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DOI: 10.1055/s-0044-1782186
Isolated or Combined Ascending Aortic Replacement through a Partial Sternotomy: Early and Midterm Outcomes
Abstract
Background We aimed to investigate the in-hospital and midterm outcomes of patients undergoing ascending aortic replacement (AAR) through a partial or a full sternotomy approach through a propensity matching analysis.
Methods We retrospectively included all patients (n = 167) who underwent elective AAR in our institution between 2013 and 2020. The study population was divided into two groups according to the surgical access (40 patient in the partial sternotomy or “PS” group and 127 in the full sternotomy or “FS” group). Due to the significant differences between the groups, a propensity matching of 1:3 was applied. In-hospital complications, survival, and reoperation at follow-up were investigated.
Results The PS group showed higher cross-clamp and cardiopulmonary bypass times than the FS group (94.2 vs. 83 minutes and 164.2 vs. 126.8 minutes, respectively). Moreover, the postoperative ventilation time was significantly higher in the PS group, but it did not affect the length of stay in the intensive care unit (ICU). The incidences of bleeding, stroke, and mortality were comparable between the two groups (11 vs. 3%, 3 vs. 6%, and 5 vs. 3%, respectively). After a median follow-up of 2 ± 1.98 years, the Kaplan–Meier analysis showed no significant differences between the two groups (log-rank, p = 0.17) in terms of survival.
Conclusion The surgical ascending aorta replacement through a partial sternotomy is associated with longer operative times, but this does not affect the early as well as the long-term follow-up.
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Introduction
Proximal thoracic aortic aneurysm is a life-threating pathology that can potentially lead to aortic dissection or rupture. Although there are advances in endovascular technologies, which are under investigational use at the time of writing, surgical aortic valve replacement remains the gold standard of treatment.[1] However, if the operative mortality among patients having elective surgery is low, the perioperative complications are considerable. In a recent multicenter analysis of the Society of Thoracic Surgeons (STS) database, the mortality was 2.2%, while the incidence of perioperative complications was 48.2%.[2] Moreover, the patients surviving surgery showed a significantly higher mortality at long-term follow-up (FU) compared with a matched group.[3] Given the high impact of surgical aortic repair (SAR) on both survival and morbidity, advances and improvements in surgical techniques that are able to reduce this impact on patient's life are desirable.
Minimally invasive approaches, such as partial sternotomy (PS), could reduce the surgical trauma and were proven to be safe for valve-related procedures.[4] [5] SAR has been historically performed with full sternotomy (FS). Only few studies up to now have investigated the outcome of SAR through a PS approach.[6] [7] [8]
We aimed to investigate the short- and mid-term outcomes of patients undergoing SAR through a PS or an FS approach through a propensity matching analysis.
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Methods
Patient Selection
We conducted a retrospective cohort single-center study, considering all consecutive patients undergoing elective SAR in our institution between January 1, 2013 and December 31, 2020. Patients who received a surgical treatment in cases of emergency situations for aortic dissection were excluded. Patients younger than 18 years, pregnant patients, patients suffering from tumor, endocarditis patients, or patients who needed a combined mitral valve and myocardial revascularization intervention were also excluded from the study. In total, 167 patients met the inclusion criteria and were included in the analysis. Of these, 127 received an FS, while 40 received a PS. Every patient underwent a preoperative echocardiography and computed tomography for assessment and anatomical definition of the underlying aortic disease.
