Minimal Access Surgery of Ascending and Proximal Arch of the Aorta: A 9-Year Experience

Minimally Invasive Approach for Replacement of the Ascending Aorta towards the Proximal Aortic Arch

Objectives: In recent years, minimally invasive approaches have been used with increasing frequency, even for more complex aortic procedures. However, evidence on the practicability and safety of expanding minimally invasive techniques from isolated operations of the ascending aorta towards more complex operations such as the hemiarch replacement is still scarce to date. Methods: A total of 86 patients undergoing elective surgical replacement of the ascending aorta with (n = 40) or without (n = 46) concomitant proximal aortic arch replacement between 2009 and 2023 were analyzed in a retrospective single-center analysis. Groups were compared regarding operation times, intra- and postoperative complications and long-term survival. Results: Operation times and ventilation times were significantly longer in the hemiarch replacement group. Despite this, no statistically significant differences between the two groups were observed for the duration of the ICU and hospital stay and postoperative complication rates. At ten-year follow-up, overall survival was 82.6% after isolated ascending aorta replacement and 86.3% after hemiarch replacement (p = 0.441). Conclusions: Expanding the indication for minimally invasive aortic surgery towards the proximal aortic arch resulted in comparable postoperative complication rates, length of hospital stay and overall long-term survival compared to the well-established minimally invasive isolated supracommissural ascending aorta replacement.

Tailored surgical strategies for mini-access open total arch repair

Objective

Open arch repair is perceived as a challenging, high-risk procedure, with a barrier against the use of a minimally invasive approach. We aimed to present a mini-access total arch replacement performed by stratified approaches and to evaluate perioperative outcomes to contribute to the body of evidence.

Methods

We evaluated 40 consecutive patients (aged 69.5 years; interquartile range, 65.6-76.3 years) undergoing elective total arch replacement using 5- to 8-cm upper mini-sternotomy between 2018 and 2022. Surgical strategies, including arterial inflow site and methods of branching vessel reconstruction, were systematically selected at the individual level. To evaluate comparative outcomes, contemporary cases undergoing total arch replacement via sternotomy with similar eligibility criteria served as a control group, and the inverse-treatment-weighting method was used to adjust for baseline characteristics.

Results

Arch-first anastomosis using trifurcate graft, distal-first anastomosis using 4-branch graft, and island anastomosis were used in 18 (45%), 12 (30.0%), and 10 (25%) patients, respectively. Lower body and cardiac ischemic times were 23.4 minutes (interquartile range, 18.0-29.0 minutes) and 66.7 minutes (interquartile range, 50.1-78.2 minutes). There was no early (30-day or in-hospital) mortality, and 2 patients experienced disabling stroke (5.0%). The contemporary control group comprised 55 patients. After an adjustment, a mini-access group showed lower risks of stroke (odds ratio, 0.88; 95% CI, 0.78-1.00; P = .049) and a composite of major complications (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .003), compared with a sternotomy approach.

Conclusions

Based on present results, mini-access total arch replacement may be performed with reasonable safety and efficiency.

Surgery of the ascending aorta via a right anterior minithoracotomy: initial surgical experience of a single center

OBJECTIVES

Full median sternotomy (FMS) is the common surgical access for patients undergoing replacement of the ascending aorta (AA) with or without aortic valve replacement (AVR). The right anterior mini-thoracotomy (RAMT) approach has been increasingly adopted for AVR. This approach has been shown to decrease blood loss and hospital length of stay (LOS) compared with FMS. The RAMT approach may also be beneficial in selected patients requiring AA procedures with or without AVR. We present our initial clinical experience of patients who have undergone a RAMT for supracommissural replacement of the tubular AA with or without AVR.

METHODS

This is a single-center retrospective review of 10 patients who underwent an elective RAMT for replacement of the tubular AA with or without AVR between November 2019 and January 2022. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital LOS, time to extubation, operative times, as well as postoperative complications such as stroke and bleeding.

RESULTS

Median cross-clamp and cardiopulmonary bypass times were 109 and 148 min, respectively. Median time to extubation was 2.5 h and median intensive care unit and hospital stay were 2 and 10 days, respectively. There were two re-thoracotomies for postoperative bleeding and two cases of sub-xiphoidal pericardial drainage for pericardial effusion. There were no strokes and no in-hospital nor 30-day mortalities.

CONCLUSIONS

The replacement of the AA with or without concomitant AVR can be performed through a RAMT in carefully selected patients. However, the safety of this approach, as compared to full/partial median sternotomy, remains to be proven.

Beyond Conventional Operations: Embracing the Era of Contemporary Minimally Invasive Cardiac Surgery

Over the past two decades, minimally invasive cardiac surgery (MICS) has gained a significant place due to the emergence of innovative tools and improvements in surgical techniques, offering comparable efficacy and safety to traditional surgical methods. This review provides an overview of the history of MICS, its current state, and its prospects and highlights its advantages and limitations. Additionally, we highlight the growing trends and potential pathways for the expansion of MICS, underscoring the crucial role of technological advancements in shaping the future of this field. Recognizing the challenges, we strive to pave the way for further breakthroughs in minimally invasive cardiac procedures.

Effect of minimally invasive versus conventional aortic root replacement on transfusion and postoperative wound complications in patients: A meta-analysis

We examined whether small incision aortic root replacement could reduce the amount of blood transfusion during operation and the risk of postoperative complications. An extensive e-review of the 4 main databases (PubMed, Cochrane, Web of Science and EMBASE) was carried out to determine all the published trials by July 2023. The search terms used were associated with partial versus full sternotomy and aortic root. This analysis only included the study articles that compared partial and full sternotomy. After excluding articles based on titles or abstracts, selected full-text articles had reference lists searched for any potential further articles. We analysed a total of 2167 subjects from 10 comparable trials. The minimally invasive aortic root graft in breastbone decreased the duration of hospitalization (MD, -2.58; 95% CI, -3.15, -2.01, p < 0.0001) and intraoperative red blood cell transfusion (MD, -1.27; 95% CI, -2.34, -0.19, p = 0.02). However, there were no significant differences in wound infection (OR, 0.88; 95% CI, 0.16, 4.93, p = 0.88), re-exploration for bleeding (OR, 0.96; 95% CI, 0.60, 1.53, p = 0.86), intraoperative blood loss (MD, -259.19; 95% CI, -615.11, 96.73, p = 0.15) and operative time (MD, -7.39; 95% CI, -19.10, 4.32, p = 0.22); the results showed that the microsternotomy did not differ significantly from that of the routine approach. Small sternotomy may be an effective and safe substitute for the treatment of the aorta root. Nevertheless, the wide variety of data indicates that larger, well-designed studies are required to back up the current limited literature evidence showing a benefit in terms of complications like postoperative wound infections or the volume of intraoperative red blood cell transfusion.

Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques

Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved.

Comparison of minimally invasive versus conventional thoracic aortic operations: Early and midterm results in a series of 624 patients

OBJECTIVE

Despite minimally invasive techniques having gained wider application in cardiac surgery, current evidence on minithoracic aortic surgery is still limited. The aim of this study was to compare early and midterm outcomes of patients undergoing operations of the proximal thoracic aorta through ministernotomy (MS) versus full sternotomy (FS).

METHODS

Data from 624 consecutive patients who underwent proximal aortic repair through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at two aortic centers were analyzed. Treatment selection bias was addressed using propensity score matching (MS vs. FS). After matching, two well-balanced groups of 202 patients each were created.

RESULTS

Median cardiopulmonary bypass and cross-clamp times were 88 and 68 min, respectively, with no difference between groups. Overall, 30-day mortality was 1% (n = 2) in MS and 0.5% (n = 1) in FS (p = .6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4, 2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%). Patients receiving MS showed a lower incidence of respiratory insufficiency compared with FS (0% vs. 2.5%, p = .04). Intensive care unit and hospital stays were similar between groups. Two-year survival rate was 97.2% in MS and 96.5% in FS (p = .9).

CONCLUSIONS

Mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Both J- and L-shaped upper hemisternotomy approaches are suitable for total arch replacement with frozen elephant trunk in patients with Type A dissection

BACKGROUND

Minimally invasive total arch replacement (TAR) with frozen elephant trunk (FET) implantation can be carried out through J-, L-, and inverted T-shaped upper ministernotomy. L- and inverted T-shaped upper ministernotomy are selected mostly for their better surgical view compared to J-shaped. However, few studies have paid attention to the difference in clinical effects between J- and L-shaped upper hemisternotomy in acute Type A aortic dissection (ATAAD).

MATERIALS AND METHODS

We retrospectively analyzed 74 consecutive patients with ATAAD who underwent TAR with FET implantation between December 2019 and October 2020. Patients were divided into the L group (n = 31, L-shaped upper hemisternotomy) and the J group (n = 43, J-shaped upper hemisternotomy). Perioperative characteristics were recorded.

RESULTS

No significant difference was found in any of the pre-operative, post-operative, or follow-up variables between the two groups. However, the CPB establishment time in the J group was significantly shorter than that in the L group (65.0 ± 17.9 min vs. 77.9 ± 17.2 min, P < 0.05). Other intraoperative variables showed no significant difference.

CONCLUSION

Total arch replacement with frozen elephant trunk implantation is feasible and can be carried out safely through J-shaped or L-shaped incision. A J-shaped incision might be beneficial for single incision, while an L-shaped incision might be beneficial if an extra incision is required to achieve better artery perfusion.

Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients

Background

Excellent partial upper sternotomy outcomes have been reported for patients undergoing aortic surgery, but whether this approach is particularly beneficial to obese patients remains to be established. This study was developed to explore the outcomes of aortic surgical procedures conducted via a partial upper sternotomy or a full median sternotomy approach in obese patients.

Methods

We retrospectively examined consecutive acute type A aortic dissection patients who underwent aortic surgery in our hospital between January 2015 to January 2021. Patients were divided into two groups based on body mass index: ‘non-obese’ and ‘obese’. We then further stratified patients in the obese and non-obese groups into partial upper sternotomy and full median sternotomy groups, with outcomes between these two sternotomy groups then being compared within and between these two body mass index groups.

Results

In total, records for 493 patients that had undergone aortic surgery were retrospectively reviewed, leading to the identification of 158 consecutive obese patients and 335 non-obese patients. Overall, 88 and 70 obese patients underwent full median sternotomy and partial upper sternotomy, respectively, while 180 and 155 non-obese patients underwent these respective procedures. There were no differences between the full median sternotomy and partial upper sternotomy groups within either BMI cohort with respect to preoperative baseline indicators and postoperative complications. Among non-obese individuals, the partial upper sternotomy approach was associated with reduced ventilation time (P = 0.003), shorter intensive care unit stay (P = 0.017), shorter duration of hospitalization (P = 0.001), and decreased transfusion requirements (Packed red blood cells: P < 0.001; Fresh frozen plasma: P < 0.001). Comparable findings were also evident among obese patients.

Conclusions

Obese aortic disease patients exhibited beneficial outcomes similar to those achieved for non-obese patients via a partial upper sternotomy approach which was associated with significant reductions in the duration of intensive care unit residency, duration of hospitalization, ventilator use, and transfusion requirements. This surgical approach should thus be offered to aortic disease patients irrespective of their body mass index.

Minimal access compared to sternotomy for aortic root and arch surgery

INTRODUCTION

Partial upper sternotomy is an established technique for aortic valve surgery in numerous centers. Based on the favorable results, this access can be extended for more complex procedures. We assessed the outcomes of aortic root and arch surgery through partial versus full sternotomy.

PATIENTS AND METHODS

From January 2013 to December 2020, 100 patients underwent proximal aortic surgery. The minimal access approach was used in 73 patients. Operative variables and outcomes were retrospectively analyzed and compared between both groups.

