Minimal access median sternotomy for aortic valve replacement in elderly patients

Abstract

Background: We report our clinical experience with a approach for aortic valve replacement (AVR) via minimal access skin incision and complete median sternotomy. This approach was used in patients with higher age and multiple co-morbidities, facilitating an easy access with short bypass and cross clamp times. It was especially performed in patients asking for an excellent cosmetic result, who did not qualifying for minimally-invasive AVR via partial upper sternotomy.

Methods: AVR via minimal-access median sternotomy, was performed in 58 patients between 01/2009 and 11/2011. Intra- and postoperative data including cross clamp time, cardiopulmonary bypass time, mortality, stroke, pacemaker implantation, re-operation for bleeding, ventilation time, ICU and hospital stay, wound infection, sternal dehiscence or fracture and 30 day mortality were collected.

Results: Mean patients age was 76.1 +/-9.4 years, 72% were female. Minimal-access AVR could be performed with a mean length of midline skin incision of 7.8 cm. Aortic cross-clamping time was 54.6 +/-6.3 min, cardiopulmonary bypass time 71.2+/-11.3 min and time of surgery 154.1 +/-26.8 min. Re-operation for bleeding had to be performed in 1 case (1.7%). There were no strokes or pacemaker implantations needed. Mean ventilation time was 4.5 h, ICU stay was 2 days and mean length of hospital stay was 6 days. 6 months follow up showed mortality of 0% and no sternal dehiscence or wound infection was observed.

Conclusion: Minimal-access AVR via complete median sternotomy can be performed safely,in this elderly patient cohort without adding additional operative risk compared to conventional AVR. By avoidiance of large skin incisions this approach combines excellent cosmetic results with fast surgery time and excellent postoperative recovery.

Figure 1

Position of the scar. (a) Scar (black arrows) position approximately 5 cm below jugulum (red arrows). (b) chest x-ray showing sclerotic aorta and adaptation of the sternum with standard steel wires.

Figure 2

Intraoperative situs. (a) Limited skin incision is placed approximately 5 cm below jugulum. (b) A complete median sternotomy is performed using a pendulum saw. (c) Excellent access to the right atrial appendage and aortic root. (d) Clear arrangement and easy access to the operation field facilitates fast and save cannulation. (e) Aortic cross clamping and standard transverse aortotomy is conducted for AVR. (f) Intracutaneous suture of 7.5 cm.