Aortic root replacement by ministernotomy: technique and potential benefit

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.

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.

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.

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.

Effect of Elective Bentall Procedure on Left Ventricular Systolic Function and Functional Status: Long-Term Follow-Up in 90 patients

Because there are so few data on the long-term effects on left ventricular systolic function and functional status in patients who electively undergo Bentall procedures, we established a retrospective study group of 90 consecutive patients. This group consisted of 71 male and 19 female patients (mean age, 54 ± 10 yr) who had undergone the Bentall procedure to correct aortic valve disease and aneurysm of the ascending aorta, from 1997 through 2003 in a single tertiary-care center. We monitored these patients for a mean period of 117 ± 41 months for death, left ventricular ejection fraction and volume indices, and functional capacity as determined by New York Heart Association (NYHA) class. There were no operative deaths. The survival rate was 73.3% during follow-up. There were 10 cardiac and 13 noncardiac deaths, and 1 death of unknown cause. Echocardiography was performed before the index procedure and again after 117 ± 41 months. In surviving patients, statistically significant improvement in left ventricular ejection fraction, in comparison with preoperative values (0.49 ± 0.11 vs 0.41 ± 0.11; P <0.0001), was noted at follow-up. Similarly, we observed statistically significant reductions in left ventricular end-systolic (39.24 ± 28.7 vs 48.77 ± 28.62 mL/m(2)) and end-diastolic volumes (54.63 ± 6.97 vs 59.17 ± 8.92 mL/m(2); both P <0.0001). Most patients (53/66 [80.3%]) progressed from a higher to a lower NYHA class during the follow-up period. The Bentall procedure significantly improved long-term left ventricular systolic function and functional status in surviving patients who underwent operation on a nonemergency basis.

Sutureless Aortic Valve Replacement via Partial Sternotomy

OBJECTIVE

: For elderly patients with symptomatic aortic valve stenosis, aortic valve replacement with tissue valves is still the treatment of choice. Stentless valves were introduced to clinical practice for better hemodynamic features as compared with stented tissue valves. However, the implantation is more complex and time demanding, especially in minimal invasive aortic valve replacement. We present our clinical data on 22 patients having received a sutureless ATS 3f Enable aortic bioprosthesis via partial upper sternotomy.

METHODS

: The procedure was performed using CPB with cardioplegic arrest. After resection of the stenotic aortic valve and debridement of the annulus, the valve was inserted and released. Mean age was 79 years, and mean logistic Euroscore was 13. Subvalvular myectomy was performed in two patients. Prosthetic valve sizes were 19 mm (n = 1), 21 mm (n = 7), 23 mm (n = 6), 25 mm (n = 6), and 27 mm (n = 2).

RESULTS

: Implantation of the valve required 10 ± 6 minutes. Cardiopulmonary bypass and aortic crossclamp time were 87 ± 16 and 55 ± 11 minutes, respectively. Early mortality (<90 days) was 9% (2 patients). No paravalvular leakage was detected intraoperatively or in follow-up echocardiography. The mean transvalvular gradients were 9 ± 6 mm Hg at discharge and 8 ± 2 mm Hg at 1-year follow-up.

CONCLUSIONS

: Sutureless valve implantation via partial sternotomy is feasible and safe with the ATS 3f Enable bioprosthesis. Reduction of cardiopulmonary bypass and aortic crossclamp time seems possible with increasing experience. Hemodynamic data are very promising with low gradients at discharge and after 12 month. Sutureless valve implantation via minimal invasive access may be an alternative treatment option for elderly patients with high comorbidity.

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.

Treatment of ascending aorta disease with Bentall-De Bono operation using a mini-invasive approach

BACKGROUND

Use of minimally invasive approaches in cardiac surgery is increasing, obtaining a wide consensus and representing a challenging alternative technique for many surgeons. We report our experience of the treatment of ascending aorta disease using the Bentall-De Bono procedure through a minimally invasive approach.

METHODS

Between September 1997 and June 2005 at 'Policlinico San Matteo', Pavia, we treated 40 patients affected by ascending aorta disease and aortic valve regurgitation using a Bentall-De Bono procedure through a minimally invasive approach, by means of a reversed T or J ministernotomy. Data were analyzed retrospectively. Thirty patients were men. Short-term and mid-term mortality and peroperative complications were analyzed.

RESULTS

None of the patients died during the 30-day postoperative period. The mean ICU and length of stay times were 3.3 +/- 8.2 and 9.3 +/- 7.2 days, respectively. Six patients (15%) had one or more postoperative complications. One patient (2.5%) underwent early reoperation for bleeding. None underwent a procedure-related reoperation. Mechanical ventilation was longer than 48 h in five patients (12.5%). The mean follow-up was 38.4 +/- 31 months. Survival at 1, 3 and 5 years was, respectively, 94.1, 90.6 and 90.6%. At the end of the follow-up, there were 37 survivors. Twenty-seven (73%) patients were in New York Heart Association I, six (16%) were in New York Heart Association II and four (11%) were in New York Heart Association III.

CONCLUSION

Reversed T or J ministernotomy is a feasible and secure alternative to complete sternotomy. The short incision may enhance the outcome and does not affect the survival, offering proper access to the anatomic structures.

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.