RESULTS

There was no significant difference in cross-clamping and extracorporeal circulation times, as well as no difference in postoperative acute renal failure, stroke, myocardial infarction, and re-exploration for bleeding. However, there was a significant difference in favor of partial upper sternotomy in red blood cell transfusion (0 vs. 234 mL; p = 0.01), postoperative drainage volume (300 vs. 750 mL; p < 0.001), ventilation time (median 3 vs. 24 h; p < 0.001), sepsis (1 [1.4%] vs. 4 [14.8%]; p = 0.02), intensive care unit (median 2 vs. 4 days; p = 0.002) and hospital stay (median 7 vs. 10 days; p < 0.001). Only one patient required intraoperative conversion due to massive bleeding. There was no difference in 30-day mortality between both groups.

CONCLUSION

The partial upper sternotomy approach is safe and feasible for aortic root and arch surgery with morbidity and mortality rates similar to full sternotomy, with the advantages of less blood loss and transfusions need, faster extubation, and shorter length of hospital stay.

Partial upper sternotomy for extensive arch repair in older acute type A aortic dissection patients

OBJECTIVES

The partial upper sternotomy (PUS) approach is acceptable for aortic valve replacement, and even aortic root operation. However, the efficiency of PUS for extensive arch repair of acute type A aortic dissection (AAAD) in older adult patients has not been well investigated.

METHODS

Between January 2014 and December 2019, 222 older adult patients (≥ 65 years) diagnosed with AAAD went through extensive arch repair, among which 127 received PUS, and 95 underwent full sternotomy (FS). Logistic regression analysis was used to identify risk factors for early death, and negative binomial regression analysis was applied to explore risk factors related to post-operative ventilator-supporting time and intensive care unit stay time.

RESULTS

Total early mortality was 8.1% (18/222 patients). The PUS group had shorter Cardiopulmonary bypass time (133.0 vs.155.0 min, P < 0.001), cross-clamp time (44.0 vs. 61.0 min, P < 0.001) and shorter selective cerebral perfusion time (11.0 vs. 21.0 min, P < 0.001) than the FS group. Left ventricle ejection fraction  < 50% (odds ratio [OR] 17.05; 95% confidence interval [CI] 1.87-155.63; P = 0.012) and malperfusion syndromes (OR 65.83; 95% CI 11.53-375.86; P < 0.001) were related to early death. In the multivariate model, the PUS approach contributed to shorter ventilator-supporting time (incidence rate ratio [IRR] 0.76; 95% CI 0.64-0.91; P = 0.003), when compared with the FS group.

CONCLUSIONS

The early results of emergency extensive arch repair of AAAD via PUS in older adult patients were satisfactory. However, the long-term results remain to be investigated.

Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing

Objectives

A right minithoracotomy approach with a sternal sparing technique is a minimally invasive option for surgeons performing aortic root surgery. This report presents our initial clinical results of the right minithoracotomy Bentall procedure.

Methods

Clinical data of 15 patients were retrospectively analyzed who underwent the minimally invasive Bentall procedure through the right anterior thoracotomy via the second intercostal incision without any costochondral cartilage invasion at our institution between October, 2019 and June, 2021. The operative time, length of intensive care unit stay and postoperative hospital stay, perioperative outcomes, and follow-up results were analyzed.

Results

The median aortic cross-clamping time was 95.0 (85.5–98.8) min. Three (21.4%) patients received blood transfusion. The median drainage volume in the first 24 h was 200.0 ml, with no redo for bleeding. The median duration of mechanical ventilation was 12.5 (11.0–25.0) h, and median length of intensive care unit stay was 1.5 (1.0–3.0) day. All patients discharged 5.8 ± 1.2 days following surgery, with no dead patients found. At 6 months following surgery, all patients survived with an improved New York Heart Association (NYHA) functional class.

Conclusion

The right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. This approach should be considered as an option in carefully selected patients requiring aortic root replacement.

Minimally invasive approach: is this the future of aortic surgery?

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.

Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis

Limited uptake of minimally invasive surgery (MIS) of the aorta hinders assessment of its efficacy compared to median sternotomy (MS). The objective of this systematic review is to compare operative and perioperative outcomes for MIS versus MS. Online databases Medline, EMBASE, Cochrane Library and Web of Science were searched from inception until July 2018. Both randomized and observational studies of patients undergoing aortic root, ascending aorta or aortic arch surgery by MIS versus MS were eligible for inclusion. Primary outcomes were 30-day mortality, reoperation for bleeding, perioperative renal impairment and neurological events. Intraoperative and postoperative timing measures were also evaluated. Thirteen observational studies were included comparing 1101 MIS and 1405 MS patients. The overall quality of evidence was very low for all outcomes. Mortality and the incidence of stroke were similar between the 2 cohorts. Meta-analysis demonstrated increased length of cardiopulmonary bypass (CPB) time for patients undergoing MS [standardized mean difference 0.36, 95% confidence interval (CI) 0.15-0.58; P = 0.001]. Patients receiving MS spent more time in hospital (standardized mean difference 0.30, 95% CI 0.17-0.43; P < 0.001) and intensive care (standardized mean difference 0.17, 95% CI 0.06-0.27; P < 0.001). Reoperation for bleeding (risk ratio 1.51, 95% CI 1.06-2.17; P = 0.024) and renal impairment (risk ratio 1.97, 95% CI 1.12-3.46; P = 0.019) were also greater for MS patients. There was substantial heterogeneity in meta-analyses for CPB and aortic cross-clamp timing outcomes. MIS may be associated with improved early clinical outcomes compared to MS, but the quality of the evidence is very low. Randomized evidence is needed to confirm these findings.

Mini-access open arch repair

Background

The use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty.

Methods

This study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible.

Results

Hemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1 (1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%).

Conclusions

Mini-access open arch repair is technically feasible and achieved excellent early outcomes.

The mini-Bentall approach: Comparison with full sternotomy

Background

The upper mini sternotomy Bentall (mini-Bentall) procedure may result in less trauma and earlier recovery compared with the full sternotomy Bentall procedure (full Bentall). This study compares immediate and 1- and 3-year survival rates after mini- and full Bentall procedures.

Methods

Between February 2009 and July 2019, 48 patients underwent a mini-Bentall and 49 underwent a full Bentall. Patients who required concomitant procedures, reoperations, or hypothermic circulatory arrest were excluded from our analysis. The mean patient age was 60.7 years in the mini-Bentall group and 59.0 years in the full Bentall group.

