Minimally invasive aortic arch surgery: Early and late outcomes

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.

Mitral Valve Surgery via Upper Ministernotomy: Single-Centre Experience in More than 400 Patients

Background: Minimally invasive mitral valve (MV) surgery has emerged as an alternative to conventional sternotomy aiming to decrease surgical trauma. The aim of the study was to describe our experience with minimally invasive MV surgery through partial upper sternotomy (PUS) regarding short- and long-term outcomes. Methods: From January 2004 through March 2014, 419 patients with a median age of 58.9 years (interquartile range 18.7; 31.7% females) underwent isolated primary MV surgery using PUS. Myxomatous degenerative MV disease was the predominant pathology (77%). The patients’ mean EuroSCORE II risk profile was 3.9 ± 3.6%. Results: Mitral valve repair was performed in 384 patients (91.6%) and replacement in 35 patients (8.4%). Thirty-day mortality was 3.1%. In total, 29 (6.9%) deaths occurred during the follow-up. The overall estimated survival at 1, 5, and 10 years was 93.1 ± 1.3%, 87.1 ± 1.9%, and 81.1 ± 3.4%. Reoperation was necessary in 14 (3.3%) patients. The overall freedom from MV reoperation at 1, 5, and 10 years was 98.2 ± 0.7%, 96.1 ± 1.2%, and 86.7 ± 6.7% and the overall freedom from recurrent MV regurgitation > grade 2 in repaired valves at 1, 5, and 10 years was 98.8 ± 0.6%, 98.8 ± 0.6%, and 94.6 ± 3.3%. Conclusions: Minimally invasive MV surgery via PUS can be performed with particularly good early and late results. Thus, the PUS approach with the use of standard surgical instruments and cannulation techniques can be a valuable option for the MV surgery either in patients contraindicated or not suitable to minithoracotomy.

Frozen elephant trunk: minimally invasive implantation of a new trifurcated hybrid aortic prosthesis

Implantation of hybrid prostheses using frozen elephant trunk (FET) technique has become a standard procedure for aortic arch and proximal descending aorta pathologies. New devices have been introduced to reduce the surgical complexity by enabling to perform FET in proximal segments of the aorta. This facilitates use of minimally invasive approach and provides a safe and durable aortic arch repair. We herein report on the first-in-man experience with the new trifurcated FET aortic prosthesis E-vita OPEN NEO using a minimally invasive technique.

Single-Stage Treatment of Aneurysm of the Distal Aortic Arch and Proximal Descending Aorta Using the Frozen Elephant Trunk Procedure. Case Report

Aneurysms of the thoracic aorta involving the distal arch and the proximal descending aorta have traditionally been treated with two open procedures. During the first stage, the aortic arch pathology has been addressed through a median sternotomy. Several weeks or months later, a second stage followed and included completing the repair of the descending aorta through a lateral thoracotomy.We, herein, report a single stage repair of an aneurysm involving the distal aortic arch and the proximal descending aorta using the frozen elephant trunk operative technique. Vascular hybrid stent graft prosthesis, specifically designed for treatment of extensive aortic aneurysms, has been used to replace the arch component and exclude the descending aorta component of the aneurysm through a median sternotomy, using bilateral antegrade cerebral perfusion and mild systemic hypothermia for intraoperative organ protection.

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.