Advantages and Limitations of Ascending Aortic Surgery via an Upper Partial Sternotomy

Background: The upper partial sternotomy offers an alternative to the standard access way to the ascending aorta (AA). Aim of this single center analysis is the assessment of pros and cons of this approach.

Methods: Following previous CT-scan, 108 patients with AA aneurysm or type-A-dissection were assigned between 11/2011 and 4/2017 for aortic replacement via an upper partial sternotomy. Four patients were converted to full sternotomy and were excluded. Finally 104 patients (65% male; 64 ± 12 years, EuroSCORE II 3.9 ± 3.0) underwent supra-coronary replacement ± AVR (56%), Bentall- (34%) or David-procedure (10%). CPB was assessed via direct aortic (92%) or axillary artery (8%) and right atrial cannulation. Clinical data, complications, incidence of re-do aortic and/or cardiac surgery, mortality- and stroke-rates as well as the patient's satisfaction with the surgical result were analyzed in a 2-year follow-up.

Results: Cause for conversion to full sternotomy was an extended aortic pathology (n = 3) and a right ventricular perforation during venous cannulation (n = 1). Mean operation-time was 257 ± 79 minute, CPB-time 142 ± 63 minute and aortic cross-clamp-time 98 ± 47 minute. The mean chest-tube output was 500 ± 292 ml/24h. An average of 3.4 ± 4.6 erythrocytes concentrates; 2.3 ± 3.2 g fibrinogen and 659 ± 1260 IE PPSB were needed. Ten re-thoracotomies (9.6%), three superficial (3%) but no deep sternal infection or instability occurred. In the 2-year follow-up the mortality- and stroke-rate was 6% and 5% respectively; re-do surgery was needed in 5% [n = 3 (3%) Re-Bentall; n = 2 (2%) CABG]. 88% of the patients declared to be satisfied with the postoperative result.

Conclusion: The upper partial sternotomy facilitates the entire surgical spectrum on the AA, with good postoperative results. The preservation of the thoracic architecture represents the major benefit of this technique. Its limitations consist in a diminished access to the heart and the distal aortic arch. Therefore precise preoperative planning, with exclusion of more complex pathologies, is required. Cause to the high patient's contentment, the upper partial sternotomy should be considered liberally for AA surgery.