Results

There were no in-hospital mortalities. The median cardiopulmonary bypass time (mini-Bentall: 165 minutes [interquartile range (IQR), 155.5-183 minutes]; full Bentall: 164 minutes [IQR, 150-187 minutes]; P = .619) and aortic cross-clamp times (139 minutes [IQR, 128.5-153 minutes] vs 137 minutes [IQR, 125-156 minutes]; P = .948) were not significantly different between the 2 groups. The mini-Bentall group had a significantly shorter median ventilation time compared with the full Bentall group (5.5 hours [IQR, 3-14 hours] vs 17 hours [IQR, 11-23 hours]; P < .001). None of the patients in the mini-Bentall group had postoperative bleeding necessitating reoperation, whereas 4 patients (8.2%) underwent reoperation after full Bentall (P = .043). The mini-Bentall group also had a shorter median hospital length of stay (6 days [IQR, 5-8 days] vs 7 days [IQR, 6-8 days]; P = .086). Survival at 1 and 3 years was 100% in both cohorts.

Conclusions

Patients required significantly less ventilation time and reoperations for bleeding after the mini-Bentall procedure. There were no significant differences in cardiopulmonary bypass, aortic cross-clamp times, or intensive care unit and hospital length of stay between the mini-Bentall and full Bentall groups. The mini-Bentall approach is associated with low morbidity and mortality.

Midterm results of less invasive approach to ascending aorta and aortic root surgery

Background

Minimally invasive aortic valve (AV) surgery has become widely accepted alternative to standard sternotomy. Despite possible reduction in morbidity, this approach is not routinely performed for aortic surgery. Current report aimed to demonstrate early and mid-term outcomes in patients undergoing minimally invasive aortic root- and ascending aorta-replacement with or without concomitant AV replacement (AVR).

Methods

Between 2011 and 2018, 167 selected low- and intermediate risk patients (mean age: 64.1±11.3; 70% men; EuroSCORE II 2.58±3.26) underwent minimally invasive aortic surgery. The “V” shaped partial upper sternotomy was performed through a 6-cm skin incision. Patients were divided into minimally invasive root reimplantation/replacement/remodelling (root RRR), supracoronary aorta replacements (SCAR) and SCAR+AVR. Kaplan-Meier estimates of survival were used.

Results

Mean follow-up was 3.1 year (max 7.7 years). Of 167 patients, 82 (49%) underwent SCAR; 44 (26%) SCAR + AVR. Forty-one patients (25%) underwent minimally invasive root RRR. Average aortic diameter was 6.00±0.46 cm. The cardiopulmonary bypass and aortic cross-clamp time were 152.0±46.8 and 101.8±36.8 minutes. There was one conversion to sternotomy. Median intensive care unit stay was 2.0 (IQR: 1.0–3.0) days. Thirty-day mortality was 1%. Within investigated follow-up, there was one late reoperation due to aortic valve thrombosis; late survival was estimated at 95% without differences between types of surgery: hazard ratio, 0.81; 95% CI: 0.36–1.81; P=0.61.

Conclusions

Minimally invasive aortic surgery performed through “V” shaped partial upper sternotomy is feasible and safe in selected patients regardless of the extent of repair, from supracoronary aorta replacements to complex root surgery.

Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches

Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.

Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy

Background

Use of minimally invasive approaches for isolated aortic valve or ascending aorta surgery is increasing. However, total arch replacement or aortic root repair through a minimally invasive incision is rare. This study was performed to report our initial experience with surgery of the ascending aorta with complex procedures through an upper mini-sternotomy approach.

Methods

We retrospectively analyzed 80 patients who underwent ascending aorta replacement combined with complex procedures including hemi-arch, total arch, and aortic root surgeries from September 2010 to May 2018. Using standard propensity score-matching analysis, 36 patients were matched and divided into 2 groups: the upper mini-sternotomy group (n = 18) and the median sternotomy group (n = 18). The preoperative assessment revealed no statistically significant differences between the two groups.

Results

Hospital mortality occurred in one patient (2.8%). The mini-sternotomy group showed a longer cross-clamping time (160 ± 38 vs. 135 ± 36 min, p = 0.048) due to higher rate of valve-sparing aortic root replacement and total arch repair. The cardiopulmonary bypass time in mini-sternotomy group was shorter than that of full sternotomy group (209 ± 47 min vs 218 ± 62 min, p = 0.595) but fell short of significance. There was no significant difference in lower body hypothermia circulatory arrest time between the two groups (40 ± 10 min vs 48 ± 20 min, p = 0.139). The upper mini-sternotomy group displayed a shorter ventilation time (22 vs. 45 h, p = 0.014), intensive care unit stay (4.6 ± 2.7 vs. 7.9 ± 3.7 days, p = 0.005), and hospital stay (8.2 ± 3.8 vs. 21.4 ± 11.9 days, p = 0.001). The upper mini-sternotomy group showed a lower postoperative red blood cell transfusion volume (4.6 ± 3.3 vs. 6.7 ± 5.7 units, p = 0.042) and postoperative drainage volume (764 ± 549 vs. 1255 ± 745 ml, p = 0.034). The rates of dialysis for newly occurring renal failure, neurological complications, and re-exploration were similar between the two groups (p = 1.000).

Conclusion

The upper mini-sternotomy approach is safe and beneficial in ascending aorta surgery with complex procedures for aortic dissection, including total arch replacement and aortic root repair.

Perioperative Outcomes of Minimally Invasive Aortic Arch Reconstruction with Branched Grafts Through a Partial Upper Sternotomy

BACKGROUND

Ministernotomy has been advocated over recent years as an alternative technique for different cardiovascular surgical procedures to reduce the surgical trauma associated with conventional full sternotomy. In recent years, several reports have addressed minimally invasive approaches to the proximal aorta and aortic arch through a partial upper sternotomy (PUS). We reviewed our experience of minimally invasive open aortic arch reconstruction with a branched graft through a PUS.

