Sternal No Touch Technique For Surgery On The Aortic Root And Ascending Aorta
Sebastian Arzt, Manuel Wilbring, Konstantin Alexiou, Klaus Matschke, Utz Kappert.
Heart Centre Dresden, Dresden, Germany.
BACKGROUND - Right anterior minithoracotomy (RAM) is an alternative access route for minimally invasive aortic valve surgery. Herein, we describe adaptation of the RAM-access to perform surgery on the aortic root and the ascending aorta as well. On the basis of a case series, we emblaze technical aspects and - furthermore crucial - focus on decision-making of which particular anatomical conditions are feasible. METHODS - Out of 355 cases of RAM-access procedures, predominantly consisting of isolated aortic valve surgery, five minimally invasive procedures on the ascending aorta and aortic root using the RAM-access were identified. Surgery consisted of three Bentall-procedures, one Wheat-procedure and one isolated replacement of the ascending aorta. Midterm outcomes were collected by telephone survey. The mean age of the patients was 54.0±2.0 years. The average EuroScore II and STS-PROM were, 1.40±0.46 and 0.72±0.21, respectively. RESULTS - Preoperative decision-making included CT-scan of the chest and thoracic aorta as well as echocardiography, aortic course, size of intercostal spaces and anatomic conditions in general were taken into consideration. In all cases, cardiopulmonary bypass was established using femoral cannulation. All procedures were uneventful, particularly no conversion to median sternotomy was required. The mean operating time was 178.6±66.1 minutes with mean aortic clamp time of 68.6±19.1 minutes. A biological aortic valve was implanted in four patients. The postoperative course likewise was uneventful in all patients. The median hospital stay was 7 days (6-11 days). No wound or bleeding complications occurred. There was no 30-day mortality. The median follow-up was 16 months (3-61 months). All patients are asymptomatic, physically resilient and pursue a regular occupation. CONCLUSIONS - Thoroughly patient selection using CT-scan and echocardiography avoids getting screwed by the access route. In our experience, under particular consideration of anatomical screening, RAM is a feasible approach for procedures on the aortic root and ascending aorta. The RAM-access as a sternal no-touch technique is associated with excellent clinical results and mid-term outcomes. Fast mobilization, quick recovery and negligible rates of wound complications are further advantages.
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