Different approach, similar outcomes: the impact of surgical access routes in minimally invasive cardiac surgery on enhanced recovery after surgery.

Objectives: Enhanced recovery after surgery (ERAS) is a growing phenomenon in all surgical disciplines and aims to achieve a faster functional recovery after major operations. Minimally invasive cardiac surgery (MICS) therefore integrates well into core ERAS values. Surgical access routes in MICS include right anterolateral mini-thoracotomy (MT) as well as partial upper mini-sternotomy (PS). We seek to compare outcomes in these two cohorts, both of which were enrolled in an ERAS scheme. Methods: 358 consecutive patients underwent MICS and perioperative ERAS at our institution between 01/2021 and 03/2023. Patients age >80 years, with BMI > 35 kg/m², LVEF ≤ 35%, endocarditis or stroke with residuum were excluded. Retrospective cohort analysis and statistical testing was performed on the remaining 291 patients. The primary endpoint was successful ERAS, secondary endpoints were the occurrence of major bleeding, ERAS-associated complications (reintubation, return to ICU) as well as access-related complications (wound infection, pleural and pericardial effusions). Results: 170 (59%) patients received MT for mitral and/or tricuspid valve surgery (n = 162), closure of atrial septal defect (n = 4) or resection of left atrial tumor (n = 4). The remaining 121 (41%) patients had PS for aortic valve repair/replacement (n = 83) or aortic root/ascending surgery (n = 22) or both (n = 16). MT patients' median age was 63 years (IQR 56-71) and 65% were male, PS patients' median age was 63 years (IQR 51-69) and 74% were male. 251 (MT 88%, PS 83%, p = 0.73) patients passed through the ERAS program successfully. There were three instances of reintubation (2 MT, 1 PS), and three instances of readmission to ICU (2 MT, 1 PS). Bleeding requiring reexploration occurred six times (3 MT, 3 PS). There was one death (PS), one stroke (MT), and one myocardial infarction requiring revascularization (MT). There were no significant differences in any of the post-operative outcomes recorded, except for the incidence of pericardial effusions (MT 0%, PS 3%, p = 0.03). Conclusions: Despite different surgical access routes and underlying pathologies, results in both the MT and the PS cohort were generally comparable for the recorded outcomes. ERAS remains safe and feasible in these patient groups.

Partial upper median sternotomy for anterior aortopexy for innominate artery compression syndrome: a case series.

Background: Innominate artery compression syndrome (IAS) is caused by an abnormally originating innominate artery compressing the trachea anteriorly. One option to relieve such compression is an anterior aortopexy (AA). We describe our technique of an AA via a partial upper median sternotomy. Case Description: Nine consecutive patients underwent AA for IAS via a partial upper median sternotomy from July 2017 to November 2020 at two US teaching hospitals. The median age was 9 months [interquartile range (IQR), 3-16.5 months]. The male to female ratio was 1.25. All patients had >70% compression by flexible bronchoscopy. Two patients had previous surgeries. The median follow-up was 6 months (IQR, 4-8.5 months). The indications for the operation were: acute life-threatening events (ALTEs) (4/9 patients), recurrent intubation (4/9), and severe stridor with >70% luminal reduction (1/9). Technical success (defined as ≤20% residual stenosis) was achieved in 78% (7/9) of the patients. The two patients with unsuccessful AAs required either a tracheal resection or an innominate artery reimplantation. Both achieved full symptom resolution. Overall, 78% (7/9) of patients experienced full symptom resolution. Of the two patients without full symptom resolution, one had mild stridor at 6 months post-operation. The other patient without full resolution is awaiting further vocal cord surgery for an associated glottic pathology. Conclusions: A partial upper sternotomy provides a very versatile approach to an AA for IAS. In addition to facilitating an adequate AA, a partial upper sternotomy provides options for direct tracheal surgery or an innominate artery reimplantation in case an optimal result is not obtained by an AA.

Ewing's sarcoma of kidney extending into IVC and RA: resection using modified cannulation strategy for CPB.

Ewing's sarcoma of the kidney is a rare tumor. Although renal carcinomas are known to involve the inferior cava, extension of the tumor up to the right atrium is not common. In the majority of cases when the tumor extends into the infrahepatic part of the inferior vena cava, it can be removed from the abdominal approach. Few patients require the use of cardiopulmonary bypass for removal of the tumor in the inferior vena cava and right atrium. The management of patients requiring resection of kidney tumors and right atrial mass is more complicated and requires a team approach consisting of oncosurgeons, cardiac surgeons, and cardiac anesthetists. The resection of the kidney tumor with a mass in the right atrium is usually done concomitantly. The cardiopulmonary bypass cannulation strategy needs to be modified in such cases.

Total Thyroidectomy by Median Sternotomy for Treatment of Substernal Goiter: A Case Report.

