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OBJECTIVE: Minimally invasive approach trough upper mini-sternotomy has become the standard approach at our institution for procedures involving any diseases of aortic valve and aorta. The choice of the best ministernotomy approach in terms of type (reverse L vs reverse T) and extension (3^rd vs 4^th intercostals-space) however is often debatable. We report our experience with an original CT-based patient-specific simulation of the surgical vision using different upper ministernotomy approach in order to optimize preoperative planning of surgical approach
METHODS: An original multi-step reconstructive and simulative protocol was adopted in patients undergoing aortic surgery. Our protocol combines the capabilities of both free imaging softwares (e.g., Osirix) and technical computational programmes (e.g., Matlab) in order to create ad-hoc reconstructions to support the preoperative decision-making process.
In particular, once the DICOM data from synchronized multisliced CT-scan were obtained, Osirix imaging software was used to isolate the structures of mediastinum with specific focus on the aortic root, ascending aorta and right atrium appendage. Different surgical windows were virtually reproduced (ie 3^rd and 4^th intercostals space). Finally, Matlab computational software was used to manage the DICOM data and overlap the windowed rib cage to the aortic root/ascending aorta. The procedure was performed for each supposed surgical window in order to identify the optimal one.
RESULTS: Computational multistep simulation was obtained in ten patients undergoing aortic root surgery. Fig 1 shows the results of the simulation of surgical window at 3^rd is in a patient undergoing aortic root surgery. The target surgical key points to define the optimal approach were easily and accurately identified in all cases. Results of simulation accurately matched intraoperative findings.
CONCLUSIONS: The evolution of imaging techniques and post-processing tools have led to real useful support during the surgical operation planning. Based on the results of our experience we do support a widely application in clinical practice.