METHODS

Between February 2016 and December 2018, 22 patients underwent open arch repair through a PUS. Moderate hypothermic circulatory arrest and antegrade selective cerebral perfusion were used for organ protection. The median patient age was 76 years (range, 65-86). Renal insufficiency was observed in 14 patients (64%) and chronic lung disease, in 11 (50%). Total arch replacement was performed in 20 patients (91%), while the remaining 2 (9%) received partial arch replacement with reconstruction of two supraaortic vessels. Aortic valve replacement with a tissue valve or aortic valve repair was each performed concomitantly in one patient (5%) as a concomitant procedure. The median durations of cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest were 214, 109, and 50 min, respectively.

RESULTS

No early deaths, permanent neurological deficits, or spinal cord injuries occurred. One patient (5%) required intraoperative conversion to full sternotomy because of bleeding caused by a venting cannula injury. Three patients (14%) required re-exploration because of bleeding. Prolonged ventilation occurred in 2 patients (9%) with severe chronic obstructive pulmonary disease.

CONCLUSIONS

Minimally invasive aortic arch reconstruction with branched grafts through a PUS can be safely performed with satisfactory perioperative outcomes.

Mini Bentall operation: technical considerations

Bentall operation via median sternotomy has been largely shown to be safe and long-term efficacious and currently represents the "gold standard" intervention in patients presenting with aortic valve and root disease. However, over the last years, minimally invasive techniques have gained wider clinical application in cardiac surgery. In particular, minimally invasive aortic valve replacement through ministernotomy has shown excellent outcomes and becomes the first choice approach in numerous experienced centers. Based on these favorable results, ministernotomy approach has also been proposed for complex cardiac procedures such as aortic root replacement and arch surgery. Herein, we present our technique for minimally invasive Bentall operation using a ministernotomy approach.

Innominate vein cannulation: easy but neglected technique

Introduction: Our experience in minimally invasive procedures and improvement of graft technology enables easy and successful operation carried out even with complex thoracic aortic diseases from limited surgical area. However, it should be more than one incision or cannulation site for such intervention. We aimed to present our experience and results of 23 patients who has ascending aorta and aortic arch pathologies of which we operated with J-shaped partial sternotomy and innominate vein cannulation.

Methods: From January 2014 to January 2016, 23 patients with aorta and aortic valve pathologies who underwent aortic surgery with J-shaped partial sternotomy and innominate vein cannulation included. Operation findings, cardiopulmonary bypass (CPB) values, postoperative results, surgical mortality and morbidity rates, late conversion to full sternotomy rates, ICU and hospital length of stay were evaluated.

Results: The mean age of the patients was 53.7±12 (range 19-68) and 18 (78.2%) were males. Arcus aorta debranching applied to 4 patients (17.3%) and one of these procedures was frozen elephant trunk procedure (4.3%). Neither mortality nor cerebrovascular accident occurred. Mean CPB peak flow was 4.6±0.4 L/min, mean flow index calculated as 2.01±0.38 L/min/m2 and there was no CPB problem intraoperatively. Innominate vein ligation was carried out in 5 patients but no complication was seen except one who had left arm swelling treated with elevation.

Conclusion: Innominate vein cannulation with J-shaped partial sternotomy is a reliable and easily applicable method providing effective utilization of limited operative field not only in ascending aorta and aortic arch operations but also with the advancements of hybrid systems used in descending aorta pathologies.

Current Trends in Aortic Root Surgery: The Mini-Bentall Approach

OBJECTIVE

The mini-sternotomy approach is becoming a widespread technique for aortic valve surgery. However, its safety for aortic root replacement has yet to be established. The aim of the present study was to compare the operative outcomes of patients who underwent aortic root replacement via upper mini-sternotomy (mini-Bentall) to patients who underwent Bentall procedure via median sternotomy (full-sternotomy Bentall).

METHODS

Between November 1998 and November 2016, 91 consecutive patients underwent full-sternotomy Bentall procedure and 26 patients underwent mini-Bentall procedure. The mini-Bentall procedure was performed via an upper hemisternotomy incision extending to the right fourth intercostal space. Patients with concomitant procedures and those who underwent deep hypothermic circulatory arrest were excluded from the analysis. Outcome variables were operative mortality and major surgical complications, including prolonged length of hospital stay, transfusion rates, reoperation for bleeding, and prolonged ventilatory support.

RESULTS

No significant differences were observed on the preoperative, operative, and postoperative characteristics between the two treatment groups. The median cardiopulmonary bypass and aortic cross-clamp times were 169 minutes (interquartile range = 156.0-188.5) and 148 minutes (interquartile range = 131.3-160.3) in the mini-Bentall group, respectively. The median duration of hospitalization in the mini-Bentall group was 6.5 days (interquartile range = 5.0-11.0 days). In-hospital mortality and new renal insufficiency occurred at a frequency of 1.1% and reoperation for bleeding at 6.6% in the group of patients who underwent the conventional Bentall procedure compared with 0% for all these measures in the mini-Bentall group (P > 0.33). There was no significant difference in intraoperative red blood cell transfusion and other major postoperative complications. No strokes were observed in either group, and there were no conversions to median sternotomy in the mini-Bentall group.

CONCLUSIONS

An upper hemisternotomy is a feasible technique in patients undergoing elective aortic root replacement surgery. However, future prospective studies are required before these procedures become the standard of care.

Right Mini-thoracotomy Bentall Procedure

Objective

Bentall procedures are traditionally performed through a median sternotomy. The right mini-thoracotomy approach is increasingly used in aortic valve replacement. This approach has been shown to have decreased blood loss and hospital length of stay compared with sternotomy. A right mini-thoracotomy approach may also be beneficial in selected patients requiring aortic root surgery. We present our initial clinical experience of patients who have undergone a right mini-thoracotomy Bentall.

Methods

This is a single-center retrospective review of seven patients who underwent a primary elective right anterior mini-thoracotomy Bentall. A thoracoscope was used in each case. Automated suturing technology was used for annular suturing in three of the seven patients. Clinical outcomes evaluated include 30-day mortality, intensive care and hospital length of stay, time to extubation, operative times, as well as postoperative sequelae including stroke, infection, and bleeding.

