Minimal Invasive Cardiac Surgery for Aortic Valve Replacement Through an Upper Mini-Sternotomy: Multicenter Experience

Abstract

Background: Aortic valve replacement (AVR) by minimally invasive cardiac surgery (MICS) performed through an upper mini-sternotomy has reduced pain after surgery, the risk of bleeding, and the length of hospital stay. Patients and Methods: From January 2019 until December 2022, 230 patients underwent AVR through a partial upper sternotomy (J or inverted-L). The study assessed our early experience with AVR via mini-sternotomy, including cannulation, the progression of the learning curve and patient selection, and finally morbidity and mortality. Results: Early mortality was 1% (2 patients), and morbidities were 4% (4 patients). The average age was 58 ± 9.7. The mean Euro-SCORE was 4.7% ± 3.2 and the ejection fraction (EF) was 40% ± 4.3. The cannulation was performed peripherally in the femoral artery and vein by the direct or percutaneous approach; however, three cases required central cannulation. The average aortic cross clamping time (ACC) for MICS-AVR patients was 83 ± 17 minutes, and the cardiopulmonary bypass (CPB) time was 114 ± 34 minutes. The mean duration of mechanical ventilation (MV) was 4.3 ± 2.5 hours, the average stay in an intensive care unit (ICU) was 1.4 ± 1.2 days, and the mean hospital stay was 4.3 ± 1.3 days. 30-day mortality was 2 patients (1%). The incidence of blood loss and reopenings for bleeding decreased. Conclusions: An upper mini-sternotomy can be used safely to replace an aortic valve, and the minimally invasive approach was not associated with increased morbidity or mortality.

Full text

BOHR International Journal of Research on Cardiology and Cardiovascular Diseases
2022, Vol. 1, No. 1, pp. 28–30
https://doi.org/10.54646/bijrccd.004
www.bohrpub.com
Minimal Invasive Cardiac Surgery for Aortic Valve Replacement
Through an Upper Mini-Sternotomy: Multicenter Experience
Yasser Mubarak
Faculty of Medicine, Minia University, Minia, Egypt
Madinah Cardiac Center, King Fahd Hospital, Madinah, Saudi Arabia
King Salman Heart Center, King Fahd Medical City, Riyadh, Saudi Arabia
E-mail: yassermubarak73@gmail.com
Abstract.
Background: Aortic valve replacement (AVR) by minimally invasive cardiac surgery (MICS) performed through an
upper mini-sternotomy has reduced pain after surgery, the risk of bleeding, and the length of hospital stay.
Patients and Methods: From January 2019 until December 2022, 230 patients underwent AVR through a partial
upper sternotomy (J or inverted-L). The study assessed our early experience with AVR via mini-sternotomy,
including cannulation, the progression of the learning curve and patient selection, and finally morbidity and
mortality.
Results: Early mortality was 1% (2 patients), and morbidities were 4% (4 patients). The average age was 58 ±9.7.
The mean Euro-SCORE was 4.7% ±3.2 and the ejection fraction (EF) was 40% ±4.3. The cannulation was performed
peripherally in the femoral artery and vein by the direct or percutaneous approach; however, three cases required
central cannulation. The average aortic cross clamping time (ACC) for MICS-AVR patients was 83 ±17 minutes, and
the cardiopulmonary bypass (CPB) time was 114 ±34 minutes. The mean duration of mechanical ventilation (MV)
was 4.3 ±2.5 hours, the average stay in an intensive care unit (ICU) was 1.4 ±1.2 days, and the mean hospital stay
was 4.3 ±1.3 days. 30-day mortality was 2 patients (1%). The incidence of blood loss and reopenings for bleeding
decreased.
Conclusions: An upper mini-sternotomy can be used safely to replace an aortic valve, and the minimally invasive
approach was not associated with increased morbidity or mortality.
Keywords: Mini-sternotomy, minimal invasive cardiac surgery, upper partial sternotomy, aortic valve replacement.
INTRODUCTION
Partial upper sternotomies are described for a mini-
mally invasive approach to valvular and ascending aortic
surgery [1]. Nowadays, MICS-AVR is growing to be per-
formed by many surgeons [2]. MICS-AVR did not increase
morbidity or mortality; however, they may be reduced
without compromising the excellent outcome. It reduced
postoperative bleeding, the need for blood transfusions,
the length of stay in the hospital, and sternal dehiscence [3].
Upper mini-sternotomy improves surgical outcome and
reduces morbidity in AVR [4]. Other authors enumerated
disadvantages of the minimally invasive approach, like
longer CPB and ACC times and an increased incidence
of stroke due to retrograde perfusion through femoral
cannulation [5].
METHODS
In MICS-AVR, all surgical steps were similar to a standard
full sternotomy except those steps. A roll is placed behind
the right shoulder to elevate that side 30◦–45◦. External
defibrillator pads are placed because we cannot use inter-
nal pads due to a small incision.
The sternum was incised down to the 4th space with
preservation of the right internal thoracic artery (RITA)
28

