Upper Hemisternotomy With Bilateral Transverse Split For Minimally Invasive Cardiac Surgery: Atrial Septal Defect Repair.
Domenico Calcaterra, MD, PhD1, Robert S. Farivar, MD, PhD1, Mohammad Bashir, MD2, Joseph Turek, MD2, Yousuf Mahomed, MD3.
1Minneapolis Heart Institute at Abbott Northwestern, Minneapolis, MN, USA, 2University of Iowa, Iowa City, IA, USA, 3Indiana University, Indianapolis, IN, USA.
OBJECTIVE: the standard paradigm of completing cardiac surgery operations through a median sternotomy has been modified in recent years by the upsurge of minimally invasive techniques which allow to safely perform cardiac operations with better cosmetic results and the potential benefits of faster postoperative recovery and faster return to baseline functional activity. Upper hemisternotomy with right-side split is the most popular minimally invasive approach for minimally invasive aortic valve replacement. This method has also been anecdotally used for replacement of the ascending aorta and aortic root operations. Its main limitation can be represented by the compromised exposure compared to the standard full sternotomy, with the downside that operations other than aortic valve replacement can become more challenging and less safe.
METHODS: we used a simple modification of the standard upper hemisternotomy incision adding a transverse split to the left side of the sternal incision completing a “reverse T” partial upper sternotomy. With this modification we improved significantly the exposure compared to the traditional upper hemisternotomy being able to safely perform more challenging procedures.
RESULTS: we applied this technique initially to minimally invasive aortic valve replacements in patients with body mass index above 30. Subsequently, we were able to safely perform operations of root and ascending aortic replacement, correction of anomalous coronary arteries and tricuspid valve repair or replacement. In the video we show the pericardial patch repair of a secundum type atrial septal defect to illustrate the versatility of this approach. The closure of the reverse-T upper hemisternotomy is completed using stainless steel sternal wires in a modified double-looped technique as demonstrated in the video. We did not encounter any intraoperative or postoperative complications with this approach and results were perfectly comparable to the ones of our traditional upper hemisternotomy aortic valve replacements.
CONCLUSIONS: we believe that this simple modification can add safety to operations performed through an upper hemisternotomy and expand the applicability of this approach to cardiac surgery procedures.
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