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Surgical Techniques
All the patients were treated in a standard operating room in general anesthesia, with cardiopulmonary bypass (CPB) and hypothermia. The decision to perform a median full FS or a PS was left at the discretion of the surgeon. During the observational period, one surgeon, performing the replacement procedure, used the access through a partial upper sternotomy. The PS was performed in the fourth intercostal space, allowing the central cannulation and a perfect surgical view ([Figs. 1] and [2]). In both cases, the preferred arterial cannulation site was the brachiocephalic trunk, thus allowing a complete resection of the ascending aorta with selective cerebral perfusion and moderate hypothermic circulatory arrest; alternatively, the distal ascending aorta, one of the carotid arteries, or the aortic arch were cannulated. Arterial cannulation at the right axillary artery, in general, is another option for establishing CPB, but it is not routinely performed for elective surgeries in our institution, for many reasons. First, it requires an additional cut, and in case of direct cannulation it can leave the upper limb without perfusion (depending on the calibers of vessel and cannula). Furthermore, the flow is—even though for a short time—retrograde. The caliber of the innominate artery, on the other hand, is larger, allowing in most cases the insertion of a larger caliber cannula even directly, without the interposition of vascular prostheses. The innominate artery can be reached through the same surgical incision necessary to perform the operation and allows the head and the right upper limb to be perfused in an anterograde manner at the same time, thus allowing direct monitoring of the perfusion pressures during the operation, particularly during the selective cerebral perfusion phase. Therefore, it was not used in the patient cohort in this study. The venous cannulation site was the right atrium in case of FS and the superior vena cava in the case of PS. The latter technique was already reported as standard for isolated aortic valve replacement in PS.[9] In case of concomitant aortic valve pathologies, a repair or a valve replacement was performed. An aortic valve repair was performed if a successful result was expected. The performed reconstruction techniques depended on the defect pathology. Cusp stretching, cusp defect patching, annulus ring (BioStable, United States), or a combination of these were used to gain sufficient aortic valve closure. The valve replacements were performed with a mechanical or biological valve in accordance with patient̀s preferences. Some patients required an additional aortic arch replacement. This included hemiarch replacement as well as full arch replacements in some cases. For easier evaluation, there was no differentiation of both arch replacement options, and the numbers were summarized.
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Outcomes
The postoperative outcomes were defined along the guidelines accounting for mortality and morbidity in cardiac valve interventions.[10] Early mortality was defined as in-hospital death or death 30 days after surgery. A stroke was defined as a newly appearing neurological impairment, either temporary (>72 hours) or permanent, diagnosed by adequate imaging technique. Bleeding complications, like pericardial effusion or intrathoracic bleeding, were included if reoperation or subcutaneous intervention was necessary. The primary outcomes were in-hospital mortality and complications. The secondary outcomes were survival and major adverse events at FU.
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Data Collection and Follow-Up
The pre-, intra-, and postoperative characteristics as well as FU data were obtained for every patient. In-hospital data were retrieved from our internal prospective digital register. FU data were collected regarding survival, stroke, myocardial infarction, which was defined as an ischemic myocardial damage with clinical symptoms, detected by elevated cardiac troponin and ischemic electrocardiographic (ECG) changes, cardiac reoperation, and permanent pacemaker implantation.
FU was via telephonic contact with the patient or the general practitioner, if possible and permitted by privacy policy, or according to data of subsequent hospital stays.
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Statistical Analysis
Data were checked for data consistency and normality as well as gamma distributions using Kolmogorov–Smirnov tests. The descriptive results were presented as mean and standard deviation, number (%), or median with interquartile range. Due to the significant differences between the two groups regarding age, gender, body mass index (BMI), European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), and a combined aortic valve operation ([Table 1]), an optimal propensity score matching with a 1:3 ratio was performed. Age, BMI, gender, and EuroSCORE II were used as covariate variables and the propensity score was computed based on the combined aortic valve operation. The Mahalanobis distance including the propensity score was used as the distance calculation method. The order for matching was done at random. No maximum number of iterations was set for the optimization algorithm. Thirty-eight patients with PS and 118 with FS were selected for the matching, which was conducted along the previously mentioned variables. Fisher's exact test, Pearson's chi-squared test, t-tests, and bootstrap-t-tests were used to analyze the independence of all pre-, intra-, and postoperative characteristics as well as FU variables for significance.
Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; CPB, cardiopulmonary bypass; EuroSCORE II, European System for Cardiac Operative Risk Evaluation II; FU, follow- Up; ICU, intensive care unit; IMC, intermediate care unit; LVEF, left ventricular ejection fraction.
Note: Values are presented as mean (±standard deviation), number (%), or median [interquartile range].
Generalized linear models based on gamma distributions and the logarithm as link function were used to compare various variables between the two patient groups. A Kaplan–Meier analysis was performed to compare the overall survival in both groups over time and a two-sided log-rank test to compare the overall survival. A p-value less than 0.05 was considered statistically significant. All analyses were done using NCSS (NCSS 10, NCSS, LLC., Kaysville, UT) and STATISTICA 13 (Hill, T. & Lewicki, P. Statistics: Methods and Applications. StatSoft, Tulsa, OK).
