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Razionale. La crescente esperienza nelle tecniche mini-invasive, supportata sia dagli ottimi risultati e sia dall’eccellente esposizione chirurgica dell’intera aorta ascendente tramite ministernotomia, ha motivato i chirurghi ad utilizzare tale approccio anche in procedure più complesse quali il trattamento della radice e dell’arco aortico.Materiali e metodi. Da settembre 2016 ad aprile 2024 sono stati arruolati 243 pazienti sottoposti a trattamento chirurgico dell’aorta prossimale con approccio ministernotomico presso l’Unità di Cardiochirurgia del Centro Cardiovascolare Lancisi di Ancona - Università Politecnica delle Marche. In tutti i casi è stata eseguita un’angio-tomografia computerizzata dell’aorta toraco-addominale preoperatoria.Risultati. L’età media della popolazione era di 65 ± 12 anni e 176 pazienti (72%) erano di sesso maschile. La patologia valvolare aortica era presente nel 66.9% dei casi (n=85) con riscontro di insufficienza o stenosi valvolare più che moderata rispettivamente in 127 (52%) e 44 (18%) casi. La valvola aortica appariva di morfologia bicuspide nel 29% dei pazienti (n=70). Le procedure chirurgiche comprendevano il trattamento della radice aortica (n=88) utilizzando la tecnica di Bentall (n=64) o David (n=24), la sostituzione isolata dell’aorta ascendente (n=73) e la sostituzione combinata dell’aorta ascendente e della valvola aortica (n=82). Il tasso di mortalità a 30 giorni e di ictus è stato dello 0.4%. In 132 casi (54%) l’estubazione è avvenuta entro le prime 6 h dopo il trattamento chirurgico. La mediana di degenza ospedaliera è stata di 7 giorni con il 48% (n=107) dei pazienti dimesso a domicilio senza necessità di alcuna riabilitazione cardiorespiratoria successiva. Conclusioni. La chirurgia dell’aorta prossimale può essere eseguita in maniera sicura ed efficace attraverso la ministernotomia superiore in centri cardiochirurgici specializzati. Un’attenta e accurata analisi dell’anatomia aortica del paziente all’imaging preoperatorio è essenziale per consentire un’efficace pianificazione del trattamento e favorire un’esposizione chirurgica ottimale.

The ministernotomy approach with sutureless aortic bioprosthesis may provide an attractive and safe option for aortic valve disease patients. To assess the early and mid-term outcomes of minimally invasive aortic valve replacement (miniAVR) with sutureless vs. standard prostheses. The study involved 76 consecutive patients (51 males and 25 females) with mean age of 63.2 years who were treated with miniAVR between 2015 and 2022. They were divided into 2 subgroups: group I ( = 40) subjects with sutureless bioprostheses and group II ( = 36) with standard prostheses implanted. Early and mid-term outcomes were evaluated. A probability of survival was estimated by means of the Kaplan-Meier method. No conversion to complete sternotomy was necessary. The median (minimum; maximum) aorta cross clamping and cardio-pulmonary bypass times were 49 (27; 84) and 70 (40; 188) minutes in group I whereas 69 (50; 103) and 95 (69; 170) minutes in group II, respectively ( < 0.001). In-hospital mortality was 5.0% ( = 2) and 2.8% ( = 1) in group I vs. II, respectively (ns). Permanent ICD implantation was performed in 8 (20.0%) in group I and in 3 (8.3%) subjects in group II. In the discharge echocardiography, the function of all prostheses was correct. Five-year probability of survival was much lower in group I (0.75 ±0.10) than in group II (0.94 ±0.04). No wound infection or sternum instability was noted. Intraoperative advantages of miniAVR procedures for aortic valve patients with sutureless bioprostheses do not translate directly into improved early and middle-term outcomes.