Results

Median cardiopulmonary bypass, cross-clamp, and circulatory arrest time were 217, 153, and 28 minutes, respectively. Median time to extubation was 10 hours and median intensive care unit and hospital stay was 1 and 4 days, respectively. One patient had a wound infection and one returned to the operating room for bleeding. There were no in-hospital or 30-day mortalities.

Conclusions

The Bentall procedure can be performed through a right anterior mini-thoracotomy in selected patients with excellent clinical results.

Minimally Invasive Access Aortic Arch Surgery

OBJECTIVE

Median sternotomy is still the standard approach for aortic arch surgery. Minimally invasive techniques promise faster recovery with shorter hospital stay due to thoracic stability, reduced pain, and superior cosmetic results. However, safety is a concern in complex aortic surgery. The aim of our study was to demonstrate that aortic arch surgery via partial upper sternotomy is viable, safe, and equivalent to standard procedure both in terms of its safety and the risk of major adverse cardiac and cerebrovascular events.

METHODS

We interrogated our prospectively collected database and identified a total of 21 nonemergent patients operated on at our center between October 2008 and February 2015. Indication for operation was aneurysmatic disease in 18 and aortic dissection in 3 patients. Data were analyzed for in-hospital mortality, stroke, bleeding complications, and acute kidney injury.

RESULTS

Mean ± standard deviation age of patients was 69.3 ± 14.4 years, 57.1% were female, and mean ± standard deviation logistic EuroSCORE was 17.0 ± 7.2%. Surgery on the aortic arch comprised proximal arch in 9, hemiarch in 9, and total arch replacement plus frozen elephant trunk in 3 patients. Concomitant procedures included aortic root repair in 10, aortic root replacement in 2, and aortic valve replacement in 3 patients. We lost one patient because of septic shock, no stroke occurred, but a transient neurologic deficit in three and a postoperative delirium in four patients. Re-exploration for bleeding was necessary in two patients, and one patient had acute kidney injury.

CONCLUSIONS

Minimally invasive aortic arch surgery via partial upper sternotomy does not increase the risk of morbidity or mortality. Thus, in experienced hands, it is viable, safe, and therefore favorable and as a result should be offered to more patients.

Video assisted right mini-thoracotomy for aortic root replacement

Aortic root replacement is typically performed through a median sternotomy. The right anterior mini-thoracotomy approach has been shown to decrease hospital length of stay in aortic valve surgery when compared to sternotomy. This approach is rare in ascending aortic surgery due to technical challenges which include exposure and annular suture placement. Automated suturing technology is now available to facilitate the placement of annular sutures. The use of a camera greatly enhances visualization of the aortic root. A right anterior mini-thoracotomy is performed via a 5 cm incision in the right second intercostal space with a camera port placed lateral to the incision. Peripheral arterial and venous cannulation are performed. The aortic cross clamp is placed through a 5 mm incision in the third interspace anterior to mid axillary line. Histidine tryptophan ketoglutarate (HTK) cardioplegia is administered and deep hypothermic circulatory arrest is achieved followed by completion of the distal anastomosis with a 4-0 polypropylene running suture. After aortic leaflet removal, annular and prosthetic sutures are placed with shafted instruments or with automated suturing technology. Coronary button suturing and graft-to-graft anastomoses are performed with shafted instruments. Aortic root procedures can be performed safely through a right anterior mini-thoracotomy. The use of a camera and automated suturing technology may further facilitate this procedure, enabling more surgeons to offer this less invasive approach to patients.

Mini-Bentall: An Interesting Approach for Selected Patients

OBJECTIVE

Minimally invasive surgery through an upper hemisternotomy for aortic valve replacement has become the routine approach with excellent results. Actually, the same minimally invasive access is used for complex ascending aorta procedures only in few centers. We report our experience with minimally invasive approach for aortic valve and ascending aorta replacement using Bentall technique.

METHODS

From January 2010 to November 2015, a total of 238 patients received ascending aorta and aortic valve replacement using Bentall De Bono procedure at our institution. Low- and intermediate-risk patients underwent elective surgery with a minimally invasive approach. The "J"-shaped partial upper sternotomy was performed through a 6-cm skin incision from the notch to the third right intercostal space. Patients who had previous cardiac surgery or affected by active endocarditis were excluded. The study included 53 patients, 44 male (83 %) with a median age of 63 years [interquartile range (IQR), 51-73 years]. A bicuspid aortic valve was diagnosed in 27 patients (51%).

RESULTS

A biological Bentall using a pericardial Mitroflow or Crown bioprosthesis implanted in a Valsalva graft was performed in 49 patents. The remaining four patients were treated with a traditional mechanical conduit. Median cardiopulmonary bypass time and median cross-clamp time were respectively 84 (IQR, 75-103) minutes and 73 (IQR, 64-89) minutes. Hospital mortality was zero as well as 30-day mortality. Median intensive care unit and hospital stay were 1.9 and 8 days, respectively. The study population compared with patients treated with standard full sternotomy and similar preoperative characteristics showed similar results in terms of postoperative outcomes with a slightly superiority of minimally invasive group mainly regarding operative times, incidence of atrial fibrillation, and postoperative ventilation times.

CONCLUSIONS

A partial upper sternotomy is considered a safe option for aortic valve replacement. Our experience confirms that a minimally invasive approach using a partial upper J-shaped sternotomy can be a safe alternative approach to the standard in selected patients presenting with complex aortic root pathology.

Right Minithoracotomy Approach for Replacement of the Ascending Aorta, Hemiarch, and Aortic Valve

A minimally invasive right anterior thoracotomy approach is the preferred technique used at our institution for isolated aortic valve pathology. We have recently introduced more complex concomitant minimally invasive procedures through this access site. Here, we describe how we perform a replacement of the ascending aorta and aortic valve with and without the use of circulatory arrest through a 6-cm right minimally invasive thoracotomy incision.

Should patients undergo ascending aortic replacement with concomitant cardiac surgery?

Aim

To determine whether concomitant surgery is a predictor of mortality in patients undergoing surgery for ascending aortic aneursym.

