Surgery without Scars: Right Lateral Access for Minimally Invasive Aortic Valve Replacement.

As part of an institutionally driven holistic concept, named the "360-degree approach," all established surgical access routes -full sternotomy, partial upper sternotomy, and right anterolateral thoracotomy using the second interspace-are supported. The surgical toolbox now is completed by adding a further approach: through a 5- to7-cm skin incision in the right anterior axillary line, the third interspace is used for a minimally invasive aortic valve surgery providing striking exposition of the aortic valve and resulting in superior cosmetics with nearly no visible scars. The choice for the one or other method is institutionally driven and based on risk profiles, as well as anatomical and physiognomic considerations.

Long-term outcomes after aortic arch surgery: results of a study involving 623 patients.

OBJECTIVES: To assess early and long-term outcomes in a large cohort of patients undergoing open aortic arch surgery. METHODS: From 1996 to 2012, 623 consecutive patients (mean age: 62.8 years) underwent aortic arch interventions in our institution. Of these, 208 (33.4%) presented with an acute aortic syndrome (AAS) and 415 (66.6%) with a chronic aortic pathology (CAP). During the study period, our surgical strategy involved extensive resections of the diseased aortic tissue at elective interventions, and a tear-oriented aortic replacement in patients with acute dissection. More extensive interventions were often performed in younger patients, and in those with connective tissue diseases and bicuspid aortic valves. A total arch replacement was frequently performed (53.3%). Antegrade selective cerebral perfusion was used in all cases. RESULTS: Overall in-hospital mortality was 23.1% in patients with AAS and 11.1% in patients with a CAP; in the same groups, postoperative permanent neurological dysfunction (PND) occurred in 9.6 and 5.6%, respectively. The follow-up was 94.4% complete. For in-hospital survivors, 5- and 10-year survival (%) were 79.4 ± 2.1 and 60.9 ± 3.2, respectively, not influenced by the underlying aortic disease. Cox regression identified age (hazard ratio [HR]: 1.048; P < 0.001), preoperative renal failure (HR: 2.3; P = 0.003), diabetes (HR: 1.805; P = 0.005) and PND (HR: 2.4; P = 0.03) to be independent predictors for the follow-up mortality. Overall, 109 (59% endovascular) aortic reinterventions were performed: 18.3% were proximal and 81.7% distal to the aortic arch. Five- and 10-year freedom from aortic redo (%) were 82.8 ± 1.9 and 77.7 ± 2.6, respectively. Aortic dissection (HR: 1.7; P = 0.03) was the only independent predictor of reoperative surgery at the follow-up. CONCLUSIONS: Aortic arch surgery was associated with satisfactory early and long-term outcomes. Survival was largely determined by patient comorbidities and postoperative PND. While the underlying aortic disease did not affect long-term mortality, chronic dissection was associated with increased need for aortic reinterventions.