Objective It is debatable which minimally invasive strategy is better for aortic valve replacement (AVR). This study aims to compare the perioperative outcomes of AVR through right anterior minithoracotomy (RAT) versus ministernotomy. Methods A series of 162 consecutive patients who underwent minimally invasive AVR (107 RAT and 55 ministernotomy) from August 2013 to May 2022 were evaluated. Primary outcome measured was perioperative mortality. Secondary outcomes measured were operative time, perioperative stroke, and blood loss. Results Majority of patients were of low operative risk (93.5% vs 89.1%) and overweight/obese (body mass index ≥ 25 kg/m 2 , 76.6% vs 65.5%). No cardiac mortality or major morbidity including stroke was observed in either group. RAT was associated with lower blood loss (mean hemoglobin level at time of hospital discharge, 111.8 g/L vs 104.4 g/L, p  = 0.02). There was no statistical difference in transfusion rates between the groups (11.2% vs 14.5%, p  = 0.6). In isolated AVR, operative time was slightly shorter with ministernotomy (median bypass time, 123 minutes in RAT vs 113 minutes in ministernotomy, p  = 0.02). There was a statistically significant decline in both cross-clamp ( p  = 0.005) and bypass time ( p  = 0.004) over the study period. Conclusions Both minimally invasive AVR methods produced good clinical results. No significant difference was observed in mortality or stroke with either technique. RAT AVR may be preferred over ministernotomy due to its sternal-sparing effect despite being a slightly longer operation while one of the advantages of ministernotomy is easy allowance for concomitant procedures. Graphical Abstract

Background: new minimally invasive sternotomy (mini-sternotomy) procedures have improved the treatment outcome and reduced the incidence of perioperative complications leading to improved patient satisfaction and a reduced cost of aortic valve replacement in comparison to the conventional median sternotomy (full sternotomy). The aim of this study is to compare and gain new insights into operative and early postoperative outcomes, long-term postoperative results, and 5-year survival rates after aortic valve replacement through a ministernotomy and full sternotomy. Methods: This is a retrospective study of patients who underwent an isolated replacement of the aortic valve via a full sternotomy or ministernotomy from 2011 to 2016. From 2011 to 2016, 426 cardiac interventions were performed, 70 of which (16.4%) were of the ministernotomy and 356 (83.6%) of the full sternotomy. Through propensity score matching, 70 patients who underwent the ministernotomy (ministernotomy group) were compared with 70 patients who underwent the full sternotomy (control group). Results: in the propensity matching cohort, no statistical difference in operative time was noted (p = 0.856). The ministernotomy had longer cross clamp (88.7 ± 20.7 vs. 80.3 ± 24.6 min, p = 0.007) and bypass (144.0 ± 29.9 vs. 132.9 ± 44.9 min, p = 0.049) times, less ventilation time (9.7 ± 1.7 vs. 11.7 ± 1.4 h, p < 0.001), shorter hospital stay (18.3 ± 1.9 vs. 21.9 ± 1.9 days, p = 0.012), less 24-h chest tube drainage (256.2 ± 28.6 vs. 407.3 ± 40.37 mL, p < 0.001), fewer corrections of coagulopathy (p < 0.001), fewer patients receiving catecholamine (5.71 vs. 30.0%, p < 0.001) and better cosmetic results (p < 0.001). Moreover, the number of patients without complaints at 1 year after the operation was significantly greater in the ministernotomy group (p = 0.002), and no significant differences in the 5-year survival between the groups were observed. In the overall cohort, the ministernotomy had longer cross clamp times (88.7 ± 20.7 vs. 79.9 ± 24.8 min, p < 0.001), longer operative times (263.5 ± 62.0 vs. 246.7 ± 74.2 min, p = 0.037) and bypass times (144.0 ± 29.9 vs. 132.7 ± 44.5 min, p = 0.026), lower incidence of 30-day mortality (1(1.4) vs. 13(3.7), p = 0.022), shorter hospital stays post-surgery p = 0.025, less 24-h chest tube drainage, p < 0.001, and fewer corrections of coagulopathy (p < 0.001). Conclusions: the ministernotomy has a number of advantages compared with the full sternotomy and thus could be a better approach for aortic valve replacement.