Substernal goiter is a rare presentation of goiter but relatively frequent cause of anterior mediastinal mass. Symptomatic patients should be treated surgically with a total or partial thyroidectomy via a cervical or thoracic approach. This case report of a woman with a large symptomatic substernal goiter illustrates how the option to perform a partial median sternotomy may be useful when attempting a cervical approach. This allows for better visualization and resection of large masses and minimizes the risk of complications such as recurrent laryngeal nerve injury. Furthermore, it reinforces that cases of substernal goiter should be treated at specialized centers in order to minimize complications and reach better patient outcomes.

Minimal access aortic surgery.

Recently, there have been significant advances in small incisions through right thoracic cavity including robotic surgery. We have been performing aortic surgery through a partial sternotomy for ascending, arch, and aortic root replacement. In this article, we would like to provide tips for small incision aortic surgery at our institution by showing surgical videos of two cases. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01578-5.

Effect of minimally invasive versus conventional aortic root replacement on transfusion and postoperative wound complications in patients: A meta-analysis.

We examined whether small incision aortic root replacement could reduce the amount of blood transfusion during operation and the risk of postoperative complications. An extensive e-review of the 4 main databases (PubMed, Cochrane, Web of Science and EMBASE) was carried out to determine all the published trials by July 2023. The search terms used were associated with partial versus full sternotomy and aortic root. This analysis only included the study articles that compared partial and full sternotomy. After excluding articles based on titles or abstracts, selected full-text articles had reference lists searched for any potential further articles. We analysed a total of 2167 subjects from 10 comparable trials. The minimally invasive aortic root graft in breastbone decreased the duration of hospitalization (MD, -2.58; 95% CI, -3.15, -2.01, p < 0.0001) and intraoperative red blood cell transfusion (MD, -1.27; 95% CI, -2.34, -0.19, p = 0.02). However, there were no significant differences in wound infection (OR, 0.88; 95% CI, 0.16, 4.93, p = 0.88), re-exploration for bleeding (OR, 0.96; 95% CI, 0.60, 1.53, p = 0.86), intraoperative blood loss (MD, -259.19; 95% CI, -615.11, 96.73, p = 0.15) and operative time (MD, -7.39; 95% CI, -19.10, 4.32, p = 0.22); the results showed that the microsternotomy did not differ significantly from that of the routine approach. Small sternotomy may be an effective and safe substitute for the treatment of the aorta root. Nevertheless, the wide variety of data indicates that larger, well-designed studies are required to back up the current limited literature evidence showing a benefit in terms of complications like postoperative wound infections or the volume of intraoperative red blood cell transfusion.

Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome.

Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22-74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9-16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6-20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1-45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures.

Right anterolateral thoracotomy with partial sternotomy for chronic type B aortic dissection with right aortic arch and Kommerell's diverticulum.

Chronic type B aortic dissection with the right aortic arch was rare. We present the case of a 59-year-old man with a right aortic arch and chronic type B aortic dissection, with a maximum size of 80 mm. Graft replacement was successfully performed through right anterolateral thoracotomy with partial sternotomy through the fourth intercostal space. The patient's postoperative course was uneventful. He had no paralysis and was extubated on postoperative day 2 and discharged from the hospital on postoperative day 15. Anterolateral thoracotomy with partial sternotomy could be a suitable approach for right-sided aortic aneurysms.

A Case of Innominate Artery Transection after the Covered Stent Placement for the Recurrent Tracheo-Innominate Artery Fistula / 日本心臓血管外科学会雑誌

Tracheo-Innominate artery fistula is a rare but devastating complication after tracheostomy. We report a 17-year old man who underwent the transection of the innominate artery and tracheal patch closure (under partial sternotomy) after the endovascular covered stent placement for the recurrent tracheo-innominate artery fistula. Fortunately, his postoperative course was uneventful without any new neurological, bleeding, or infective complication 34 months after the surgery.

Minimally invasive surgical aortic valve replacement via a partial upper ministernotomy.

Minimally invasive aortic valve replacement has become a feasible approach to treat various aortic valve pathologies with limited procedural trauma. Several minimally invasive aortic valve replacement approaches with different levels of complexity and technical requirements are currently available.

