Midterm results of less invasive approach to ascending aorta and aortic root surgery

Abstract

Background: Minimally invasive aortic valve (AV) surgery has become widely accepted alternative to standard sternotomy. Despite possible reduction in morbidity, this approach is not routinely performed for aortic surgery. Current report aimed to demonstrate early and mid-term outcomes in patients undergoing minimally invasive aortic root-and ascending aorta-replacement with or without concomitant AV replacement (AVR). Methods: Between 2011 and 2018, 167 selected low-and intermediate risk patients (mean age: 64.1±11.3; 70% men; EuroSCORE II 2.58±3.26) underwent minimally invasive aortic surgery. The "V" shaped partial upper sternotomy was performed through a 6-cm skin incision. Patients were divided into minimally invasive root reimplantation/replacement/remodelling (root RRR), supracoronary aorta replacements (SCAR) and SCAR+AVR. Kaplan-Meier estimates of survival were used. Results: Mean follow-up was 3.1 year (max 7.7 years). Of 167 patients, 82 (49%) underwent SCAR; 44 (26%) SCAR + AVR. Forty-one patients (25%) underwent minimally invasive root RRR. Average aortic diameter was 6.00±0.46 cm. The cardiopulmonary bypass and aortic cross-clamp time were 152.0±46.8 and 101.8±36.8 minutes. There was one conversion to sternotomy. Median intensive care unit stay was 2.0 (IQR: 1.0-3.0) days. Thirty-day mortality was 1%. Within investigated follow-up, there was one late reoperation due to aortic valve thrombosis; late survival was estimated at 95% without differences between types of surgery: hazard ratio, 0.81; 95% CI: 0.36-1.81; P=0.61. Conclusions: Minimally invasive aortic surgery performed through "V" shaped partial upper sternotomy is feasible and safe in selected patients regardless of the extent of repair, from supracoronary aorta replacements to complex root surgery.

Minimally invasive approach: is this the future of aortic surgery?

“…On the other hand, doing an L-shaped MS increases the exposure of the proximal and distal aortic arch as well as the aortic root. A V or inverted T-shaped upper MS has been also reported by some groups [2,3]. While this access certainly improves visualization, it may reduce postoperative sternal stability and be associated with an increased risk of both left and right mammary arteries injury.…”

“…Current evidence on MIAS is limited to retrospective observational studies since no well-powered randomized controlled trial comparing less invasive approaches and conventional surgery has been performed (Table 1). The largest single-center series on mini ascending and root interventions showed that MIAS is a safe and efficacious procedure and is associated with excellent outcomes, in selected patients [3,17,20,22,25]. Early mortality ranges from 0 to 1%, with a stroke rate of 0.6-1%.…”

Both J- and L-shaped upper hemisternotomy approaches are suitable for total arch replacement with frozen elephant trunk in patients with Type A dissection

“…Inoue et al reported T-shaped hemisternotomy instead of L-shaped hemisternotomy as a standard incision procedure ( 11 ). Staromłyński et al reported hemi-arch replacement through V-shaped hemisternotomy with an incision of only 6 cm ( 16 ).…”

Minimally Invasive Aortic Valve Surgery

“…Short-and long-term mortality was 1% and 5%, respectively. Seven % reoperations for bleeding, 1.7% prolonged ICU stays and 4.8% postoperative AKIs were observed [23].…”