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Shah VN, Binongo J, Wei J, Till BM, King C, McGee J, Plestis KA. Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:39-45. [PMID: 38087894 DOI: 10.1177/15569845231213074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
OBJECTIVE Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR. METHODS There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded. RESULTS In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05). CONCLUSIONS The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.
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Affiliation(s)
- Vishal N Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jane Wei
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Brian M Till
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Colin King
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jacqueline McGee
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Konstadinos A Plestis
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Helms F, Schmack B, Weymann A, Hanke JS, Natanov R, Martens A, Ruhparwar A, Popov AF. Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1618. [PMID: 37763737 PMCID: PMC10534602 DOI: 10.3390/medicina59091618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
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.
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Affiliation(s)
- Florian Helms
- Division for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
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Boudart A, Yilmaz A, Kaya A. Minimal access compared to sternotomy for aortic root and arch surgery. Acta Chir Belg 2022; 122:144-149. [PMID: 35255771 DOI: 10.1080/00015458.2022.2050979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Hou B, Zhao R, Wang D, Wang W, Zhao Z, Sun X, Qian X, Yu C. Outcomes of the Valve-Sparing Root Replacement Procedure with Partial Upper Sternotomy. J Cardiovasc Dev Dis 2021; 8:jcdd8110154. [PMID: 34821707 PMCID: PMC8618798 DOI: 10.3390/jcdd8110154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 11/25/2022] Open
Abstract
Due to better postoperative convalescence and quality of life, experienced centers focus on minimally invasive surgical techniques and approaches, but this approach is not routinely performed for valve-sparing root replacement procedures. The purpose of this study was to assess the safety and feasibility of valve-sparing root replacement via partial upper sternotomy. Between January 2016 and April 2021, 269 patients underwent a valve-sparing root replacement procedure, and partial upper sternotomy was performed in 52 patients. The clinical outcomes of the partial upper sternotomy (PUS) and complete sternotomy (CS) groups, including mortality, degree of aortic insufficiency, blood loss and consumption of blood products, postoperative complications, and hospitalization expenses, were compared. The Kaplan–Meier method was used to assess the degree of aortic regurgitation. Propensity score matching was performed as a sensitivity analysis. There was only one in-hospital death (in the CS group, p = 1) and no postoperative moderate to severe aortic insufficiency in either group. The blood loss and consumption of blood products in the PUS group were also lower than in the CS group, especially for plasma use. Regarding the need for re-exploration because of bleeding, acute kidney injury, pericardial pleural effusion, drainage volume within the first 24 h, mechanical ventilation time, and arrhythmia, the two groups were comparable. Patients in the CS group showed a longer ICU time (74.20 ± 47.21 vs. 50.9 30.16 h, p = 0.001) and higher hospitalization expenses (135,649.52 ± 29,992.21 vs. 123,380.15 ± 27,062.82 yuan, p < 0.001). None of the patients died or reoperated during the follow-up. Freedom from moderate or severe aortic insufficiency remained comparable after matching (p = 0.97). Minimally invasive valve-sparing aortic replacement via partial upper sternotomy can be safely performed in selected patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Cuntao Yu
- Correspondence: or ; Tel.: +86-1088392345
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Radwan M, Salewski C, Hecker F, Miskovic A, Risteski P, Hlavicka J, Moritz A, Walther T, Holubec T. Mitral Valve Surgery via Upper Ministernotomy: Single-Centre Experience in More than 400 Patients. Medicina (B Aires) 2021; 57:medicina57111179. [PMID: 34833397 PMCID: PMC8625394 DOI: 10.3390/medicina57111179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Medhat Radwan
- Division of Thoracic and Cardiovascular Surgery, University of Tübingen, 72076 Tübingen, Germany; (M.R.); (C.S.); (P.R.)
| | - Christoph Salewski
- Division of Thoracic and Cardiovascular Surgery, University of Tübingen, 72076 Tübingen, Germany; (M.R.); (C.S.); (P.R.)
| | - Florian Hecker
- Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (F.H.); (A.M.); (J.H.); (A.M.); (T.W.)
| | - Aleksandra Miskovic
- Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (F.H.); (A.M.); (J.H.); (A.M.); (T.W.)
| | - Petar Risteski
- Division of Thoracic and Cardiovascular Surgery, University of Tübingen, 72076 Tübingen, Germany; (M.R.); (C.S.); (P.R.)
| | - Jan Hlavicka
- Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (F.H.); (A.M.); (J.H.); (A.M.); (T.W.)
| | - Anton Moritz
- Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (F.H.); (A.M.); (J.H.); (A.M.); (T.W.)
| | - Thomas Walther
- Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (F.H.); (A.M.); (J.H.); (A.M.); (T.W.)