Minimalinvaziv aortabillentyu-beultetes soran nyert kezdeti tapasztalataink / Minimálinvazív aortabillentyu-beültetés során nyert kezdeti tapasztalataink

Introduction: Due to the aging population, aortic valve stenosis is the most frequently diagnosed acquired cardiac disease amongst adults. Various surgical techniques have been developed and median sternotomy has become the standard practice for exploration. Improvements in cardiological intervention techniques allow surgery to provide the same quality with less invasiveness.Objective: Our aim was to compare the results of the isolated aortic valve surgeries (AVR) performed as either full or partial sternotomy during the study period in terms of pre-, intra-, and postoperative variables.Patients and methods: We examined the results of the isolated AVR performed at Gottsegen National Cardiovascular Center between January 2019 and March 2020 (99 AVR and 151 mini-AVR). During mini-AVR we opened the sternum with J shape ministernotomy up to the 3rd or 4th intercostal space while in median sternotomy we separated the sternum in its total length.Results: Blood consumption (unit) (AVR: 2.90 [2.90]; mini-AVR: 1.85 [2.12]; p<0,05), days of hospitalization (AVR: 9.75 [2.99]; mini-AVR: 8.85 [2.85]; p<0,05) and length of surgery (minutes) (AVR:148.49 [34.4]; mini-AVR: 134.6 [34.8]; p<0,05) were significantly better in the mini-AVR group. In terms of preoperative variables, the two groups were not homogeneous therefore we corrected the strong predictive variables. As a result, levels of bio-statistical significance have disappeared but there is still a trend in favour of minimally invasive surgery.Conclusions: Mini-AVR surgery is considered a more cost-effective intervention compared to standard surgery in terms of less surgical trauma, reduced blood consumption, and shorter operative time.

Partial upper sternotomy for aortic valve replacement provides similar mid-term outcomes as the full sternotomy.

Background: Minimally invasive aortic valve replacement via upper partial sternotomy (MiniAVR) provides very good short-term results and delivers certain advantages in the postoperative course. There is limited data regarding the mid-term mortality and morbidity following this minimally invasive surgery. Methods: We provide a retrospective analysis of the patients, undergoing MiniAVR versus full sternotomy (FS) for aortic valve replacement with biological prosthesis. As the primary combined end-point the combination of death, stroke, and rehospitalization within 3 years postoperatively was defined. Data have been collected from National Cardiac Surgery Registry and insurance companies. Results: Two hundred consecutive patients with aortic valve replacement (100 ministernotomy in MiniAVR group and 100 full sternotomy in FS group) with biological prosthesis were included in this study. Ministernotomy had longer cross-clamp and bypass times (median difference 6.5 min, P=0.005, and 8.5 min, P=0.002 respectively). Patients operated via upper partial sternotomy had a lower postoperative bleeding [300 mL (IQR, 290) vs. 365 mL (IQR, 207), P=0.031]. There was no difference in the 3-year mortality (14% vs. 11%, P=0.485). The mean number of readmission 3 years after surgery per capita was almost the same in both groups (1.65 vs. 1.60, P=0.836). Median time to the first readmission was longer in the MiniAVR group (difference 8.9 months). The incidence of combined end-point during 3 years postoperatively in both groups was not statistically different (P=0.148), as well as readmissions from cardio-vascular reasons (subhazard ratio 0.90, P=0.693). Conclusions: Upper partial sternotomy can be performed safely for aortic valve replacement, without increased risk of death, stroke or re-admission in 3 years postoperatively.

Total arch replacement with both frozen elephant trunk and transthoracic aorto-axillary extra-anatomical bypass through partial sternotomy for acute aortic dissection in a tracheostomy patient.

Median sternotomy near an existing tracheostoma risks deep sternal wound infection after cardiac surgery. We present herein a case of acute type A aortic dissection in a patient with a permanent tracheostoma after laryngectomy. Total arch replacement with both frozen elephant trunk and extra-anatomical bypass for supra-aortic trunks was performed through T-shaped partial sternotomy, resulting in recovery without deep sternal wound infection.

Sternotomy Approach to the Anterior Cervicothoracic Spine.

The anterior cervicothoracic spine is a challenging region to approach given the various vascular, osseous, nervous, and articular structures, which prevent adequate exposure. This region is susceptible to lesions ranging from tumors, degenerative disease, infectious processes, and traumatic fractures. Our objective was to critically evaluate the sternotomy approach in spine surgery to give the technical implications of its usage. The safety and efficacy of the transsternal approach are discussed as well as the advantages, disadvantages, indications, and contraindications. The transsternal approach is the most direct access to pathologies in the upper anterior cervicothoracic spine and enables the spine surgeon to gain direct exposure to the cervicothoracic junction for ideal visualization. Anatomical considerations must be kept in mind while performing a sternotomy to prevent complications such as denervation or bleeding. This technique is useful for the armamentarium of spinal surgeons.

Mini-access open arch repair.

BACKGROUND: The use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty. METHODS: This study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible. RESULTS: Hemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1 (1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%). CONCLUSIONS: Mini-access open arch repair is technically feasible and achieved excellent early outcomes.

Tricuspid valve repair via partial sternotomy for traumatic valve insufficiency.

