

 

[Luana]

Hi, everyone...I'm new here. First, I want to thank everyone for the wealth of info that's been collected on this site. It's been very helpful to me. Now, I have a question for anyone who's had portal access surgery to replace a valve.

I'm a 56-year old female, diagnosed in October with severe aortic stenosis. Luckily, I'm not suffering any symptoms--the only reason I got checked at all was because of my family's history with heart disease. Mom died at 41, brother had bypass surgery at 38 and died at 61, niece had a heart attack at 32 and got three stents, and in August my nephew (while suffering NO SYMPTOMS) discovered he had SEVEN blocked arteries. Well, it turns out (yay!) my arteries are totally clear but that little heart murmur I've always had...well, you know the drill. Time for replacement.

In June, my 87-yr old father was diagnosed with multiple myeloma and began radiation treatments for tumors on his spine. Six days later, my brother died. This leaves me as the person responsible for looking after my dad's health and financial affairs plus running the family business alone now that my brother's gone.

When I learned I was facing heart surgery, I started doing research to see if there was ANY alternative to the traditional...and this is why I became so interested in the "less invasive" portal access (through the rib) procedure. Long story short, talked my insurance company into letting me see a surgeon who performs the procedure...but here's my problem: he'll DO it, but he kinda tried to talk me out of it. As have lots of friends.

I "GET" the argument: why not give your surgeon the best playing field possible? Make his job as easy as possible?

So my question is: to those of you who opted for this procedure, how did you justify it to yourself? I keep asking myself whether I should do the "smart" thing and go traditional. Am I taking a "gamble" by going for the alternative procedure?

Is it true that the post-op experience is shorter?? Is it true that the intubation time is shorter?

I've never been sick a day in my life. Never been through childbirth; never been in the hospital. The idea of OHS is SO DAUNTING to me; that's why the less invasive freaks me out so much less.

Anyway, I'm curious as to the thought process that led others to making their decision.

Thanks!

Randy

Hi Randy,
I had AVR surgery in Nov and had it was a small incision, about 3 inches on the right side of my chest just above the right breast. I'm not sure if this is called portal access or mini thoracotomy. On Adam's Web site he has an illustration of portal access as 3 very tiny incisions on the right side, and 1 a bit larger on the right chest. I had none of these. Scroll down and he has a picture of a man who had a mini thoracotomy, and that's pretty much what my scar looks like. On the consent form I had for the surgery it did say portal access, but my incision is not like others I've seen for that approach. Whatever, it's called, it's a small incision between the ribs. My sternum was not cut.

One of the reasons I put off seeing a doctor for long about my valve was that I had a hard time handling the idea of the sternotomy incision. When I was told I could have my aortic valve replaced without having that huge scar on my chest, it made the whole thing a bit more palatable for me. I know it sounds silly, but what can I say?

I, too, did research online, and didn't find much other than robotic repair for mitral valves. I found out I needed my aortic valve replaced when I had an angiogram done. The surgeon met with me when I was in recovery and said he was quite sure he could do the minimally invasive approach but that I would also need to have a chest CT to confirm that. I did and he said it would be no problem to do.

If your surgeon is trying to talk you out of it, I would see about getting another opinion. Most likely what will happen is on the consent form you sign for your surgery it will say "possible port access" (as mine did), meaning if he thinks a different approach will be better, that's what he'll do.

As for post-op experience, well, I hit a couple of bumps, was in the hospital 7 days after surgery. Had I not gotten atrial fib, I would have been discharged after 5 days.

I was still on the ventilator when I got to CCU and it was removed at 6 pm. Surgery started somewhere around 8 or 9 a.m. Not sure when I got to CCU; remember cardiologist coming in and talking to me around 3:30 (he said the time), but dang if I could get an eye open or even more a hand or finger. I was pretty much awake by about 5. I'm not sure when others are extubated. I know in the "old days" people stayed on the ventilator one or two days after surgery, but I think now they try to get everyone who can be off within a few hours after getting to CCU.

