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Less Invasive Surgery of the Proximal Aorta
Petar Risteski, Nadejda Monsefi, Tanja Josic, Sherife Bala, Ali Al-Sayed, Anton Moritz, Andreas Zierer.
Johann Wolfgang Goethe University, Frankfurt am Main, Germany.

OBJECTIVE: Partial upper sternotomy (PUS) is established less invasive approach for single and double valve surgery. Reports of aortic surgery performed through PUS are rare.
METHODS: The records of 52 patients undergoing primary elective surgery on the proximal aorta through PUS between 2005 and 2011 were reviewed. Patients mean age was 57±16 years, 35% were in New York Heart Association Class III or IV, 59% had recent cardiac decompensation, and 17% had pulmonary hypertension. The PUS was taken down to either the 4th (44 patients; 85%) or 5th (8 patients; 15%) left intercostal space as appropriate.
RESULTS: No conversion to full sternotomy was necessary. The aortic cross-clamp, cardiopulmonary bypass and operative times averaged 136 ± 20 min., 186 ± 36 min. and 327 ± 83 min., respectively. In eight patients, the right axillary artery was cannulated for establishing cardiopulmonary bypass; the other 44 patients were cannulated centrally. All patients except one received a procedure on the ascending aorta, either replacement in 30 (58%) or reduction aortoplasty in 21 (40%). Aortic root replacement was additionally performed in 31 patients (60%), including David procedure in 20 (38%) and Ross procedure in 6 (11.5%). Furthermore, the aortic arch was replaced either partially in 5 (10%) or totally in 3 (6%) patients, in moderate hypothermia employing antegrade cerebral perfusion. Additional procedures, among others, included mitral valve repair in 15 (29%) patients and coronary grafting with the left internal thoracic artery to left anterior descending in 3 (6%) patients. Ventilation time, intensive care unit and hospital stay averaged 17 ± 12 hours, 2 ± 1, and 11 ± 9 days. Myocardial infarction was not observed. Chest drainage was 470 ±
380 ml/24 hours. Permanent neurologic deficit did not occur. Wound dehiscence was observed in a single patient (2%). Thirty-day and hospital mortality were not observed.
CONCLUSIONS: Less invasive surgery on the aortic root, ascending aorta and aortic arch can be performed safely and reproducibly. Potential benefits include a minimized risk of wound dehiscence and reduced postoperative bleeding. The PUS does not compromise the quality of the operation


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