Minimally access aortic root and ascending aortic surgery: Are we pushing the limits too far?

Objective: Even though minimally access Cardiac Surgery may reduce morbidity, this approach is not widely used, especially for technically demanding aortic root and ascending aortic surgery. The purpose of this study was to assess the results of aortic surgery via an upper mini-sternotomy up to the 3^rd intercostal space.

Methods: Between 6/2009 and 5/2012 40 patients underwent elective first-time aortic surgery via an upper mini-sternotomy. Six patients underwent supra-commisural ascending aortic replacement, 12 patients underwent aortic valve replacement (AVR) and ascending aortic replacement, 12 patients underwent Bentall procedure and 10 underwent David procedure, respectively.

Results: There was no 30 day mortality. CPB-time was 145 ± 53 min, X-Clamp 88 ± 36 mins, respectively. There was no intra-operative conversion to full sternotomy. Peri-operative echocardiography revealed no aortic insufficiency in David patients. One patient was re-opened (via minimally access) due to post-operative bleeding.

Conclusions: Even though aortic root and ascending aortic surgery is technically demanding, this series shows that minimally access aortic surgery can safely be performed with excellent results. The key to success is a step by step technique of moving from minimally access AVR to more demanding aortic root surgery. Meticulous hemostasis & attention to surgical details is of utmost importance to prevent post-operative complications. Such surgery can be routinely performed in selected patients in centres of excellence.