I've never had heart surgery before, so I don't have anything to compare it to. I know some people who had told me the sternum healing was one of the hardest part of recovery. Though I had some incision pain it really was not anything bad at all.

I didn't I need to justify anything to myself with this approach. Surgeon was more than willing to do it and I had trust that he would do fine. I will say now that there are times now that I'll look at my scar and think how on earth did he have enough room to do what he needed to do?

OHS is daunting and I agree with you that a less invasive incision freaked me out a whole bunch less.

I wish you all the best!
Luana

 

[Luana]

Mine was a mitral valve repair, but my surgeon seemed to have no qualms about doing the right port access/mini-thoracotomy approach For the record, I'm 5'3" and small-framed, while the doctor is over 6 feet, with hands in proportion to his height. They told me that they deflate the right lung for the surgery, so I'd assume that give quite a bit more room to work.

My surgery was on a Thursday, and I was out of the hospital the following Tuesday. I had a 15 pound lifting limit on the right side only, for only a couple weeks, and was not allowed to drive as long as I was on the "good stuff" (Tylenol 3, etc).

Hope this info helps, at least a little.

Marcia

Marcia,
Was your mitral valve repair done robotically?
Luana

 

[Mentu]

RJ, greetings. My family experience is somewhat like your own. I wondered frequently about when my Doctor would inform me that I had the same heart disease that my other family members suffered from. I, too, was surprised to find that my heart problem was AVS and that my arteries were fine. One of the things about this whole process is that one learns more about your cardiovascular health than most other people will ever know about their's.

With respect to the type of surgery you select, I see no reason that you must justify one over another. The issue is whether you are a good candidate for the type of surgery you and your surgeon are discussing. You will no doubt have seen in reading other posts in VR that the individual experience varies quite a lot. I had a very straight forwards valve replacement but my surgeon closed my chest with new devices. I had very little discomfort, left the hospital five days later and was able to care for myself at home. It still took about 6-8 weeks before I could drive, begin cardiac rehab and return to work. I would encourage you to plan on giving yourself the time it takes to heal so that your recovery is a good one regardless of the type of procdures used during surgery. Your surgeon may use different methods but they are not short cuts and you will share with the rest of us many of the same issues with respect to recovery.

 

[catwoman]

Randy:

My husband had a thoracotomy for his MV repair; his surgeon (Dr. William Ryan in Dallas TX) had told us that if a repair was not possible, he could still do a replacement through the same incision.
I had a sternotomy for my MVR.
We consulted my surgeon for John's susrgery, who preferred not to do a thoracotomy, but said he could and would if John wanted one. We went with Dr. Ryan because several others here had had that type of incision and I was able to talk to them by phone.

One thing that Dr. Ryan pointed out is that not everyone is suitable for a thoracotomy: definitely not overweight or well-endowed people since the incision is under the breast. I believe he also mentioned diabetics; perhaps that's because they sometimes have more problems with wounds healing. He said he could do the incision with one or two CABG, too, I believe. He also said he could do a port access incision for a MVR reop; I quizzed him about that in particular.

A nurse at Dallas Presbyterian told us that the thoracotomy is more painful. I asked her if she had ever had OHS, and she said no. Pain is subjective, and what's painful to one person isn't to another. John had very little pain. He had his surgery on a Thursday, May 10. He went home Thursday, May 17 (a-fib bought him a couple of extra days in the hospital), and we went out of town Saturday, May 26, to a cat show. (We sent our cat ahead with friends and just took our time getting to the show, which was 2 hours' from our home.) John had lymphedema (from an incision in the groin), so he had to prop up his leg during the day; he took some walks around the small convention center; and we stopped several times en route and returning home. He looked great, and people were very surprised to see him just 2 weeks post-op.