Methods

Ninety-nine patients who underwent ascending aortic aneursym surgery between January 2010 and January 2015 were included in this study. Nineteen patients underwent ascending aortic replacement (RAA) only, 36 underwent aortic valve replacement (AVR) and RAA, 25 underwent coronary artery bypass grafting (CABG) and RAA, 11 underwent the Bentall procedure, and eight underwent AVR, CABG and RAA.

Results

Depending on the concomitant surgery performed with RAA, the mortality risk increased 2.25-fold for AVR, 4.5-fold for CABG, 10.8-fold for AVR + CABG and four-fold for the Bentall procedure, compared with RAA alone.

Conclusion

Concomitant cardiac surgery increased the mortality risk in patients undergoing RAA, but the difference was not statisticaly significant. Based on these study results, patients undergoing cardiac surgery, with a pre-operative ascending aortic diameter of over 45 mm, should undergo concomitant RAA.

Surgery of the Ascending Aorta with or without Combined Procedures through an Upper Ministernotomy: Outcomes of a Series of More Than 100 Patients

BACKGROUND

Use of a minimally invasive approach for isolated aortic valve surgery is increasing. However, management of the root and/or ascending aorta through a mini-invasive incision is not so frequent. The aim of this study is to report our initial experience with surgery of the ascending aorta through a ministernotomy approach.

METHODS

We retrospectively analyzed 102 patients treated for ascending aorta disease through a ministernotomy. Several types of surgeries were performed, including isolated or combined surgical procedures. Pre-operative and operative parameters and in-hospital clinical outcomes were retrospectively analyzed.

RESULTS

Patient mean age was 63.9 ± 13.6 years (range 29-85). There were 33 (32.4%) female and 69 (67.6%) male patients. Preoperative logistic EuroSCORE I was 7.4% ± 2.1%. Mean cardiopulmonary bypass and aortic cross-clamp time were 123.7 ± 36.9 and 100.8 ± 27.5 min, respectively. In-hospital mortality was 0%.

CONCLUSIONS

Our experience shows that surgery of the ascending aorta with or without combined procedures can be safely performed through an upper ministernotomy, without compromising surgical results. Although our series is not large, we believe that the experience gained on the isolated aortic valve through a ministernotomy can be safely reproduced in ascending aorta surgery as a routine practice.

Minimally invasive aortic valve replacement: Comparison of long-term outcomes

Background

Minimally invasive aortic valve replacement tends to be performed in specialist centers. Little data exists with regard to long-term outcomes of the upper hemi-sternotomy technique. We sought to evaluate the short- and long-term outcomes of this procedure in our institution.

Methods

Data were collected from our cardiac surgical database. We compared the outcomes of all patients who underwent minimally invasive aortic valve replacement with all who underwent conventional aortic valve replacement between July 1999 and December 2013. Propensity-matching analysis was performed to evaluate hospital outcomes.

Results

There were 125 patients who underwent minimally invasive aortic valve replacement and 1446 who had conventional surgery. After propensity score matching, there were no differences in postoperative mortality or complications between the 2 groups. The only significant differences were longer bypass (62.69 ± 10.12 vs. 68.94 ± 14.79 min, p = 0.002) and crossclamp times (45.48 ± 8.08 vs. 52.30 ± 16.29 min, p < 0.001) in conventional surgery. Long-term survival after minimally invasive aortic valve replacement at 2, 6, and 10 years was 88% ± 3.0%, 79% ± 4.0%, and 66% ± 6.0%, respectively. Predictors of long-term survival were age, peripheral vascular disease, and low ejection fraction ( p < 0.005).

Conclusion

Minimally invasive aortic valve replacement has similar hospital outcomes compared to conventional aortic valve replacement. The operation is quicker and does not confer any significant increase in complications or length of hospital stay. The long-term outcomes are favorable and justify its continued use by specialist surgeons in the United Kingdom.

A Minimally Invasive, Algorithm-Based Approach for Anomalous Aortic Origin of a Coronary Artery

Objective

Operative repair for anomalous aortic origin of a coronary artery (AAOCA) has been described using various innovative techniques. Common to each series is the use of a full sternotomy. As demand for minimally invasive approaches to adult cardiac surgery has increased, the upper hemisternotomy has emerged as a safe and effective technique for aortic valve and root replacement. This report reviews our results and describes the application of an upper hemisternotomy to an algorithm-based surgical approach for AAOCA.

Methods

From January 2012 to March 2013, the aortic root was approached via a 7-cm skin incision and upper hemisternotomy for all patients undergoing repair of an AAOCA. The type of repair performed was in accordance with a predefined surgical algorithm. The anomalous vessel had a slit-like ostium and followed a supracom-missural intramural course in three patients with symptomatic anomalous right coronary artery. These patients underwent coronary unroofing. In contrast, a patient with an anomalous left coronary artery presented without an intramural segment and underwent vessel translocation and reimplantation.

Results

All patients underwent AAOCA repair according to our surgical algorithm and via an upper hemisternotomy. The median length of stay was 4 days. All patients had resolution of symptoms, and there were no reported complications at a median follow-up of 16.5 months.

Conclusions

This series describes a minimally invasive approach to AAOCA repair. When used in conjunction with a defined surgical algorithm, this technique enables a safe and effective repair in all forms of AAOCA without concomitant coronary artery disease.

Outcomes of Aortic Valve and Concomitant Ascending Aorta Replacement Performed via a Minimally Invasive Right Thoracotomy Approach

Objective

Replacement of the aortic valve with concomitant replacement of the ascending aorta performed via a minimally invasive right anterior thoracotomy approach has not been reported. We evaluated the feasibility and safety of this procedure.

Methods

We retrospectively reviewed all minimally invasive aortic valve replacements (AVRs) with concomitant replacement of the ascending aorta performed at our institution between January 1, 2012, and December 30, 2012. The operative times, intensive care unit and hospital lengths of stay, postoperative outcomes, as well as mortality were analyzed.

