Conventional aortic aneurysm surgery is a safe and feasible procedure providing excellent outcome. The mortality of elective surgical repair of ascending aortic aneurysms via complete median sternotomy is 3% to 5%. Thoracic aortic repair requires cardiopulmonary bypass and the aneurysm is generally resected and replaced with a prosthetic graft of appropriate size. Depending on the involvement of the aortic root and the valve insufficiency different techniques (e.g. Bentall procedure or David Operations) are established. The standard incision in cardiac surgery is a median sternotomy, which has proven to be a versatile and reliable approach. However minimally-invasive approaches have been developed to reduce morbidity and mortality and offer patients the benefits of open heart operations with decreased pain and limited skin incision and improved cosmesis.
In our institution the minimally invasive approach for aortic valve or aortic aneurysm repair is routine. Nevertheless the minimally invasive approach must be carried out without further risk to the patient or increased difficulty for the surgeon and simultaneously providing a good field for operation. Over the last two decades, different minimally-invasive approaches for aortic valve replacement (AVR) have been developed and are increasingly being utilized. The experience with this approach can be transferred to the surgical repair of the ascending aortic aneurysm.
A limited superior median sternotomy (j-type) has been shown to provide a good exposure for aortic valve. We present our experiences with a minimal invasive approach for a combined procedure of aortic valve repair or replacement and a supracoronary replacement of the ascending aorta.
Between September 2012 and May 2015, 30 patients (range: 33-84 years; w/m: 9/21) underwent primary elective surgery for aneurysms of the ascending aorta in minimal invasive approach via superior ministernotomy in our institution. The operative, perioperative and 30-days follow-up data was analyzed.
A midline skin incision is started approximately 2-3 cm below the jugulum and extended to a maximum of 5-7 cm. The soft tissue over the body- and manubrium sterni is undermined to expose the 1st intercostal space below the manubrium using a pendulum saw. A retractor is inserted and the pericardium is opened through a vertical incision followed by traction sutures to expose the ascending aorta and the right atrial appendage. Two purse- string sutures are placed in the distal ascending aorta, another on the right atrial appendage. Aortic cannulation is performed using a standard 24 F (French). arterial cannula. For venous cannulation a 34/46 F two-stage venous cannula is utilized. A LV-Vent (13F) is inserted transvalvular or via right pulmonary vein.
Cardiopulmonary bypass is started with systemic hypothermia (depending on procedure extent) and cardiac arrest is induced by antegrade cold crystalloid cardioplegia (Custodiol, HTK). After aortic cross clamping , the aortic procedure is performed as it would be in case of a standard median sternotomy with conventional skin incision. At the end of the procedure the sternum is closed with 5 steel wires. Soft tissue is closed with absorbable suture.(Figure 1-3)
RESULTS: Preoperatively, 13 patients had an aortic valve stenosis, 10 an aortic valve insufficiency and 6 a combination of both. David-Procedures were used in 7 Patients and Bentall-technique in 8 Patients. A supra-commissural ascending aorta with (n=10) und without (n=5) valve replacement were performed in 15 patients. Intraoperative TEE and postoperative TTE revealed no residual valve regurgitation after aortic valve repair. One arch repair was realized through limited incision (with cranial expansion of 1cm). All patients survived the procedure. Perioperative morbidity such as neurological complications, wound infection, and sternum instability did not occur. Temporary dialysis was done in 3 Patient with pre-existing renal impairment. Rethoracotomy via the same minimal access for bleeding occurred in one patient. There was no 30- days mortality. Surgical exposition was without exception excellent and no conversion to conventional full sternotomy was needed. Cardipulmonary bypass could be realised without any restriction. Although surgical replacement of aortic arch aneurysms is particularly challenging, it could be successfully performed in one patients without increased difficulty for the surgeon.
CONCLUSIONS: Minimal invasive access in surgery for aneurysms of the ascending aorta including arch repair in selected patients is not only a safe but also a less invasive surgical technique with good cosmetics and excellent patient outcome. Smaller incisions and limited dissection attenuate intraoperative trauma and complications. In addition, patient satisfaction is increased in association with smaller surgical scars and rapid recovery.