Aortic valve replacement through J-shaped partial upper sternotomy

Abstract

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.

Keywords: Aortic valve replacement (AVR); J-shaped limited sternotomy; minimal access surgery; minimally invasive surgery; partial upper sternotomy.

Figure 1

(A) Skin incision for partial sternotomy; (B) Finocchietto retractor separating sternal edges with pericardial stay sutures in place; (C) Cardioplegia cannula and cross clamp demonstrated; (D) Aortotomy and aortic valve excision demonstrated.

Figure 2

Kaplan-Meier analysis for late survival in patients undergoing ministernotomy versus full sternotomy AVR.