Choice of an artificial lung ventilation technique for the correction of mitral valve pathology from a mini-thoracotomy approach

Background. In recent years, there has been a growing number of cardiac surgeries performed using minimally invasive techniques. However, there is still debate about the optimal ventilation support for these operations, which are performed through a mini-thoracotomy.

The objective was to study the possibility of using high-frequency jet ventilation during minimally invasive mitral valve surgery performed from right-sided mini-thoracotomy, to evaluate its effectiveness and safety.

Materials and methods. 80 patients were divided into two groups: one group received high-frequency jet ventilation (HFJV), and the other received low-volume ventilation (LVV). Before surgery, during surgery, and in the intensive care unit, invasive hemodynamic parameters, arterial blood gas composition, and metabolic markers were assessed. The nature and incidence of postoperative complications were also analyzed.

Results. In the HFJV group, compared to the LVV group, the level of oxygen tension in arterial blood (PaO₂) was significantly higher at 30 minutes after thoracotomy – 307 (220–352) mmHg versus 106 (90–127.5) mmHg, p < 0.001, and at 30 minutes after the end of cardiopulmonary bypass (CPB) – 264 (188–323) mmHg versus 147 (109.5–183.5) mmHg, p < 0.001. PaO₂/FiO₂ was also higher in the HFJV group compared to the LVV group at these stages – 623 (450–714) versus 214 (171.3–263.3), p < 0.001 and 534 (367–654) versus 260 (200.5 – 358), p < 0.001. The number of patients with a PaO2/FiO2 of 200 or lower in the HFJV group was significantly lower than in the LVV group – 2.5 % compared to 32 %, p < 0,001 before CPB and 5 % compared to 25 %, р = 0,013 after CPB.

There was no statistically significant difference between the groups in the number of postoperative pulmonary complications, as well as the duration of artificial lung ventilation (ALV) and stay in the intensive care unit (ICU).

Conclusions. The use of high-frequency jet ventilation during minimally invasive mitral valve surgery performed through right-sided mini-thoracotomy provides adequate oxygenation and prevents the development of hypoxemia. This technique does not increase the number of postoperative complications.

1. Akselrod B. A., Pshenichnyy T. A., Tolmacheva N. N. et al. High-frequency ventilation in minimally invasive coronary artery bypass surgery. Russian Jour nal of Cardiology and Cardiovascular Surgery, 2022, vol. 15, no. 4, pp. 377–384. (In Russ.). https://doi.org/10.17116/kardio202215041377.

2. Vyzhigina M. A., Mizikov V. M., Sandrikov V. A. et al. Respiratory support in anaesthetic management for thoracic surgery and their comparative charac teristics: over 2000 anaesthesia experience. Russian Journal of Anaesthesiology and Reanimatology, 2013, no. 2, pp. 34–41. (In Russ.).

3. Krichevsky L. A., Semenychev N. V., Magilevets A. I. et al. Anesthe sia maintenance during mini-invasive cardiac valve surgery. Gen eral Reanimatology, 2013, vol. 9, no. 3, pp. 48. (In Russ.). https://doi.org/10.15360/1813-9779-2013-3-48.

4. ARDS Definition Task Force; Ranieri V. M., Rubenfeld G. D. et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA, 2012, vol. 307, no. 23, pp. 2526–33. https://doi.org/10.1001/jama.2012.5669. PMID, vol. 22797452.

5. Buise M., van Bommel J., van Genderen M. et al. Two-lung high-frequency jet ventilation as an alternative ventilation technique during transthoracic esophagectomy. J Cardiothorac Vasc Anesth, 2009, vol. 23, no. 4, pp. 509–512. https://doi.org/10.1053/j.jvca.2008.12.025.

6. Campos J. H., Feider A. Hypoxia during one-lung ventilation-a review and update. J Cardiothorac Vasc Anesth, 2018, vol. 32, no. 5, pp. 2330–2338. https://doi.org/10.1053/j.jvca.2017.12.026.

7. Ding C., Wang C., Dong A. et al. Anterolateral minithoracotomy versus median sternotomy for the treatment of congenital heart defects, vol. a me ta-analysis and systematic review. J Cardiothorac Surg, 2012, vol. 7, pp. 43. https://doi.org/10.1186/1749-8090-7-43.

8. Elkassabany N., Garcia F., Tschabrunn C. et al. Anesthetic management of patients undergoing pulmonary vein isolation for treatment of atrial fibril lation using high-frequency jet ventilation. J Cardiothorac Vasc Anesth, 2012, vol. 26, no. 3, pp. 433–438. https://doi.org/10.1053/j.jvca.2011.11.011.

9. Ender J., Brodowsky M., Falk V. et al. High-frequency jet ventilation as an alternative method compared to conventional one-lung ventilation us ing double-lumen tubes during minimally invasive coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth, 2010, vol. 24, no. 4, pp. 602–607. https://doi.org/10.1053/j.jvca.2009.10.029.

10. Falk V., Cheng D. C., Martin J. et al. Minimally invasive versus open mitral valve surgery, vol. a consensus statement of the international society of minimally invasive coronary surgery , no. ISMICS) 2010. Innovations (Phila), 2011, vol. 6, no. 2, pp. 66–76. https://doi.org/10.1097/IMI.0b013e318216be5c.

11. Ganapathy S. Anaesthesia for minimally invasive cardiac surgery. Best Pract Res Clin Anaesthesiol, 2002, vol. 16, no. 1, pp. 63–80. https://doi.org/10.1053/bean.2001.0208.

12. Goode J. S. Jr., Taylor R. L., Buffington C. W. et al. High-frequency jet ventilation, vol. utility in posterior left atrial catheter ablation. Heart Rhythm, 2006, vol. 3, no. 1, pp. 13–19. https://doi.org/10.1016/j.hrthm.2005.09.013.