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Results
After propensity score matching was performed ([Fig. 3]), there were38 patients in the PS group and 118 in the FS group. A significant difference, regarding the ejection fraction, remained after matching ([Table 1]). To avoid further reduction of the study population, this variable difference was tolerated.
[Table 2] shows the intraoperative variables for the PS and FS groups. Regarding the arterial perfusion strategy, there was no statistical difference between the groups according to the cannulation site for CPB. The majority of patients were operated on with a brachiocephalic cannulation (PS = 68% vs. FS = 63%, p = 0.3) and selective cerebral perfusion (PS = 68% vs. FS = 59%, p = 0.3) in both groups. Further, no difference was observed in the rate of combined aortic arch replacement surgery additive to the replacement of the ascending aorta. A significant difference, between these two groups, could be seen in the ratio of combined aortic root replacement, which was more often performed in the FS group, precisely 22 patients in the FS group versus 1 patient in the PS group. While there was no discrepancy, in general, among the two groups in terms of associated aortic valve surgical intervention, an associated aortic valve pathology was noted more frequently in patients undergoing valve reconstruction: 14 patients (37%) in the PS group versus 18 patients (15%) in the FS group. There was no statistical significance between both groups in the ratio of aortic valve replacement. As the underlying pathology that led to an aortic valve intervention, stenosis and combined aortic valve stenosis and insufficiency occurred equally in both groups, but an aortic valve insufficiency was more often detected as the leading valve pathology in the PS group. Half of the patients treated with a partial upper sternotomy in the matched population suffered from an aortic valve insufficiency.
Abbreviations: CPB, cardiopulmonary bypass; FS, full sternotomy; PS, partial sternotomy.
Note: Values are presented as mean (±standard deviation), number (%), or median [interquartile range].
Notably, no operation started with a partial upper sternotomy had to be converted to a median FS during the operation. Regarding the three specific cardiac surgery timelines, the operation time, from dermal incision up to dermal suturing, the cross-clamp time, and the CPB time, a statistically significant difference could be observed, showing a prolonged duration of all three time variables in the PS group of 270 minutes (SD, ± 63.4) and 218.9 minutes (SD, ± 53.6) for operation time, cross-clamp time with means of 94.2 (SD, ± 26.6) minutes and 83 (SD, ± 26.1) minutes, and CPB time with means of 164.2 (SD ± 47.2) minutes and 126.8 (SD, ± 37.1) minutes.
[Table 3] shows the postoperative in-hospital outcomes. The postoperative ventilation time was significantly prolonged in the PS population, with a mean of 41.5 (SD, ± 98.8) versus 22.5 (SD, ± 58.5) hours of ventilation time on average in the FS group. However, this did not affect the length of intensive care unit (ICU) stay, which was not statistically different between the groups. Furthermore, no significant difference could be detected in the rate of reintubation, stroke, mortality, revision due to active bleeding, postoperative pacemaker implantation, or sternal wound complications. With an average hospital stay of 11.8 (SD, ± 7.1) days in the PS group and 10.9 (SD, ± 4.7) days in the FS group, no significant differences in the overall hospital stay could be observed between the two groups.
Abbreviations: FS, full sternotomy; ICU, Intensive care unit; IMC, Intermediate care unit; IQR, interquartile range; PS, partial sternotomy.
Note: Values are presented as mean (±standard deviation), number (%), or median [interquartile range].
The mean FU was 2 (±1.98) years, without significant differences between the groups ([Table 4]). The FU was conducted in the first quartile in 2022 and only one patient (in the PS group) could not be reached. The patients of the PS group reported no complications like stroke and myocardial infarction or implantation of a cardiac pacemaker. Regarding these outcomes, no statistically significance between both groups could be found. Cardiac reoperations were observed in two patients (6%) of the PS group and in eight (7%) patients of the FS group. The reason for the reoperation was hemodynamic relevant pericardial effusion in the PS group, which was successfully treated with a subxiphoid drainage placement. In the FS group, patients were reoperated because of pericardial effusion (n = 3), sternal complications (n = 2), tricuspid valve insufficiency (n = 1), aortic valve replacement (n = 1), or tube prosthesis endocarditis by Streptococcus gallolyticus (n = 1). The overall survival was over 90% in both groups at the time of FU and there was no significant difference between the two groups. Thirty-three of 35 patients (94%) in the PS group and 110 of 115 patients (96%) in the FS group were alive on the date of FU performance. The Kaplan–Meier analysis showed no significant differences between the PS and FS group (log-rank, p = 0.17; [Fig. 4]).
