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Full or partial sternotomy rather than right minithoracotomy: tailoring the best approach for each patient in aortic valve replacement
Elisa Mikus, Simone Calvi, Marco Panzavolta, Marco Paris, Mauro Del Giglio.
Maria Cecilia Hospital, GVM for Care & Research, Cotignola (Ra), Italy.

OBJECTIVE: Over the past decade, minimally invasive cardiac surgery has emerged as a valid approach to treat aortic valve disease. Various techniques have been developed: partial sternotomy (V-shaped, Z-shaped, inverse-T, J reverse-C and reverse-L partial) and right mini-thoracotomy at the 2nd or 3th intercostale space. We describe our 6 years, single center experience, using either standard full sternotomy or upper “j” hemisternotomy or right minithoracotomy.
METHODS: From January 2010 to October 2015, 1550 isolated, aortic valve operations were performed at our Institution. Surgical approach included standard sternotomy (509, 32.8%), minimally invasive technique using upper J hemisternotomy (695, 44.8%) or right anterior minithoracotomy (346, 22.4%). Aortic clamping was direct in all patients. Total central cannulation was used whenever possible.
RESULTS: Bivariate and multivariate regression analysis revealed that preoperative renal insufficiency is a common independent risk factor for death. In addition, in case of minimally invasive approach with upper hemisternotomy, obesity results as an independent risk factor (p=0.05. Adj OR 5.06, CI 1.01-25.28), as well as peripheral extra-cardiac vascular disease for the full sternotomy group (p=0.02.Adj OR 4.42, CI 1.27-15.34).
Hospitalmortality rate in minimally invasive approach (right minitoracotomy 1.7%, upper hemisternotomy 2.9%) was at least comparable to the standard full sternotomy (3.5%).
CONCLUSIONS: Minimally invasive surgery must be considered as a safe option for aortic valve replacement. Our experience shows that, in case of high body mass index or peripheral vascular disease, the right minithoracotomy could have some advantages over other surgical approaches.

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