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.

Keywords: Minimally invasive surgery; aortic root; extracorporeal circulation; mini-sternotomy; valvular disease.

Figure 1

Preoperative CT imaging. Diverse retrosternal aorta positions (A,B: left sided; C,D: central; and E,F: right-sided) with corresponding percentage distribution across study population.

Figure 2

Surgical access to minimally invasive aortic surgery: skin incision (A); V-shaped” sternal incision (B); aorta exposure (C); cannulation for cardiopulmonary bypass (D).

Figure 3

Step by step surgical technique: identification of 4th intercostal spaces (A); “arrow” shaped incision lines (B); a side-cut from intercostal space to sternal midline (C); “V-shaped” sternal incision (D).

Figure 4

Direct aortic cannulation (A); David procedure (B); final result, prosthesis in place (C) courtesy of EACTS: MITACS 20–22 June Warsaw, Poland Course Report.

Figure 5

Closing of the sternum with 3 steel wires (A,B) arrows point to the wires in place; one-month cosmetic outcome (C).

Figure 6

Kaplan-Meier curve for the analysis of overall survival in patients undergoing minimally invasive aortic surgery (A) and stratified by aortic surgery technique (B). SCAR, supracoronary aortic replacement; AVR, aortic valve replacement; RRR, reimplantation/replacement/remodelling HR, hazard ratio; CI, confidence interval.