13. Inoue K., Hiraoka A., Chikazawa G. et al. Preventive strategy for reexpansion pulmonary edema after minimally invasive cardiac surgery. Ann Thorac Surg, 2020, vol. 109, no. 5, pp. e375–e377. https://doi.org/10.1016/j.athoracsur.2019.10.073.

14. Irisawa Y., Hiraoka A., Totsugawa T. et al. Re-expansion pulmonary oedema after minimally invasive cardiac surgery with right mini-thoracotomy. Eur J Cardiothorac Surg, 2016, vol. 49, no. 2, pp. 500–505. https://doi.org/10.1093/ejcts/ezv089.

15. Ito T. Minimally invasive mitral valve surgery through right mini-thoracotomy, vol. recommendations for good exposure, stable cardiopulmonary bypass, and secure myocardial protection. Gen Thorac Cardiovasc Surg, 2015, vol. 63, no. 7, pp. 371–378. https://doi.org/10.1007/s11748-015-0541-z.

16. Karzai W., Schwarzkopf K. Hypoxemia during one-lung ventilation, vol. prediction, prevention, and treatment. Anesthesiology, 2009, vol. 110, no. 6, vol. 1402–1411. https://doi.org/10.1097/ALN.0b013e31819fb15d.

17. Keyl C., Staier K., Pingpoh C. et al. Unilateral pulmonary oedema after minimally invasive cardiac surgery via right anterolateral minithoracotomy. Eur J Cardiothorac Surg, 2015, vol. 47, no. 6, pp. 1097–102. https://doi.org/10.1093/ejcts/ezu312.

18. Keyl C., Siepe M. Unilateral lung injury after minimally invasive cardiac surgery, vol. more questions than answers. Eur J Cardiothorac Surg, 2014, vol. 9, no. 2, pp. 505–506. https://doi.org/10.1093/ejcts/ezv130.

19. Kim H. Y., Baek S. H., Je H. G. et al. Comparison of the single-lumen endotracheal tube and double-lumen endobronchial tube used in minimally invasive cardiac surgery for the fast track protocol. J Thorac Dis, 2016, vol. 8, no. 5, pp. 778–783. https://doi.org/10.21037/jtd.2016.03.13.

20. Madershahian N., Wippermann J., Sindhu D. et al. Unilateral re-expansion pulmonary edema: a rare complication following one-lung ventilation for minimal invasive mitral valve reconstruction. J Card Surg, 2009, vol. 24, no. 6, pp. 693–694. https://doi.org/10.1111/j.1540-8191.2009.00813.x.

21. Maj G., Regesta T., Campanella A. Optimal management of patients treated with minimally invasive cardiac surgery in the era of enhanced recovery after surgery and fast-track protocols: a narrative review. J Cardiothorac Vasc Anesth, 2022, vol. 36, no. 3, pp. 766–775. https://doi.org/10.1053/j.jvca.2021.02.035.

22. Misiolek H., Knapik P., Misiolek M. et al. High-frequency ventilation is not suitable for mini-thoracotomy. Eur J Anaesthesiol, 2009, vol. 26, no. 8, pp. 701–702. https://doi.org/10.1097/EJA.0b013e32832a0b91.

23. Modi P., Hassan A., Chitwood W. R. Jr. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg, 2008, vol. 34, no. 5, pp. 943–952. https://doi.org/10.1016/j.ejcts.2008.07.057.

24. Piekarski F., Rohner M., Monsefi N. et al. Anesthesia for minimal invasive cardiac surgery: the bonn heart center protocol. J Clin Med, 2024, vol. 13, no. 13, pp. 3939. https://doi.org/10.3390/jcm13133939.

25. Salenger R., Lobdell K., Grant M. C. Update on minimally invasive cardiac surgery and enhanced recovery after surgery. Curr Opin Anaesthesiol, 2024, vol. 37, no. 1, pp. 10–15. https://doi.org/10.1097/ACO.0000000000001322.

26. Salis S., Mazzanti V.V., Merli G. et al. Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery. J Cardiothorac Vasc Anesth, 2008, vol. 22, no. 6, pp. 814–822. https://doi.org/10.1053/j.jvca.2008.08.004.

27. Schmitto J. D., Mokashi S. A., Cohn L. H. Minimally-invasive valve surgery. J Am Coll Cardiol, 2010, vol. 56, no. 6, pp. 455–462. https://doi.org/10.1016/j.jacc.2010.03.053.

28. Sen O., Onan B., Aydin U. et al. Robotic-assisted cardiac surgery without lung isolation utilizing single-lumen endotracheal tube intubation. J Card Surg, 2020, vol. 35, no. 6, pp. 1267–1274. https://doi.org/10.1111/jocs.14575.

29. Vernick W. J., Woo J. Y. Anesthetic considerations during minimally invasive mitral valve surgery. Semin Cardiothorac Vasc Anesth, 2012, vol. 16, no. 1, pp. 11–24. https://doi.org/10.1177/1089253211434591.

30. White A., Patvardhan C., Falter F. Anesthesia for minimally invasive cardiac surgery. J Thorac Dis, 2021, vol. 13, no. 3, pp. 1886–1898. https://doi.org/10.21037/jtd-20-1804.

31. Yamashiro S., Arakaki R., Kise Y. et al. Prevention of pulmonary edema after minimally invasive cardiac surgery with mini-thoracotomy using neutrophil elastase inhibitor. Ann Thorac Cardiovasc Surg, 2018, vol. 24, no. 1, pp. 32–39. https://doi.org/10.5761/atcs.oa.17-00102.