Abbreviations: FS, full sternotomy; IQR, interquartile range; PS, partial sternotomy; SD, standard deviation.
Note: Values are presented as mean (±standard deviation), number (%), or median [interquartile range].
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Discussion
Surgical aortic replacement is a major operation burdened by mortality and morbidity. Because of the continuous development of new surgical approaches and modern operation techniques, which potentially lead to better acceptance in the population of potential patients, this retrospective study aimed to investigate the outcomes and survival of patients who underwent a minimally invasive partial upper sternotomy in comparison to patients who received the same treatment through the current gold standard access, a median FS.
In our retrospective study we found the following:
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The PS approach for aortic surgery (when compared with the FS approach) is associated with longer operative and ventilation time.
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This fact did not negatively affect the in-hospital outcomes.
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There were no differences in the midterm FU as well.
The longer operative times in the PS group could be due to the difficulties associated with the procedure, but there could be other causes as well. The PS group had a significantly higher incidence of aortic valve reconstruction (37 vs. 15%), which could be more time-consuming than a standardized replacement. The significantly higher rate of additional aortic valve repair operations in the PS group is most likely the result of the underlying aortic valve pathology as evident from the isolated aortic valve insufficiency found in 50% of the patients in the PS group. On the other hand, the FS group had a higher incidence of root replacements (mostly according to Yacoub's technique, but also David or Bentall–De Bono technique). However, the latter procedures are (although time-consuming) highly standardized in comparison with a valve replacement, which needs additional time for inspection and verification of the results (not only during cardioplegic arrest, but also during CPB weaning with the transesophageal echocardiography).
In the absence of higher major bleedings or reintubation rates, the prolonged mechanical ventilation times can be easily explained by a hemodynamic instability in the immediate hours following the longer surgical and CPB times. Interestingly, neither the longer operative time nor the prolonged ventilation times did affect the postoperative course. The length for ICU and intermediate care unit (IMC) stay or hospital stay was not different to that of the FS group. The noninferiority regarding the postoperative course was found also in the midterm FU. These results support the conduction of an aortic surgery through a minimally invasive approach as an alternative to the present standard of care.
Our study is one of the few studies investigating this approach for aortic surgery. Recently, Haunschild et al[8] found in their retrospective study that the combined treatment of an ascending aortic aneurysm and an additional aortic valve pathology through a minimally invasive partial upper sternotomy was not inferior, regarding morbidity and mortality, to the FS. With 117 patients in the PS group and 234 in the FS group, a 1:2 propensity score matching was performed for adequate comparison of the population results. Thereby, no significant difference could be observed in the postoperative and FU complication and cardiac reoperation rates. Our results are in line with those of Haunschild et al. However, it is worth mentioning that there was discrepancy in the length of FU (median: 466 vs. 234 days) in their study.
Deschka et al[11] investigated a population of 50 patients, who received surgical treatment for ascending aortic aneurysm and eventually combined aortic arch replacement and/or aortic valve intervention via a partial upper sternotomy. With a mean total operation time of 249 (±51) minutes, cross-clamp time of 95 (±27) minutes, and CPB time of 141 (±35) minutes, this study, with a comparable number of patients to our study, observed intraoperative results that slightly deviate from our surgery times.
As Haunschild et al[8] mentioned, the experiences with partial superior sternotomy in general is an important parameter, especially their influence on surgical times. Performing surgical procedures like the isolated aortic valve replacement via a PS form the basis of future minimally invasive perspectives, which is routinely used in our institution since 2010. This indicates a constant increase of experience with this access, and therefore makes it more usable for different operations. Speaking about prolonged surgery, there is also the financial argument to be taken in consideration, which in the end should not be the limitation of inventing new techniques.
Besides the prolonged surgical times, the rates of stroke (3% in the PS group in our study; 0.9% in Haunschild et al[8] and 2% in Deschka et al[11]), revision for bleeding (11% in the PS group in our study; 3.4% in Haunschild et al[8] and 2% in Deschka et al[11]), or major postoperative complications showed only small deviations between our study and Haunschild et al[8] and Deschka et al.[11] The rates of in-hospital mortality, which is 5% in the PS group in our study versus 1.7% in Haunschild et al,[8] are comparable at a low level.
