Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts

Abstract

As the population ages, an increasing number of patients with patent coronary grafts will require subsequent aortic valve replacement. Major operative problems include those associated with re-entry and, in particular, damage of the patent grafts. Between January 2007 and October 2008, 10 patients who had previous coronary bypass surgery underwent aortic valve replacement through upper j-shaped mini re-sternotomy. In all patients the previous grafts were patent. The operation was performed with normothermic cardiopulmonary bypass without dissection and temporary closure of the arterial and venous coronary bypass grafts. The mean age was 73.2+/-13.6 years. The patients had a mean of 2.8+/-0.6 bypass grafts. There were no intraoperative complications due to redo ministernotomy and at no time conversion to full re-sternotomy was necessary. No damage to the previous grafts was reported and the incidence of perioperative myocardial infarction was 0%. One patient required a pacemaker implantation for atrio-ventricular block. The in-hospital mortality was 0%. Aortic valve replacement in previous coronary bypass grafting can be performed safely with a mini re-sternotomy. This approach avoids extensive dissection, decreasing the risk of injuries to heart chambers and previous patent coronary grafts with low morbidity and mortality.

Minimally invasive aortic valve replacement in high risk patient groups

“…In this series, there were no CABG graft injuries and the 5-year actuarial survival was 85%. A small series of ten patients with previous CABG undergoing mini-AVR was also reported by Dell'Amore et al (36). There was no in hospital mortality and no injury to the bypass grafts.…”

The Efficacy and Outcome of Ministernotomy Compared to Those of Standard Sternotomy for Aortic Valve Replacement

“…With a perioperative mortality of 2.3% ( = 1) for ministernotomy and 3.3% ( = 10) for sternotomy ( = 1.0), ministernotomy was not associated with higher perioperative mortality in our series. Our perioperative mortality was comparable to that in the current literature [1,3,[9][10][11][12]. The long-term survival in our series was slightly better following ministernotomy; the 1-, 3-and 7-year survival for ministernotomy was 93.8%, 93.2%, and 88.3%, respectively; for sternotomy, it was 87.7%, 83.7%, and 82.6%, respectively (95% CI 0.273 to 1.325, = .20); however, this difference in survival did not reach a level of statistical significance.…”

“…Other advantages include cosmetic benefits such as a smaller incision and keeping the sternum intact in the lower half of the chest [1]. Although some authors have recommended the ministernotomy for AVR [2,3], others have reported no advantage of minimally invasive AVR in early or midterm followup [4,5]. This study was undertaken to compare the outcomes of ministernotomy with those of conventional sternotomy.…”

Surgery of the Ascending Aorta with or without Combined Procedures through an Upper Ministernotomy: Outcomes of a Series of More Than 100 Patients

“…4,5) The indication for surgery, initially restricted only to selected elective patients, is now extended to more complex surgeries, including both the aortic root, the ascending aorta and redo-operations. [4][5][6][7][8][9][10][11][12] Especially in complex aortic surgery and in high risk patients, a ministernotomy approach can improve respiratory function recovery and allow earlier extubation, reducing ICU and hospital stay. 6) Other authors have previously reported on surgery of the aortic root or ascending aorta through a ministernotomy.…”