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