John was extubated within 1 hour of his surgery. They took him straight from the OR to ICU and he had no tube. He was moved to a private room the next morning. (His surgery was mid- to late afternoon.) By contrast, my surgery was at 7 a.m., I was on the ventilator until that night.

John's scar is barely noticeable.

I didn't ask Dr. Ryan about thoracotomy for AVR.

 

[RANDYJEAN]

Wow...thank you so much for all the great insights and best wishes!

At this point, I'm waiting to see if my insurance company will give me authorization to have the procedure performed by the surgeon who said he could/would do the "less invasive." Getting permission isn't a slam dunk...so, I'm kinda thinking if I DO get it, then that's the way I'll go--as if it's kinda "meant." If not, I'll go with the original referral to the first surgeon I saw--the one who only does "traditional."

I totally understand that either way, it's friggin' heart surgery, no? Euw. And, yeah...I agree that "less invasive" is a misnomer.

For me, I guess, it's a psychological thing. Somehow, the smaller incision just seems less scary. Don't get me wrong--I'm fully cognizant of the fact that it's still a major deal, and that I'll need to take my time recovering no matter which procedure I have.

And I'm aware that, according to the statistics, 10% of the time, they end up--for various reasons--doing the sternotomy AFTER beginning the portal access procedure. Geesh, I'd just hate to be in that group that ends up with BOTH incisions. By the way, as I understand it, for AVR, the incision is ABOVE the breast, right?

Anyway, thanks again for the feedback. Y'all have set a lot of my concerns to rest and answered some lingering questions.

Randy

 

[river-wear]

Hi Randyjean,

Looks like the incision would be above the breast for AVR.

http://www.medtronic.com/mics/pdf/VTG1_1.pdf
(page 2)

 

[RANDYJEAN]

Yikes, now I can practically perform the procedure myself.

Actually, though, that site brought up another question. I read on a women's heart site somewhere that the portal access procedure isn't used when the valve is calcified. I chalked it up to being out-of-date because I hadn't seen that elsewhere. Now I see something similar mentioned on the Medtronic site referred to above...where they say a severely calcified ascending aorta would exclude the patient from this type of surgery. I KNOW my valve is calcified; can I assume that my angiogram showed a "clear" ascending aorta? I remember reading in the written report something I took to mean that my "root" was okay.

Also, someone mentioned above that they were given a CT scan to further support their candidacy for the procedure. I haven't been told of a need for that...guess it's a question to add to the list for my surgeon.

Randy

 

[river-wear]

LOL, at least I didn't link to the video they have!

You'll have to ask your surgeon about whether this technique is appropriate in your case. It seems that a calcified valve could present a higher risk and might require more working room; or the restriction for the ascending aorta is because they'd replace not only the valve but the surrounding tissue.

My doctor only mentioned the need for a catheterization (angiogram) prior to surgery, which seems to be standard procedure with other folks here. The CT scan appears to be a bit more unusual.

Good luck!

 

[Luana]

Yikes, now I can practically perform the procedure myself.

Actually, though, that site brought up another question. I read on a women's heart site somewhere that the portal access procedure isn't used when the valve is calcified. I chalked it up to being out-of-date because I hadn't seen that elsewhere. Now I see something similar mentioned on the Medtronic site referred to above...where they say a severely calcified ascending aorta would exclude the patient from this type of surgery. I KNOW my valve is calcified; can I assume that my angiogram showed a "clear" ascending aorta? I remember reading in the written report something I took to mean that my "root" was okay.

Also, someone mentioned above that they were given a CT scan to further support their candidacy for the procedure. I haven't been told of a need for that...guess it's a question to add to the list for my surgeon.

Randy

Hi Randy,
It was I who wrote that my surgeon said he needed the CT to determine if he could do the smaller incision. I think it was to see just how my aorta sat in my chest, or something to that effect. Got this when I first met him after having an angiogram, in the recovery unit when I had to still be lying flat on my back, and I was mildly loopy; pretty much all I could think of was that I couldn't think of any reasonable questions to ask him.