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (F.H.); (A.M.); (J.H.); (A.M.); (T.W.)
- Correspondence: ; Tel.: +49-69630180094
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Haunschild J, van Kampen A, von Aspern K, Misfeld M, Davierwala P, Saeed D, Borger MA, Etz CD. Supracommissural replacement of the ascending aorta and the aortic valve via partial versus full sternotomy-a propensity-matched comparison in a high-volume centre. Eur J Cardiothorac Surg 2021; 61:479-487. [PMID: 34453828 DOI: 10.1093/ejcts/ezab373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/26/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Full sternotomy (FS) is the common surgical access for patients undergoing open aortic valve replacement (AVR) with concomitant supracommissural replacement of the tubular ascending aorta. Since minimally invasive approaches are being used with increasing frequency in cardiac surgery, the aim of this study was to compare outcomes of patients undergoing AVR with supracommissural replacement of the tubular ascending aorta via FS versus partial upper sternotomy (PS). METHODS We included all patients who underwent elective AVR with concomitant supracommissural replacement of the tubular ascending aorta at our institution between 2000 and 2015. Exclusion criteria were emergency surgery, other major concomitant procedures and reoperations. After 2:1 propensity score matching, outcomes of patients with PS and FS were compared. RESULTS A total of 652 consecutive patients were included, 117 patients operated via PS and 234 patients operated via FS. Cardiopulmonary bypass time and aortic cross-clamp time of the PS and FS groups were 89 vs 92 min (P = 0.2) and 65 vs 70 min (P = 0.3), respectively. Postoperative morbidity was low and there were no significant differences in postoperative outcomes between patient groups. In-hospital mortality was 1.7% in the PS vs 0.4% in the FS group (P = 0.3). Kaplan-Meier analysis revealed no difference in mid-term survival (P = 0.3). Reoperation rates for valve or aortic complications were very low with no significant difference between groups. CONCLUSIONS In a high-volume centre with extensive experience in minimally invasive cardiac surgery, AVR with concomitant supracommissural replacement of the tubular ascending aorta via PS results in similar outcomes with regard to safety and longevity when compared to conventional FS.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Antonia van Kampen
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Martin Misfeld
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Cardiac Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Institute of Academic Surgery, RPAH, Sydney, NSW, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | - Piroze Davierwala
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Diyar Saeed
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Robinson DA, Johnson CA, Goodman AM, Knight PA. Concomitant Annular Enlargement in Minimally Invasive Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:159-167. [PMID: 31039682 DOI: 10.1177/1556984519827685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy. METHODS Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed. RESULTS Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m2. All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%. CONCLUSIONS Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.
