Elsevier

Cardiovascular Surgery

Volume 10, Issue 4, August 2002, Pages 333-338
Cardiovascular Surgery

Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy

https://doi.org/10.1016/S0967-2109(02)00026-1Get rights and content

Abstract

Background: the theoretical advantages of mini-invasive cardiac surgery are shorter hospitalisation, better surgical results and costs reduction. In November 1997 we started a non-coronary mini-invasive surgery program using a partial upper median sternotomy. This study has been conceived to retrospectively compare two groups of patients who underwent isolate aortic valve replacement using the conventional and the mini-invasive technique.

Material and methods: in Group A 100 patients (mean age 62±12 years; 58 male) underwent isolated aortic valve replacement through a partial upper median sternotomy. Group B was composed by the last 100 patients (mean age 63±8 years; 56 male) who underwent the same operation through a conventional median sternotomy. For both groups we recorded the ECC and ischaemic times, postoperative intubation time, total postoperative bleeding, intensive care unit length of stay and total hospitalisation time. Major and minor complications were reported.

Results: operating times, were significantly longer in Group A (p<0.001). Mechanical ventilation time, ICU and total hospital stay, and total postoperative bleeding showed no significant difference. Adjunctive statistical evidenced the absence of learning curve. Mortality and other complications failed to reveal any significant difference between the two groups.

Conclusions: in our experience, partial upper median sternotomy does not increase surgical risks but failed to demonstrate clear advantages. Apart for an increase in operating times, the surgical results are similar to those of a conventional median sternotomy with only improvement in the aesthetical aspect. In our opinion, this supports the conviction that this approach can be proposed to selected patients, to obtain a better cosmethical result for the same given risk.

Introduction

During the last few years mini-invasive surgery has become a standard surgical approach virtually in all types of surgery. The theoretical advantages gained through mini-invasive surgery, which can validate this techniques, is to shorten hospitalisation and improve the surgical results, including the aesthetical, and consequently reducing global medical costs. As in other surgical fields, also in cardiac surgery, during the last few years, the new so-called mini-invasive techniques have rapidly developed and gained field of interest.

Coronary mini-invasive surgery has been the first to be implemented to reduce surgical invasiveness for the patient. As a matter of fact, today, surgical revascularization of left anterior descending coronary artery by using left internal thoracic artery is the main indication to use a left anterior small thoracotomy (LAST) [1].

More recently, different mini-invasive approaches have been developed for different cardiac operations apart from myocardial revascularization. Navia and Cosgrove [2], [3] first proposed a right longitudinal parasternal approach for cardiac valves surgery. Konertz and Waldenberger, and Svensson and D’Agostino [4], [5] described a mini-invasive approach to the same structures through a shorter median sternotomy, with initial very satisfactory results. A transverse sternotomy has been used to operate on the aortic valve. Chitwood et al. and Carpentier et al. [6], [7], [8] used video-assisted surgery to operate on the mitral valve through a small right lateral thoracotomy.

Various mini-invasive approaches, with very small differences among each other, have been developed [9], [10], [11], [12], [13]. Each of them has some technical disadvantages, like removal of costal cartilages, cut through of the mammary arteries, cannulation of the groin vessels or the use of complex surgical aids, expensive and difficult to use with longer learning curve.

In November 1997 at the Cardiac Surgical Department of S.Giovanni Di Dio e Ruggi d’Aragona General Hospital in Salerno (Italy), we started a program for non-coronary mini-invasive surgery using a partial upper median sternotomy through an 8 cm longitudinal cutaneous incision.

This study has been conceived to retrospectively compare a group of patients who underwent aortic valve replacement using this technique, with another group of patients operated on for the same pathology through a conventional median sternotomy.

Section snippets

Material and methods

Between November 1997 and November 1999. in our department, 212 patients underwent a cardiac operation through a median partial upper sternotomy. One hundred of them underwent isolated aortic valve replacement. This group was named Group A and was compared to Group B, composed by the last 100 patients who underwent the same operation, before the starting of the new technique, through a conventional median sternotomy. In group A mean age was 62±12 years; 58 patients were male, 52 patients

Results

Operating times, taking into consideration extra corporeal circulation and cardiac ischaemia times, were significantly longer in Group A (82.4±22 min vs 66.8±16 and 63.8±17.2 min vs 50.2±13 min, respectively), (p<0.001). Mechanical ventilation time, ICU length of stay and total hospital stay, on the opposite, showed no statistical significant difference. Total postoperative bleeding failed to show statistical difference between the two groups. These data are illustrated in Table 2.

In order to

Discussion

During the last few years reduction of surgical invasiveness through mini-invasive techniques has gained increasing interest; growing enthusiasm towards these approaches has been stimulated by the recognition of their efficacy in different surgical specialties.

In cardiac surgery, the classical approach to the cardiac structures takes place through a median sternotomy, that gives an optimal view of the heart and great vessels. Postoperative bleeding, thoracic pain, chest wall instability with

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