I don't know if your calcified valve would appear on the angiogram or not.

As for a few other responses here, I am overweight, reasonably well-endowed and a type 2 diabetic; surgeon never mentioned any of these as being a potential problem. Incision is most definitely above the breast, just about where cleavage begins. Also, someone mentioned her right lung was deflated. I wasn't told that would be done, and don't know if it was or not. I think maybe if we were told all that would be done during surgery, we might all run for the hills and never come back.

I think the PDF of the AVR technique overview is pretty much how my surgery went; however, I did not get a Medtronic valve. Surgeon's original choice was an On-x, but for that didn't work out, so I got a St. Jude (mechanical).

As for pain, since I never had a sternotomy, I can't compare; however, if it's true that most post surgical pain comes from incisions that go through more muscle, than maybe what I had is more painful; I would guess there's more muscle between your ribs than over the sternum. Years ago, after having lower back surgery, my physical therapist told me the incision for back surgery is more painful than heart surgery because there's more muscle in the lower back. I did not have much pain post back surgery. I found the pain from the incision easier than that from the herniated disc.

Have to agree with you, for me the smaller incision was very much a psychological thing and made the whole thing a bet less fearful, and I was pretty scared about it.

Feel free to PM me if you like.
Luana

 

[catwoman]

As for a few other responses here, I am overweight, reasonably well-endowed and a type 2 diabetic; surgeon never mentioned any of these as being a potential problem. Incision is most definitely above the breast, just about where cleavage begins. Also, someone mentioned her right lung was deflated. I wasn't told that would be done, and don't know if it was or not. I think maybe if we were told all that would be done during surgery, we might all run for the hills and never come back.
Luana

Luana:

An incision ABOVE the breast would be preferable for people who are overweight or well-endowed. An incision under the breast, as my husband's was, would be more apt to have folds of skin possibly affecting the incision healing as well.

 

[RANDYJEAN]

I've read (don't know of it's true) that there are less (none?) nerve endings in the sternum; hence less pain. My niece is married to a trauma surgeon and I think he mentioned there may be more pain involved with going through the rib. (I haven't quizzed him about any of this because I've always sensed that he's less-than-thrilled to offer advice to family.)

As for the boobage problem *grin* I'm reasonably well-endowed but saggy *huge grin* which may end up a factor in my favor since the area above my breasts is not so fleshy. (Is this TMI? LOL)

And yes, as I understand it, the lung is deflated...I was wondering if the lungs aren't deflated during the traditional sternum route?? Guess not.

Well, yesterday, I'd pretty much decided that if my insurance approval for the portal access guy came through, I'd take it as a sign...and guess what?? After 40 minutes on hold with them, I discovered it has INDEED been approved. (No small feat with my insurance company.)

By the way, I've decided on a tissue valve. I know, I know. Lots of pros and cons there, too. A guy friend of mine had a valve replaced 8 years ago; he's very active and although he was only 46 at the time, he opted for tissue. Three weeks post-surgery, he got endocarditis and had to be re-opened. I asked, given the hell he went through, was he still glad he got the tissue--KNOWING he'd probably have to go through this all again. And he said, YES. He never regretted the decision. That was enough for me--besides having witnessed problems my parents have had with Coumadin.

Hey, Michele...I'm not ABOUT to watch any videos! Post-surgery, I'll definitely be tapping into some of the on-line videos, but definitely not for now!

Thanks again, everyone, for all the info! An informed patient is a ...hm...well, not a happy patient, maybe...how about a SMARTER patient?

Randy

 

[river-wear]

Hey, Michele...I'm not ABOUT to watch any videos! Post-surgery, I'll definitely be tapping into some of the on-line videos, but definitely not for now!

Randy

I don't blame you a bit! I won't watch them either. Now or after surgery (probably). That's definitely TMI pre-surgery for me.