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Karadzha A, Sharifulin R, Khrushchev S, Afanasyev A, Sapegin A, Zheleznev S, Chernyavsky A, Bogachev-Prokophiev A. Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach. Asian Cardiovasc Thorac Ann 2024:2184923241259510. [PMID: 38831608 DOI: 10.1177/02184923241259510] [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: 06/05/2024]
Abstract
OBJECTIVE Partial upper sternotomy is preferred for isolated aortic valve replacement because of its optimal surgical visibility and favorable cosmetic outcomes; however, it is not commonly used for aortic root surgery, and the conventional median sternotomy is still the preferred method for most surgeons. We aimed to compare the safety and effectiveness of a minimally invasive approach (partial sternotomy [PS]) and conventional approach (median sternotomy [FS]) for aortic root surgery. METHODS Patients who underwent aortic root surgery at our hospital from 2016 to 2021 were retrospectively enrolled and divided into two groups. After propensity score matching, the conventional group included 156 patients and the minimally invasive group-57 patients. RESULTS Bicuspid aortic valves were observed in 63 (40.4%) and 33 (57.9%) patients in the FS and PS groups, respectively. Valve-sparing surgery was performed on 69 (44.2%) and 30 (52.6%) patients in the FS and PS groups, respectively. The minimally invasive approach was beneficial in terms of blood loss during the first 24 h after surgery (p = 0.029) and postoperative blood transfusion (p = 0.023). The survival rates and freedom from reoperation or severe aortic regurgitation after the David procedure were comparable between the standard and minimally invasive groups (p = 0.25; p = 0.66) at mid-term follow-up. CONCLUSIONS A minimally invasive approach for aortic root surgery can be safely performed as the standard approach. Partial upper sternotomy has the advantage of lower blood loss in the early postoperative period and does not negatively affect the results of valve-sparing root replacement.
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Affiliation(s)
- Anastasiia Karadzha
- E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Ravil Sharifulin
- E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | | | - Alexander Afanasyev
- E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Andrey Sapegin
- E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Sergey Zheleznev
- E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
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Helms F, Deniz E, Krüger H, Zubarevich A, Schmitto JD, Poyanmehr R, Hinteregger M, Martens A, Weymann A, Ruhparwar A, Schmack B, Popov AF. Minimally Invasive Approach for Replacement of the Ascending Aorta towards the Proximal Aortic Arch. J Clin Med 2024; 13:3274. [PMID: 38892985 PMCID: PMC11172865 DOI: 10.3390/jcm13113274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
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.
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Affiliation(s)
- Florian Helms
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Ezin Deniz
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Heike Krüger
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Alina Zubarevich
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jan Dieter Schmitto
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Reza Poyanmehr
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Martin Hinteregger
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Andreas Martens
- Clinic for Cardiac Surgery, University Clinic Oldenburg, 26129 Oldenburg, Germany
| | - Alexander Weymann
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Arjang Ruhparwar
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Bastian Schmack
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Aron-Frederik Popov
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Luo ZR, Chen YX, Chen LW. Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients. J Cardiothorac Surg 2022; 17:135. [PMID: 35641935 PMCID: PMC9158371 DOI: 10.1186/s13019-022-01890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Zeng-Rong Luo
- Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yi-Xing Chen
- Department of Cardiology, Nan Ping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery and Cardiac Disease Center, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
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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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Kim SA, Pyo WK, Ok YJ, Kim HJ, Kim JB. Mini-access open arch repair. J Thorac Dis 2021; 13:2233-2241. [PMID: 34012574 PMCID: PMC8107538 DOI: 10.21037/jtd-20-3254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Shi A Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kyung Pyo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - You Jung Ok
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Richter M, Liakopoulos OJ. Commentary: The mini-Bentall approach: Small and safe! JTCVS Tech 2021; 7:69-70. [PMID: 34318209 PMCID: PMC8311827 DOI: 10.1016/j.xjtc.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Manfred Richter
- Department of Cardiac Surgery, Kerckhoff Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, Giessen, Germany
| | - Oliver J Liakopoulos
- Department of Cardiac Surgery, Kerckhoff Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, Giessen, Germany
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Al-Adhami A, Islam S, Mishra V, Eleyan L, Theologou T. Valve sparing root replacement - Are we limited in our options? J Card Surg 2020; 36:188-190. [PMID: 33283335 DOI: 10.1111/jocs.15128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank, Scotland.,Duke University, Durham, North Carolina, USA
| | - Samsul Islam
- The Shrewsbury and Telford NHS Trust, Telford, Shropshire, UK.,School of Medicine, St. George's University of London, London, UK
| | - Vaibhav Mishra
- School of Medicine, St. George's University of London, London, UK
| | - Loay Eleyan
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Thomas Theologou
- Department of Cardiothoracic Surgery, Cardiocentro Ticino, Lugano, Switzerland
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Alnajar A, Aleong EF, Azhar MZ, Azarrafiy R, Lamelas J. Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches. J Card Surg 2020; 35:3539-3544. [PMID: 33025654 DOI: 10.1111/jocs.15061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/23/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Ahmed Alnajar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Elizabeth F Aleong
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Muhammad Z Azhar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ryan Azarrafiy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joseph Lamelas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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