As the findings in our study and the above-mentioned studies suggest, PS is as safe as the current gold standard, that is FS. As seen in other surgical scenarios, minimally invasive approaches are increasingly applied. The advantages of minimally invasive aortic valve surgery include smaller skin incision, lower bleeding rate, lower postoperative pain, fewer blood product transfusions, faster mobilization, and reduced stay in the ICU.[12] Under these perspectives, the present study, supporting the evidence that minimally invasive access can be performed without risks to the patient, can act as a trailblazer for future randomized studies with a larger population which will be able to ascertain what benefits (in comparison with FS) PS can bring or possibly in which subgroup of patients, if not in all patients. Our study collected results from the whole consecutive patient population, independently from the complexity of the operation. Hypothetically, better results could be found in isolated ascending aortic replacement. Nonetheless, future studies should investigate, in a prospective design, not only subjective parameters (like pain or satisfaction with their postoperative results) but also rehabilitation times for reestablishment of functional capacity and exercise performance. Finally, we must not forget that offering a less invasive surgery can also psychologically help patients to accept the operation.
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Limitations
Nevertheless, there are a few limitations of this study. The first limitation is the retrospective and single-center nature of the study. Moreover, with 38 patients operated via partial upper sternotomy, the PS group is quite small in comparison to the FS group. Although propensity score matching was performed along some preoperative variables, some factors (e.g., preoperative LVEF and combined aortic valve reconstruction and aortic root replacement) were not matched, leading to some inhomogeneity between the two groups. This could add some bias to the results, affecting, for example, differences in the operation times.
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Conclusion
The surgical ascending aorta replacement through a PS is associated with longer operation, cross-clamp, CPB, and ventilation times in comparison with an FS. This fact does not affect the length of ICU and in-hospital stay or the rate of bleeding, stroke, and mortality. The survival and reoperation rates at FU are comparable between the PS and FS groups. Surgical ascending aorta replacement can be safely performed through a minimally invasive approach.
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Conflict of Interest
None declared.
Note
A part of the present study was performed in fulfilment of the requirements for obtaining the doctoral degree of M. Angerer.
Ethical Approval Statement
This study was approved by the hospital study center (SZ_D_159.21-I-6) and institutional review board of the Paracelsus Medical University–Campus Nuremberg (IRB-2022–015) and was conducted in accordance with the principles of the Declaration of Helsinki. A written consent was obtained from all patients for the anonymous use of in-hospital data, while a verbal consent was obtained for the telephonic follow-up.
Authors' Contribution
M.A. contributed to data collection and validation, interpretation of data, drafting of the manuscript. F.P. contributed to conception and design, data collection and validation, interpretation of data, drafting of the manuscript. W.H. contributed to statistical analysis and interpretation of data. L.W. contributed to data collection and revising of the manuscript. J.S. contributed to data collection and revising of the manuscript. T.F. contributed to critical revision of the manuscript.
* These authors contributed equally and are joint first author.
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References
- 1 Isselbacher EM, Preventza O, Hamilton Black Iii J. et al; Writing Committee Members. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80 (24) e223-e393
- 2 Mori M, Shioda K, Wang X. et al. Perioperative risk profiles and volume-outcome relationships in proximal thoracic aortic surgery. Ann Thorac Surg 2018; 106 (04) 1095-1104
- 3 Skoglund Larsson L, Ljungberg J, Johansson L, Carlberg B, Söderberg S, Brunström M. Survival after surgery of the ascending aorta: a matched cohort study. Eur J Cardiothorac Surg 2022; 62 (03) ezac161
