Comparison of Totally Endoscopic Replacement of the Ascending Aorta and the Aortic Root via Right Anterior Mini-Thoracotomy Versus Partial Upper Sternotomy

Background: Recent studies report excellent results using the minimally invasive partial upper sternotomy (PUS) for replacement of the ascending aorta (AAR) and of the aortic root. To optimize surgical results, reduce surgical trauma, and sternotomy-associated complications, minimally invasive surgery via right anterolateral mini-thoracotomy (RAMT) approach has been standardized as a well-established minimally invasive access for AAR as well as for procedures including the aortic root. Aim of the actual study is to compare postoperative outcomes between RAMT and PUS in patients undergoing AAR and the aortic root.

Methods: We retrospectively analyzed the clinical data of 96 patients who underwent AAR with or without the need of aortic valve replacement (AVR) or the aortic root via RAMT (n = 57) or PUS (n = 39) between April 2017 and July 2024. All patients with complete sternotomy or aortic dissection as well as patients received arch replacement, redo surgery, multiple valve surgery, or additional CABG were excluded from the study. Early postoperative outcome as well as ventilation time, length of intensive care unit (ICU), and 30-day mortality were analyzed.

Results: Mean age was 60.5 ± 10.9 years, with 30.2% of female gender. Baseline characteristics did not differ between the groups. Mean EuroScore II was 2.4 ± 1.0. Cardiopulmonary bypass time (95.6 vs. 174.0 minutes; p < 0.001), aortic x-clamp time (64.9 versus 126.1 minutes; p < 0.001) as well as procedure time (140.2 versus 286.2 minutes; p < 0.001) were shorter in RAMT. Conversion to sternotomy was zero in RAMT and 5.1% in PUS. 30-day mortality was 1.0%. A trend of higher pneumonia (30.8% versus 15.8%; p = 0.081) and re-intubation (5.1% versus 0.0%; p = 0.084) rate was seen in PUS. PUS was associated with longer ventilation time (28.1 versus 6.8 hours; p < 0.001) and prolonged in-hospital stay (14.0 versus 8.1 days; p < 0.001).

Conclusion: Totally endoscopic RAMT access with 3D visualization can be chosen as first-line minimally invasive approach for treating pathologies in the ascending aorta and the aortic root as a safe, feasible, and promising technique without compromising surgical quality, postoperative outcomes, or patient safety when performed by an experienced team in a high-volume center.

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Artikel online veröffentlicht:
11. Februar 2025