Partial upper sternotomy for extensive arch repair in older acute type A aortic dissection patients.

OBJECTIVES: The partial upper sternotomy (PUS) approach is acceptable for aortic valve replacement, and even aortic root operation. However, the efficiency of PUS for extensive arch repair of acute type A aortic dissection (AAAD) in older adult patients has not been well investigated. METHODS: Between January 2014 and December 2019, 222 older adult patients (≥ 65 years) diagnosed with AAAD went through extensive arch repair, among which 127 received PUS, and 95 underwent full sternotomy (FS). Logistic regression analysis was used to identify risk factors for early death, and negative binomial regression analysis was applied to explore risk factors related to post-operative ventilator-supporting time and intensive care unit stay time. RESULTS: Total early mortality was 8.1% (18/222 patients). The PUS group had shorter Cardiopulmonary bypass time (133.0 vs.155.0 min, P < 0.001), cross-clamp time (44.0 vs. 61.0 min, P < 0.001) and shorter selective cerebral perfusion time (11.0 vs. 21.0 min, P < 0.001) than the FS group. Left ventricle ejection fraction < 50% (odds ratio [OR] 17.05; 95% confidence interval [CI] 1.87-155.63; P = 0.012) and malperfusion syndromes (OR 65.83; 95% CI 11.53-375.86; P < 0.001) were related to early death. In the multivariate model, the PUS approach contributed to shorter ventilator-supporting time (incidence rate ratio [IRR] 0.76; 95% CI 0.64-0.91; P = 0.003), when compared with the FS group. CONCLUSIONS: The early results of emergency extensive arch repair of AAAD via PUS in older adult patients were satisfactory. However, the long-term results remain to be investigated.

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.

Minimally invasive aortic root surgery: Midterm results in a 2-year follow-up.

OBJECTIVES: Minimally invasive surgery (MIS) via partial upper sternotomy (PUS) for aortic root surgery represents an alternative to the full median sternotomy (FMS). PUS offers less operative trauma. We analyzed the midterm outcome of root replacement (Bentall) or valve-sparing root replacement (David) via PUS to evaluate the safety of this access. METHODS: Between November 2011 to April 2017, a total of 47 consecutive patients underwent aortic root surgery with aortic aneurysm and/or localized aortic dissection through Bentall or David operation through PUS mean age (57.9 ± 10.5 years). Bentall operation was performed in 36 patients (77%), whereas 11 patients (23%) received a David procedure. The outcome was carried out in 6-months, 1-year, and 2-years-follow up. RESULTS: Mean operation time was 287.3 ± 72.6 minutes, mean cardiopulmonary bypass (CPB) time 174 ± 54.8 minutes, mean cross-clamp time 133 ± 33.1 minutes. Rethoracotomy-rate was (4.2%). Superficial wound healing disturbance was (2%) and no deep sternal infection or sternum instability occurred. Hospitalization-and intensive care unit-stay was 11.8 ± 4.4 and 1.9 ± 1.3 days with a total median ventilation-time of 10 (IQR 7.5-13.5) hours. There was no 30-day-mortality. After 2 years the total rate of mortality, major adverse cardiac and cerebrovascular events, and redo surgery was (6.3%, 4.2%, and 4.2%). CONCLUSIONS: Minimally invasive aortic root surgery via partial upper sternotomy could be a safe alternative to the full median sternotomy. It requires longer operative times but reduces postoperative morbidity with good postoperative outcome.

Long-term outcomes following minimal invasive versus conventional aortic valve replacement: a propensity match analysis.

INTRODUCTION: Minimal invasive aortic valve replacement has become a routine procedure. In this study, we compared the outcomes between conventional and minimal invasive aortic valve replacement via the partial upper sternotomy that were performed in our Institution. METHODS: The 5 year survival and postoperative outcomes of 34 patients that underwent isolated MIAVR between the years 2010-2013 were compared with the outcomes of 34 randomly selected patients that underwent conventional AVR, after propensity match analysis. RESULTS: There was no difference between the two groups concerning the early and late postoperative outcomes. MIAVR patients had a longer mean cross-clamp time (p = 0.002) and longer cardiopulmonary bypass time (p = 0.0005) compared to the AVR patients. 5 year mortality and survival were 4.17 % vs 16.67 % (p = 0.20) and 95.8 % vs 83.3 % (p = 0.37) in the MIAVR and AVR groups respectively. CONCLUSION: This study showed a comparable 5 year survival and postoperative outcomes between the MIAVR and AVR groups. In our opinion, the minimal access aortic valve replacement can be performed safely with excellent long-term results in selected patients (Tab. 4, Fig. 1, Ref. 35).

Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach.

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.