- 4 Paparella D, Malvindi PG, Santarpino G. et al. Full sternotomy and minimal access approaches for surgical aortic valve replacement: a multicentre propensity-matched study. Eur J Cardiothorac Surg 2020; 57 (04) 709-716
- 5 Russo MJ, Thourani VH, Cohen DJ. et al. Minimally invasive versus full sternotomy for isolated aortic valve replacement in low-risk patients. Ann Thorac Surg 2022; 114 (06) 2124-2130
- 6 Lentini S, Specchia L, Nicolardi S. et al. Surgery of the ascending aorta with or without combined procedures through an upper ministernotomy: outcomes of a series of more than 100 patients. Ann Thorac Cardiovasc Surg 2016; 22 (01) 44-48
- 7 Staromłyński J, Kowalewski M, Sarnowski W. et al. Midterm results of less invasive approach to ascending aorta and aortic root surgery. J Thorac Dis 2020; 12 (11) 6446-6457
- 8 Haunschild J, van Kampen A, von Aspern K. et al. Supracommissural replacement of the ascending aorta and the aortic valve via partial versus full sternotomy-a propensity-matched comparison in a high-volume centre. Eur J Cardiothorac Surg 2022; 61 (02) 479-487
- 9 Pfeiffer S, Fischlein T, Vogt F, Santarpino G. Superior vena cava cannulation in aortic valve surgery: an alternative strategy for a hemisternotomy approach. Interact Cardiovasc Thorac Surg 2015; 20 (06) 863-865
- 10 Akins CW, Miller DC, Turina MI. et al; STS, AATS, EACTS. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008; 85 (04) 1490-1495
- 11 Deschka H, Erler S, Machner M, El-Ayoubi L, Alken A, Wimmer-Greinecker G. Surgery of the ascending aorta, root remodelling and aortic arch surgery with circulatory arrest through partial upper sternotomy: results of 50 consecutive cases. Eur J Cardiothorac Surg 2013; 43 (03) 580-584
- 12 Young CP, Sinha S, Vohra HA. Outcomes of minimally invasive aortic valve replacement surgery. Eur J Cardiothorac Surg 2018; 53 (Suppl. 02) ii19-ii23
Address for correspondence
Publication History
Received: 05 September 2023
Accepted: 02 February 2024
Article published online:
16 April 2024
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References
- 1 Isselbacher EM, Preventza O, Hamilton Black Iii J. et al; Writing Committee Members. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80 (24) e223-e393
- 2 Mori M, Shioda K, Wang X. et al. Perioperative risk profiles and volume-outcome relationships in proximal thoracic aortic surgery. Ann Thorac Surg 2018; 106 (04) 1095-1104
- 3 Skoglund Larsson L, Ljungberg J, Johansson L, Carlberg B, Söderberg S, Brunström M. Survival after surgery of the ascending aorta: a matched cohort study. Eur J Cardiothorac Surg 2022; 62 (03) ezac161
- 4 Paparella D, Malvindi PG, Santarpino G. et al. Full sternotomy and minimal access approaches for surgical aortic valve replacement: a multicentre propensity-matched study. Eur J Cardiothorac Surg 2020; 57 (04) 709-716
- 5 Russo MJ, Thourani VH, Cohen DJ. et al. Minimally invasive versus full sternotomy for isolated aortic valve replacement in low-risk patients. Ann Thorac Surg 2022; 114 (06) 2124-2130
- 6 Lentini S, Specchia L, Nicolardi S. et al. Surgery of the ascending aorta with or without combined procedures through an upper ministernotomy: outcomes of a series of more than 100 patients. Ann Thorac Cardiovasc Surg 2016; 22 (01) 44-48
- 7 Staromłyński J, Kowalewski M, Sarnowski W. et al. Midterm results of less invasive approach to ascending aorta and aortic root surgery. J Thorac Dis 2020; 12 (11) 6446-6457
- 8 Haunschild J, van Kampen A, von Aspern K. et al. Supracommissural replacement of the ascending aorta and the aortic valve via partial versus full sternotomy-a propensity-matched comparison in a high-volume centre. Eur J Cardiothorac Surg 2022; 61 (02) 479-487
- 9 Pfeiffer S, Fischlein T, Vogt F, Santarpino G. Superior vena cava cannulation in aortic valve surgery: an alternative strategy for a hemisternotomy approach. Interact Cardiovasc Thorac Surg 2015; 20 (06) 863-865
- 10 Akins CW, Miller DC, Turina MI. et al; STS, AATS, EACTS. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008; 85 (04) 1490-1495
- 11 Deschka H, Erler S, Machner M, El-Ayoubi L, Alken A, Wimmer-Greinecker G. Surgery of the ascending aorta, root remodelling and aortic arch surgery with circulatory arrest through partial upper sternotomy: results of 50 consecutive cases. Eur J Cardiothorac Surg 2013; 43 (03) 580-584
- 12 Young CP, Sinha S, Vohra HA. Outcomes of minimally invasive aortic valve replacement surgery. Eur J Cardiothorac Surg 2018; 53 (Suppl. 02) ii19-ii23