Results

A total of 20 consecutive patients who underwent minimally invasive AVR with concomitant replacement of the ascending aorta were identified. There were 16 men (80%), with a mean (SD) age of 61 (13) years. The mean (SD) left ventricular ejection fraction was 58% (8%). The aortic valve was bicuspid in 18 patients (80%), with 14 (70%) being stenotic. The median aortic cross-clamp and cardiopulmonary bypass times were 163 [interquartile range (IQR), 141–170] minutes and 291 (IQR, 177–215) minutes, respectively. Hypothermic circulatory arrest was required in 19 patients (95%), with a median hypothermic circulatory arrest time of 35 (IQR, 33–39.5) minutes. The median intensive care unit and hospital lengths of stay were 24 (IQR, 23–41) hours and 5 (IQR, 4–6) days, respectively. There were no strokes, reoperations for bleeding, or conversions to sternotomy. The 30-day mortality was zero.

Conclusions

Minimally invasive AVR with concomitant replacement of the ascending aorta, via a right anterior thoracotomy approach, can be performed with low morbidity and mortality.

Minimal-access aortic valve replacement with concomitant aortic procedure: a 9-year experience

OBJECTIVE

Minimal-access approaches through upper hemisternotomy is an established technique for aortic valve replacement (AVR) and aortic surgery in our institution. We assessed the outcome of undergoing AVR with concomitant aortic surgery through upper hemisternotomy.

METHODS

We retrospectively reviewed 109 patients from January 2002 to May 2011 who had AVR with concomitant aortic surgery through upper hemisternotomy. Aortic valve replacement with supracoronary ascending aortic replacement was performed in 65 patients; AVR with ascending and proximal arch replacement, in 8 patients; AVR with aortoplasty, in 11 patients; Bentall procedure, in 8 patients; and AVR with root enlargement, in 13 patients. In-hospital outcomes and 1- and 5-year survival were examined.

RESULTS

The mean age was 58.5 years (range, 23-89 years); 41.3% of patients had bicuspid aortic valve (n = 45). Of the patients, 82.6% had true aneurysm (n = 90), 2.8% had calcified aorta (n = 3), 8.3% had small annulus (n = 9), and 3.7% had calcified annulus (n = 4). There were 6 (5.5%) reoperations and 15 (13.8%) urgent cases. Mean perfusion time was 152 ± 61 minutes, and cross-clamp time was 108 ± 47 minutes. Nine cases were performed with deep hypothermic circulatory arrest (8.3%). Operative mortality was 2.8% (n = 3). There were 4 (3.7%) cases with reoperation for bleeding, 2 (1.8%) myocardial infarctions, and 2 (1.8%) new-onset renal failure. Mean length of stay was 7.1 ± 5.6 days. Kaplan-Meier analysis showed that 1-year postoperative survival was 96.2% and 5-year survival was 92.4%.

CONCLUSIONS

An upper hemisternotomy approach is safe and feasible for AVR and concomitant aortic surgery with good early and midterm outcomes. This approach is also associated with low morbidity rate and short length of stay.

Left Atrial Roof: An Alternative Minimal Approach for Mitral Valve Surgery

Objective

The most common surgical incisions to expose the mitral valve include a paraseptal left atriotomy or a transeptal biatrial approach. Both techniques are normally performed through a full sternotomy and bicaval cannulation. We report our experience with an alternative incision to expose the mitral valve using the left atrial roof (LAR) through a complete sternotomy or a J-shaped upper ministernotomy.

Methods

Between 2007 and 2011, a total of 512 patients underwent mitral procedures using the LAR approach. A J-shaped ministernotomy was performed in 189 patients, and 61 of these had concomitant aortic valve/root procedures. A standard sternotomy was performed in 323 patients, and 126 of these had concomitant aortic valve/root procedures. The repair rate in patients with mitral regurgitation was 398 of 460 (86.5%).

Results

In-hospital mortality was 2.3%. An adjunctive pericardial patch to repair the LAR was necessary in 1.9% of patients. A permanent pacemaker was necessary in 3.1% of patients. Four-year survival rate was 91% ± 4.2%. In patients who underwent mitral repair, 4-year freedom from mitral regurgitation greater than 2 was 97.4%.

Conclusions

The LAR approach is a safe and effective option to perform mitral valve surgery. The limited extension of this incision and the possibility to use a single venous cannula make this approach suitable for minimally invasive isolated mitral valve procedures, whereas the proximity of the LAR to the aortic root makes this approach particularly attractive for combined mitroaortic procedures through a ministernotomy.

Surgery of the ascending aorta, root remodelling and aortic arch surgery with circulatory arrest through partial upper sternotomy: results of 50 consecutive cases

OBJECTIVES

Partial upper sternotomy is a routine approach to aortic valve surgery. For surgery of the ascending aorta or the aortic arch, this method is not well established yet.

METHODS

From October 2007 to October 2010, 50 consecutive patients underwent procedures of the ascending aorta and the aortic arch using partial upper sternotomy. Thirty-six patients underwent replacement or tightening of the ascending aorta, 11 patients received additional replacement of the proximal arch and in 3 cases, a complete replacement of the aortic arch was performed. Thirty-nine patients underwent additional aortic valve surgery.

RESULTS

Mean operation time was 249 ± 51 min. Mean aortic cross-clamp and cardiopulmonary bypass time were 95 ± 27 and 141 ± 35 min, respectively. No conversion to conventional sternotomy was performed. All valves appeared competent on postoperative echocardiography. Survival was 100%. One re-exploration for bleeding was necessary. One stroke (2%) occurred, one pacemaker was implanted due to third-degree AV block and 16 patients (32%) experienced atrial fibrillation. One patient suffered from sternal wound infection. One patient needed reoperation due to severe aortic insufficiency on postoperative day 13. Median postoperative ventilation time was 13 h, median intensive care unit (ICU) and hospital stay were 22 h and 7 days, respectively.

CONCLUSIONS

Results show that minimally invasive surgical procedures of the ascending aorta and the aortic arch may be performed safely, with an excellent clinical outcomes and superior cosmesis. Short ICU and hospital stay indicate the beneficial effects of reduced surgical trauma for patient recovery.