Minimally Invasive Aortic Root Surgery: Mid-term Results in a 2-year Follow-up

Background: Minimally invasive surgery (MIS) offers an alternative to the standard full-sternotomy access to the aortic root. We report our 5-year single center results for aortic root surgery via a minimally invasive approach in terms of clinical data, complication rates, occurrence of major adverse cerebral or cardiac events (MACCE) as well as the patients' satisfaction with the operative result in a two-year follow-up.

Methods: Between 01/2012 and 12/2016 a total of 45 consecutive patients (71% male; age 59 ± 10 years; BMI 28 ± 4 kg/m²; EuroSCORE II 3.6 ± 2.6; NYHA 2.0 ± 0.8, EF 53 ± 9%) with either an ascending aortic aneurysm (n = 43; mean diameter: 55 ± 6 mm) or a type-A-dissection (n = 2) underwent an aortic root replacement via an upper partial “J”-shaped sternotomy: Bentall procedure was performed in 35 patients, in 17 (49%) using a biological, in 18 (51%) a mechanical prosthesis, whereas 10 patients received valve-sparing aortic root replacement in David technique. 30-day outcome and mortality was documented in all patients. The post-operative follow up was completed by interviewing the patients and their referral physicians in a 6-month, 1-year and 2-year interval.

Results: In all patients J-shaped sternotomy was applied. Mean operation times was 293 ± 72 minute, CPB-time 178 ± 55 minutes, cross-clamp time 135 ± 33 minutes. Re-thoracotomy due to persistent postoperative bleeding was needed in 6 (13%) patients. No deep sternal infection or sternum instability occurred. Hospitalization Time was 12 ± 4 days, with no MACCE registered; mean ICU-stay was 2 ± 1 days with a ventilation-time of 11 ± 6 hours. The 30-day mortality rate was 0%. The 6-month-, one- and two-year follow up was competed in 86%, 84% and 51%. Re-do surgery on the aortic root was necessary in 2 (4%) patients with failed valve reconstruction, who finally received a Re-Bentall. Mortality and stroke rates of the entire MIS-aortic root cohort were 2.5% each after 1 year and 4% after two years. 82% declared their satisfaction with the cosmetic result and 61% stated a better post-operative condition.

Conclusion: The MIS via an upper partial sternotomy is a safe approach for the aortic root. Although it requires a longer operation time than the conventional access, it is associated with an excellent outcome. Mid-term survival is at least comparable to that reported for conventional sternotomy with a high patient's contentment, especially regarding the short recovery and the cosmetic result.