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Affiliation(s)
- Davida A Robinson
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Carl A Johnson
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Ariana M Goodman
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
| | - Peter A Knight
- 1 Department of Surgery, University of Rochester, Rochester, NY, USA
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Wachter K, Franke UFW, Yadav R, Nagib R, Ursulescu A, Ahad S, Baumbach H. Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement. Interact Cardiovasc Thorac Surg 2017; 24:377-383. [PMID: 28040763 DOI: 10.1093/icvts/ivw362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 09/26/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives This study aims to examine the feasibility and clinical course after minimally invasive David procedure compared with those via a conventional median sternotomy. Methods One hundred and ninety-two consecutive patients who underwent elective valve-sparing aortic root replacement (David procedure) with or without additional cusp repair for aortic regurgitation ( n = 17, 8.9%), dilatation of the aortic root ( n = 95, 49.5%) or a combination of both pathologies ( n = 80, 41.7%) were included. Patients with systemic disorders, such as Marfan's syndrome, and emergency cases were excluded. Assessment of quality of life was performed by modified Short Form Health Survey (SF-36) questionnaire. To minimize baseline differences, a matched pair analysis was conducted. Results One hundred and seventeen patients (60.9%) received a minimally invasive hemisternotomy (Group 1), 75 patients a conventional median sternotomy (39.1%, Group 2). Patients of Group 1 were significantly younger (56.5 ± 13.6 vs 64.8 ± 11.6, P < 0.001). Understandably, concomitant cardiac procedures were more frequent in Group 2 ( n = 7 [6.0%] vs n = 48 [64.0%], P < 0.001). In hospital, mortality was 0.9% in Group 1 (1/117) and 2.7% in Group 2 (2/75; P = 0.562). Blood loss was significantly less in Group 1 (542.6 ± 441.8 vs 996.7 ± 822.6 ml, P < 0.001). Duration of mechanical ventilation (10.2 ± 21.8 vs 26.9 ± 109.0 h, P < 0.001) and ICU-stay (1.9 ± 3.6 vs 3.2 ± 5.6 days, P < 0.001) were significantly shorter in the minimally invasive group, but this differences did not remain after matching. According to SF-36 questionnaire, patients in the minimally invasive group tend to have a higher quality of life. Conclusions Minimally invasive valve-sparing aortic root replacement can be done safely via an upper partial sternotomy in experienced hands even if additional cusp repair is required.
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Affiliation(s)
- Kristina Wachter
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Rashmi Yadav
- Department of Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom
| | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Samir Ahad
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Hardy Baumbach
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
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Risteski P, El-Sayed Ahmad A, Monsefi N, Papadopoulos N, Radacki I, Herrmann E, Moritz A, Zierer A. Minimally invasive aortic arch surgery: Early and late outcomes. Int J Surg 2017; 45:113-117. [DOI: 10.1016/j.ijsu.2017.07.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/02/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023]
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Fudulu D, Lewis H, Benedetto U, Caputo M, Angelini G, Vohra HA. Minimally invasive aortic valve replacement in high risk patient groups. J Thorac Dis 2017; 9:1672-1696. [PMID: 28740685 DOI: 10.21037/jtd.2017.05.21] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts.
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Affiliation(s)
- Daniel Fudulu
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Harriet Lewis
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Umberto Benedetto
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Massimo Caputo
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Gianni Angelini
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Hunaid A Vohra
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
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Reser D, Holubec T, Scherman J, Yilmaz M, Guidotti A, Maisano F. Upper ministernotomy. Multimed Man Cardiothorac Surg 2015; 2015:mmv036. [PMID: 26530961 DOI: 10.1093/mmcts/mmv036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/11/2015] [Indexed: 11/13/2022]
Abstract
During the past 50 years, median sternotomy has been the gold standard approach in cardiac surgery with excellent long-term outcomes. However, since the 1990 s, minimally invasive cardiac surgery (MICS) has gained wide acceptance due to patient and economic demand. The advantages include less surgical trauma, less bleeding, less wound infections, less pain and faster recovery of the patients. One of these MICS approaches is the J-shaped upper ministernotomy which results in favourable long-term outcomes even in elderly and redo patients when compared with conventional sternotomy. Owing to its similarity to a full midline sternotomy, it has become the most popular MICS approach besides a mini-thoracotomy. It is a safe and feasible access, but certain recognized principles are mandatory to minimize complications. After identification of the landmarks, the 5-cm skin incision is performed in the midline between the second and fourth rib. The third or fourth right intercostal space is located and dissected laterally off the sternum. After osteotomy, the pericardium is pulled up with stay sutures which allow excellent exposure. The surgical procedures are performed in a standard fashion with central cannulation. Continuous CO2 insufflation is used to minimize the risk of air embolism. Epicardial pacing wires are placed before the removal of the aortic cross-clamp and one chest tube is used. Sternal closure is achieved with three to five stainless steel wires. The pectoral muscle, subcutaneous tissue and skin are adapted with resorbable running sutures. When performed properly, complications are rare (conversion, bleeding and wound infection) and well manageable.
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Affiliation(s)
- Diana Reser
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Jacques Scherman
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Murat Yilmaz
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Andrea Guidotti
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
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A Minimally Invasive, Algorithm-Based Approach for Anomalous Aortic Origin of a Coronary Artery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:101-5. [DOI: 10.1097/imi.0000000000000135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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