Minimal Invasive Aortic Valve Replacement 29
Figure 1. Partial upper sternotomy intraoperative.
(Figure 1). A smaller sternal retractor is used. We began
with central aortic and right atrial cannulation, then moved
on to femoral cannulation via open cut-down or Seldinger
technique. Transesophageal echocardiography (TOE) was
used to evaluate cannulation, de-airing, and valve function
after replacement.
Pacing wires are inserted during the arrest. Only four
stainless steel wires are used to approximate the sternal
halves.
RESULTS
The study began in January 2019 and will conclude in
December 2022, with 230 patients undergoing isolated
AVR via a mini sternotomy. Postoperative results for early
(3 months) and midterm (1 year) were followed up. Early
mortality was 1% (2 patients) due to stoke postoperatively
and prolonged mechanical ventilation.
The stroke was related to old age and a history of previ-
ous strokes. Also, there were 4% (4 patients) with different
morbidities: (i) heart failure due to severe aortic insuffi-
ciency (AI); (ii) late mild ischemic stroke resolved without
deficit; (iii) trivial paravalvular leak without hemolysis
treated with follow-up; and (iv) injury of the right internal
thoracic artery and ligation (with clip). The average age
was 58 ±9.7 years.
The average Euro-Score was 4.7% ±3.2, with an EF of
40% ±4.3. The mean ACC time for patients with MICS-
AVR was 83 ±17 minutes and the mean CPB time was 114
±34 minutes. The mean time of MV was 4.3 ±2.5 hours,
the average time in the ICU was 1.3 ±1.2 days, and the
average stay in the hospital was 4.2 ±1.3 days.
There was no case of bleeding and wound infection. No
conversion to sternotomy was performed.
DISCUSSION
The main drawback of the mini-sternotomy approach is the
difficulty of de-airing [6]. There was no problem during de-
airing by CO2insufflation, Trendelenburg position, aortic
root, and TOE.
Mini-sternotomy AVR is a safe procedure with the same
efficacy as a full sternotomy [4]. As the number of patients
increases, so does the learning curve and the efficacy of the
technique.
In MICS-AVR, there is no risk of complete sternal dehis-
cence and an early return to work [7]. As in our cases, there
was no sternal rocking or infection.
MICS-assisted AVR has the same mortality and post-
operative stroke as standard sternotomies [1]. Also, in
our cases, a minimal approach or access did not increase
mortality.
A J-shaped mini-sternotomy or partial upper sternotomy
is an approach that concerns decreasing surgical trauma,
enhancing convalescence, and improving the cosmesis of
the incision [8]. Other investigators have not been able to
show any advantage to MICS-AVR approaches except a
smaller incision [3]. Our research confirmed that this was
not just a cosmetic approach, but that it was also safe and
effective. It also improved the outcome.
CONCLUSION
MICS-AVR is a safe and effective procedure. It has the
advantage of a small cosmetic incision, patient satisfaction,
and an early return to normal activity without increasing
morbidities or mortalities.
ABBREVIATIONS
ACC: Aortic Cross Clamp, AI: Aortic Insufficiency, ARE:
Aortic Root Enlargement, CPB: Cardio Pulmonary Bypass,
EF: Ejection Fraction, MICS-AVR: Minimal Invasive Car-
diac Surgery Aortic Valve Replacement, ICU: Intensive
Care Unit, TOE: Trans Esophageal Echography, MV:
Mechanical Ventilation, RITA: Right Internal Thoracic
Artery.
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30 Yasser Mubarak
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