Proximal Aortic Surgery: Upper “J” or Conventional Sternotomy?

Hastaoğlu, İsmail Oral; Toköz, Hamdi; Ozgen, Ayca; Bilgen, Fuat

doi:10.1532/hsf.1649

Cited by 7 publications

(11 citation statements)

References 14 publications

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“…We also found that valve-sparing root replacement via partial upper sternotomy was associated with a reduction in the length of ICU stay. This finding is consistent with the current literature for minimal access cardiac surgery [13][14][15][16]. Prolonged ICU stay is associated with postoperative mortality and complications [17,18], so minimizing this would be a huge advantage of partial upper sternotomy.…”

Section: Discussionsupporting

confidence: 90%

Outcomes of the Valve-Sparing Root Replacement Procedure with Partial Upper Sternotomy

Hou

Zhao

et al. 2021

JCDD

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Due to better postoperative convalescence and quality of life, experienced centers focus on minimally invasive surgical techniques and approaches, but this approach is not routinely performed for valve-sparing root replacement procedures. The purpose of this study was to assess the safety and feasibility of valve-sparing root replacement via partial upper sternotomy. Between January 2016 and April 2021, 269 patients underwent a valve-sparing root replacement procedure, and partial upper sternotomy was performed in 52 patients. The clinical outcomes of the partial upper sternotomy (PUS) and complete sternotomy (CS) groups, including mortality, degree of aortic insufficiency, blood loss and consumption of blood products, postoperative complications, and hospitalization expenses, were compared. The Kaplan–Meier method was used to assess the degree of aortic regurgitation. Propensity score matching was performed as a sensitivity analysis. There was only one in-hospital death (in the CS group, p = 1) and no postoperative moderate to severe aortic insufficiency in either group. The blood loss and consumption of blood products in the PUS group were also lower than in the CS group, especially for plasma use. Regarding the need for re-exploration because of bleeding, acute kidney injury, pericardial pleural effusion, drainage volume within the first 24 h, mechanical ventilation time, and arrhythmia, the two groups were comparable. Patients in the CS group showed a longer ICU time (74.20 ± 47.21 vs. 50.9 30.16 h, p = 0.001) and higher hospitalization expenses (135,649.52 ± 29,992.21 vs. 123,380.15 ± 27,062.82 yuan, p < 0.001). None of the patients died or reoperated during the follow-up. Freedom from moderate or severe aortic insufficiency remained comparable after matching (p = 0.97). Minimally invasive valve-sparing aortic replacement via partial upper sternotomy can be safely performed in selected patients.

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Section: Discussionsupporting

confidence: 90%

Outcomes of the Valve-Sparing Root Replacement Procedure with Partial Upper Sternotomy

Hou

Zhao

et al. 2021

JCDD

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“…Literature searches of online databases yielded 4430 citations and an additional 33 records were found from other sources. Of these, 143 relevant articles were read in full and assessed against the inclusion criteria, and 15 studies were included in the review [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. After assessment of the risk of bias, 2 studies were rated as having critical risk of bias and were not included in further analysis [27,29], thus leaving 13 studies for descriptive analysis.…”

Section: Study Selection and Characteristics Of Included Studiesmentioning

confidence: 99%

“…The indication for operation varied between studies for the MIS and MS cohorts, though 10 articles reported aortic dilatation or aneurysm as an indication [19, 20, 23-26, 28, 31-33]. Aortic root replacement was performed in 12 institutions [19-23, 25, 26, 28, 30-32] and ascending aorta replacement was performed in 6 centres [22,24,25,28,30,32]. Four studies reported operations of the aortic arch [24,28,32,33], with only one explicitly stating that they performed complete arch replacement [28].…”

Section: Interventionsmentioning

confidence: 99%

Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis

Rayner

Harrison

Rival

et al. 2019

European Journal of Cardio-Thoracic Surgery

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Summary Limited uptake of minimally invasive surgery (MIS) of the aorta hinders assessment of its efficacy compared to median sternotomy (MS). The objective of this systematic review is to compare operative and perioperative outcomes for MIS versus MS. Online databases Medline, EMBASE, Cochrane Library and Web of Science were searched from inception until July 2018. Both randomized and observational studies of patients undergoing aortic root, ascending aorta or aortic arch surgery by MIS versus MS were eligible for inclusion. Primary outcomes were 30-day mortality, reoperation for bleeding, perioperative renal impairment and neurological events. Intraoperative and postoperative timing measures were also evaluated. Thirteen observational studies were included comparing 1101 MIS and 1405 MS patients. The overall quality of evidence was very low for all outcomes. Mortality and the incidence of stroke were similar between the 2 cohorts. Meta-analysis demonstrated increased length of cardiopulmonary bypass (CPB) time for patients undergoing MS [standardized mean difference 0.36, 95% confidence interval (CI) 0.15–0.58; P = 0.001]. Patients receiving MS spent more time in hospital (standardized mean difference 0.30, 95% CI 0.17–0.43; P < 0.001) and intensive care (standardized mean difference 0.17, 95% CI 0.06–0.27; P < 0.001). Reoperation for bleeding (risk ratio 1.51, 95% CI 1.06–2.17; P = 0.024) and renal impairment (risk ratio 1.97, 95% CI 1.12–3.46; P = 0.019) were also greater for MS patients. There was substantial heterogeneity in meta-analyses for CPB and aortic cross-clamp timing outcomes. MIS may be associated with improved early clinical outcomes compared to MS, but the quality of the evidence is very low. Randomized evidence is needed to confirm these findings.

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“…The majority of minimally invasive procedures reported are performed via an upper hemisternotomy (Figure 3). 41‐43 Currently, however, RCP is the only cerebral protection strategy that can be employed through a right minithoracotomy for a minimally invasive ascending aorta and hemiarch surgery 44 . In a minithoracotomy approach, cerebral perfusion is exclusively performed via RCP 45 …”

Section: Discussionmentioning

confidence: 99%

Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches

et al. 2020

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Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.

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Proximal Aortic Surgery: Upper “J” or Conventional Sternotomy?

Abstract: Minimally invasive techniques like an upper "J" hemi-sternotomy can be safely performed without prolonging the aortic clamp time, and with less blood loss, less ventilatory support, and shorter ICU and total hospital stays when compared to conventional methods.

Cited by 7 publications

References 14 publications

Outcomes of the Valve-Sparing Root Replacement Procedure with Partial Upper Sternotomy

Outcomes of the Valve-Sparing Root Replacement Procedure with Partial Upper Sternotomy

Minimally invasive versus conventional surgery of the ascending aorta and root: a systematic review and meta-analysis

Review of cerebral perfusion strategies for aortic surgery with application for minimally invasive approaches

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