Less invasive replacement of aortic root, ascending aorta and hemiarch via partial upper sternotomy: a propensity-score-matched comparison with full sternotomy.

OBJECTIVES: Less invasive surgery has emerged as an option for aortic pathologies. The current study compared our experience on early postoperative results of patients with aortic surgery between partial upper sternotomy (PUS) and full sternotomy (FS). METHODS: We performed a retrospective analysis of the data of patients undergoing aortic root surgery with concomitant ascending aorta and hemiarch replacement. Exclusion criteria were type A aortic dissection and other concomitant major cardiac surgery. After propensity score matching, we compared the perioperative outcomes of patients undergoing surgery with PUS versus FS. RESULTS: A total of 161 patients operated on between January 2013 and September 2022 met the inclusion criteria (PUS: n = 22, FS: n = 139). Propensity score matching yielded 22 pairs with a balanced distribution of propensity scores and covariates between the compared groups. There was no evidence that PUS affects cardiopulmonary bypass [108 (67-119) vs 113 (87-148) min, P = 0.154; PUS vs FS] and circulatory arrest duration [9 (7-10) vs 9 (8-13) min, P = 0.264; PUS vs FS]. There was a reduced cross-clamp duration in the PUS group [88 (58-96) vs 92 (71-122) min, P = 0.032]. Cumulative sum charts have shown consistently low cross-clamp and circulatory arrest duration for 2 experienced surgeons who performed 20 of the procedures in the PUS group (10 each). Perioperative mortality and morbidity were low, with no in-hospital mortality in the PUS group [0 vs 1(4.5%), P > 0.999] and absence of strokes in both groups. CONCLUSIONS: In summary, our initial experience suggests that less invasive aortic root, ascending aorta and hemiarch replacement via PUS could be performed in our patient cohort as safely as via full sternotomy. Advantages for the patient are reduced surgical trauma, improved cosmetic results and-presumably-less pain.

Do obese patients with type A aortic dissection benefit from total arch repair through a partial upper sternotomy?

Background: Minimal research has been performed regarding total arch replacement through partial upper sternotomy in patients with acute type A aortic dissection who are obese, and the safety and feasibility of this procedure need to be further investigated. The present study investigated the potential clinical advantages of using a partial upper sternotomy versus a conventional full sternotomy for total arch replacement in patients who were obese. Methods: This was a retrospective study. From January 2017 to January 2020, a total of 65 acute type A aortic dissection patients who were obese underwent total arch replacement with triple-branched stent graft. Among them, 35 patients underwent traditional full sternotomy, and 30 patients underwent partial upper sternotomy. The perioperative clinical data and postoperative follow-up results of the two groups were collected, and the feasibility and clinical effect of partial upper sternotomy in total arch replacement were summarized. Results: The in-hospital mortality rates of the two groups were similar. The total operative time, cardiopulmonary bypass, aortic cross-clamp, cerebral perfusion, and deep hypothermic circulatory arrest times were also similar in both groups. The thoracic drainage and postoperative red blood cell transfusion volumes in the partial upper sternotomy group were significantly lower than those in the full sternotomy group. Mechanical ventilation time was shorter in the partial upper sternotomy group than that in the full sternotomy group. Additionally, the incidences of pulmonary infection, hypoxemia, and sternal diaphoresis were lower in the partial upper sternotomy group than those in the full sternotomy group. Conclusion: This study showed that total arch replacement surgery through a partial upper sternotomy in patients with acute type A aortic dissection who are obese is safe, effective, and superior to full sternotomy in terms of blood loss, postoperative blood transfusion, and respiratory complications.

Do obese patients benefit from isolated aortic valve replacement through a partial upper sternotomy?

OBJECTIVE: Controversial opinions exist for aortic valve replacement (AVR) through partial upper sternotomy in obese patients. Moreover, this study sought to investigate the potential clinical advantage of partial upper sternotomy aortic valve replacement (mini-AVR) over conventional full sternotomy aortic valve replacement (con-AVR) in obese patients. METHODS: This was a retrospective and observational study. From January 2015 to December 2020, a total of 184 obese [body mass index (BMI) ≥ 30 kg  m2] patients undergoing isolated primary AVR were included: 98 patients underwent conventional full sternotomy, and 86 patients underwent partial upper sternotomy. Propensity score (PS) matching was applied to eliminate the bassline imbalances in the mini-AVR and the con-AVR groups. RESULTS: After one-to-one propensity score matching, two groups of 60 patients were obtained. No in-hospital death occurred in the two groups. In addition, cardiopulmonary bypass time and total operative time were similar across the 2 groups, but the aortic cross-clamp time was significantly shorter in the con-AVR group (P = .0.022). The amount of mediastinal drainage at 48 h after surgery (P = 0.018) and postoperative blood transfusions (P = 0.014) were significantly lower in the mini-AVR group. There was no difference in ventilation time (P = .0.145), but a shorter intensive care unit stay time (P = 0.021) in the mini-AVR group. CONCLUSION: This study demonstrates that aortic valve replacement through a mini-AVR in obese patients is a safe and effective procedure. It outperformed con-AVR in terms of blood loss, blood product transfusion, and ICU stay.

Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients.

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.

Extensive repair of acute type A aortic dissection through a partial upper sternotomy and using complete stent-graft replacement of the arch.

BACKGROUND: Partial upper sternotomy (mini-ER) can be used in some adult cardiac surgeries but is seldom performed in the treatment of acute type A aortic dissection (AAAD). This study aimed to assess the feasibility and short-term outcomes of complete stent-graft replacement of the arch with triple-branched stent graft for AAAD through a mini-ER. METHODS: From 2015 to 2018, 254 patients with AAAD underwent complete stent-graft replacement of the arch with a triple-branched stent graft. Replacement was performed with conventional full sternotomy (con-ER) in 142 patients and with mini-ER in the other 112 patients. Using propensity score matching, the clinical data were compared between 100 patients in the mini-ER group and 100 patients in the con-ER group. RESULTS: After propensity score matching, there were no significant between-group differences in aortic cross-clamp time, cardiopulmonary bypass time, or total operative time. The amount of mediastinal drainage and number of red blood cell units were significantly lower in the mini-ER group compared with the con-ER group (P < .001). The intubation time was significantly shorter in the mini-ER group (P < .001). The treatment costs were also lower in the mini-ER group (P < .001). There were no significant between-group differences in 30-day mortality (9% vs 8%; P > .99) or postoperative complications. CONCLUSIONS: This study shows that extensive repair of AAAD through a mini-ER is feasible. It was superior to con-ER in terms of blood loss, postoperative ventilation time, and treatment costs.

Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique.

OBJECTIVES: Classically, repair of extensive thoracic aortic pathologies including the aortic arch and descending aorta required two separate major surgical procedures via full sternotomy and a subsequent left lateral thoracotomy. We describe herein our preliminary institutional experience with minimally invasive single-stage extended thoracic aortic replacement employing the frozen elephant trunk (FET) technique via partial upper sternotomy (PUS) in 14 patients. METHODS: Between December 2013 and January 2015, 14 consecutive patients with elective indications for FET underwent minimally invasive FET via PUS (PUS-FET) during moderate systemic hypothermia (28°C) and selective antegrade cerebral perfusion (ACP) using the E-vita Open® hybrid prosthesis (Jotec GmbH, Hechingen, Germany). The patients' mean age was 66 ± 6 years, and 9 patients (64%) were male. The arch vessels were reimplanted en bloc in all patients. Clinical data were prospectively entered into our institutional database. RESULTS: The surgical procedure was successful in all patients with no need for conversion to full sternotomy. An additional David procedure was performed in 1 patient, whereas 2 patients received a concomitant Bentall procedure. There was no perioperative death or 30-day mortality. The mean cardiopulmonary bypass time was 214 ± 35 min, and the myocardial ischaemic time was 125 ± 14 min. The ACP time was 54 ± 9 min, whereas the ventilation time reached 11 ± 4 h. Intensive care unit stay was 2 ± 3 days. Chest tube drainage within the first 24 h was 460 ± 130 ml. None of the 14 patients required re-exploration for bleeding. Patients were discharged after a hospital length of stay of 9 ± 2 days. No postoperative permanent neurological complication occurred. Two patients (14%) experienced temporary delirium with complete resolution of symptoms prior to discharge from the hospital. CONCLUSIONS: Our preliminary experience suggests that minimally invasive single-stage extended thoracic aortic replacement can safely and reproducibly be performed by employing the concept of PUS-FET.

Aortic valve replacement through J-shaped partial upper sternotomy.

The introduction of minimally invasive techniques in general surgery, in the late 1980s, influenced cardiac surgery as well. This led to the emergence of several minimal access approaches for aortic valve replacement (AVR). Currently, the upper partial sternotomy with unilateral J-shaped extension to the right through the fourth intercostal space is the most popular minimal access approach. This approach offers the comfort factor of sternotomy, improved cosmetic result, preserved respiratory mechanics, and last but not the least cost saving as no new equipment is required. On the other hand, inability to visualize the whole heart, adequately de-air the left heart, and failure to apply epicardial pacing wires are some of the perceived disadvantages of this approach. This article provides a comprehensive review of the indications, contraindications, technical aspects, outcomes, advantages and disadvantages of AVR through J-shaped partial upper sternotomy.