Tricuspid valve insufficiency rarely follows a blunt chest trauma. When the tricuspid valve is solely injured, the cardiac trauma may stay asymptomatic and tolerable, which often makes it difficult to determine the indication for surgery. We report a case of a patient with tricuspid regurgitation secondary to trauma due to a motorcycle accident. The patient was initially asymptomatic, but shortness of breath emerged two years after the accident. He underwent the tricuspid valve repair with chordae reconstruction and annuloplasty via lower partial sternotomy. We advocate that early surgical intervention prevents right heart failure, atrial fibrillation, and valve replacement.

Resection of a desmoid-type fibromatosis with a CTNNB1 p.S45P mutation using a cervico-thoracic approach: A case report and literature review.

Desmoid-type fibromatosis (DF) is a rare, locally infiltrative, and fibroblastic proliferative disease. DF usually arises from abdominal fascial tissue, but in rare cases, it can occur in extra-abdominal areas. A 73-year-old Japanese male complained of a painless, left anterior neck mass of 3-month duration. Computed tomography revealed the mass measured 9 × 7 × 6 cm and extended to the anterior mediastinum, with invasion of the left clavicle. En bloc resection of the tumor with the left sternoclavicular joint and the medial portion of the left clavicle was performed by cervico-thoracic approach with L-shaped partial sternotomy. Histopathologic examination showed fascicular growth of spindle-shaped cells separated by abundant collagen. Immunohistologic examination revealed nuclear staining of ß-catenin and cytoplasmic staining of vimentin. Genetic analysis of 160 cancer-related genes by next-generation sequencing (NGS) demonstrated only a missense mutation in the CTNNB1 gene (c.133T>C, p.S45P). DF extending from the neck to the anterior mediastinum is rare. We report the complete resection of a large-sized DF with the clavicular invasion. A low-frequency CTNNB1 mutation of DF was identified. Genetic analysis with NGS was beneficial for the diagnosis.

Anterolateral Partial Sternotomy for Treatment of Graft Infection with Fungal Vegetation on the Frozen Elephant Trunk: A Case Report.

A 49-year-old man, who had undergone total arch replacement (TAR) with frozen elephant trunk (FET) technique for type A acute aortic dissection, was subsequently transferred to our hospital for uncontrollable infection. Since multiple blood cultures were positive for Candida parapsilosis and transesophageal echocardiography revealed vegetation attached to the FET, he was diagnosed with a graft infection. In addition, on the 18-fluorodeoxyglucose positron emission tomography scans, high uptake lesions were found around the quadrifurcated graft as well as the FET. Therefore, an extensive TAR through anterolateral thoracotomy with partial sternotomy was performed to remove all infected prothesis. Consequently, the patient completely recovered.

Two cases of symptomatic common carotid artery occlusion treated by carotid endarterectomy with L-shaped ministernotomy.

BACKGROUND: Common carotid artery occlusion (CCAO) is rare. Symptomatic lesions are resistant to medical treatment and revascularization are often required, but there is no consensus on the treatment of CCAO. In this paper, two cases of symptomatic CCAO treated by carotid endarterectomy (CEA) with L-shaped ministernotomy, in which the lesions extended to the beginning part of the CCA, are reported. CASE DESCRIPTION: Case 1 involved a 74-year-old man who presented with transient left limb numbness and an abnormal right visual field. Cerebrovascular angiography showed that the right CCA was occluded immediately after its origin and blood was supplied from the posterior circulation. CEA was performed with an L-shaped ministernotomy that allowed exposure of the CCA origin with minimal invasion. There were no complications associated with the sternal incision and he was discharged with a modified Rankin Scale (mRS) score of 0. Case 2 involved a 70-year-old man who presented with left half-blindness. Magnetic resonance imaging showed infarction in the right posterior cerebral artery region and neck echo showed CCA pseudo occlusion just before the carotid bulb. A new infarction in the right middle cerebral artery region developed during hospitalization. CEA with partial sternotomy was performed. The patient was rehabilitated with no deterioration of neurological findings and transferred with an mRS score of 3. CONCLUSION: There were no complications resulting from partial sternotomy in the two cases presented. CEA with partial sternotomy could be an effective treatment option for CCAO in which the internal carotid artery is patent and thrombus extends to the proximal CCA.

Off-pump coronary artery bypass grafting in a tracheostomy patient.

In patients who have undergone laryngectomy and have a tracheal stoma, a full median sternotomy substantially increases the risk of wound infection, osteomyelitis, mediastinitis, bleeding, tracheal injury, and poor wound healing. Several reports have been published on sternotomies and skin incisions in tracheostoma patients. Transverse bilateral thoracosternotomy, T-shaped partial sternotomy (manubrium-sparing sternotomy) with transverse skin flaps and anterolateral thoracotomy with partial sternotomy are described as successful approaches to the mediastinum for cardiac surgery. We present a successful case in which off-pump coronary artery bypass grafting (CABG) was performed in a tracheostoma patient using a low T-shaped partial sternotomy and the PAS-Port system. Good long-term results were achieved.