With the development of less invasive techniques ministernotomy has become an increasingly popular choice for minimally invasive aortic valve replacement (MIAVR). However, a large discrepancy in the published results, often derived from the center's own experience, intensifies the need for further re-evaluation in order to better define the real impact of the ministernotomy approach on postoperative clinical condition in short- and long-term observation. To assess the safety and efficacy of MIAVR in comparison to a reference full sternotomy AVR (FSAVR). Between January 2004 and January 2018, 2386 patients underwent isolated surgical aortic valve replacement (AVR) at our institution. 620 patients were treated minimally invasively (MIAVR) and 1766 patients received FSAVR. Forced propensity score 1 : 1 matching and conditional regressive methods were introduced, ensuring valid comparison and correct estimation. Ultimately, 557 well allocated pairs of treated and control patients were included. In-hospital mortality was low and comparable (1.26% for MIAVR, 1.62% for FSAVR). No significant differences in terms of serious adverse events were found, although in patients undergoing MIAVR there tended to be lower incidence of neurological complications (OR = 0.72; = 0.09) and low output syndrome (OR = 0.66; = 0.13). In addition to a much faster extubation and discharge from the ICU as well as improved blood management, MIAVR significantly reduced the risk of wound complications (OR = 0.31; < 0.0010). MIAVR is a safe, effective and reproducible procedure providing at least as good results as FSAVR. Nevertheless, it should be especially recommended to obese, diabetic patients with pulmonary and mobility disorders in order to improve their early recovery.

Background Minimally invasive aortic surgery is growing in popularity among surgeons. Although many clinical reports have proven both the safety and efficacy from a surgical point of view, there are few data regarding its impact on patients’ quality of life and whether there is a difference between ministernotomy and minithoracotomy from the patient perspective. Methods This prospective, questionnaire-based, nonrandomized study included 189 patients who underwent aortic valve replacement via a minimally invasive incision between May 2014 and December 2020 and completed at least 1 year of follow-up. The study uses the RAND SF 36-Item Health Survey 1.0 to assess and compare health-related quality of life between ministernotomy and minithoracotomy. Results There was a statistically significant improvement in the minithoracotomy group with regard to physical functioning, role limitation due to a physical problem, and social functioning (79.69 ± 20.72, 75.28 ± 26.52, 87.91 ± 16.98) compared to the ministernotomy group (70.31 ± 22.88, 58.59 ± 31.17, 66.15 ± 27.32) with p values (0.0036, 0.0001, < 0.0001), respectively. Conclusions Both minimally invasive aortic valve incisions positively impacted patient quality of life. The minithoracotomy incision showed significant improvements in physical capacity and successful patient re-engagement in daily physical and social activities. This, in turn, positively improved their general health status compared to the 1-year preoperative status. Trial registration : This study was approved by the Research Ethics Committee (REC) at the Faculty of Medicine, Ain Shams University, under the number code (FWA 000017585, FAMSU R 91 /2021).

Background Observational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting. Methods This was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events. Results Out of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition ( p  = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group ( p  = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion ( p  = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding. Conclusions Minimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy. Clinical Trial Registration http://www.clinicaltrials.gov . Unique identifier: NCT02272621.

Background: Minimally invasive aortic valve replacement (AVR) via upper ministernotomy (MiniAVR) is a standard alternative to full sternotomy access. Minimally invasive cardiac surgery has been proven to provide a number of benefits to patients. The aim of this study was to compare the short- and long-term outcomes after MiniAVR versus conventional AVR via full sternotomy (FS) using a biological prosthesis in an elderly higher-risk population. Methods: Between January 2006 and July 2009, 918 consecutive patients received AVR ± additional procedures with different prostheses at our center. Amongst them, 441 received isolated AVR using a biological prosthesis (median age of 74.5; range: 52–93 years; 50% females) and formed the study population (EuroSCORE II: 3.62 ± 5.5, range: 0.7–42). In total, 137 (31.1%) of the operations were carried out through FS, and 304 (68.9%) were carried out via MiniAVR. Follow-up was complete in 96% of the cases (median of 7.6 years, 6610 patient-years). Propensity score matching (PSM) resulted in two groups of 68 patients with very similar baseline profiles. The primary endpoints were long-term survival, freedom from reoperation, and endocarditis, and the secondary endpoints were early major adverse cardiac and cerebrovascular events (MACCEs). Results: FS led to shorter cardio-pulmonary bypass and aortic cross-clamp durations: 90 (47–194) vs. 100 (46–246) min (p = 0.039) and 57 (33–156) vs. 69 (32–118) min (p = 0.006), respectively. Perioperative stroke occurred in three patients (4.4%; FS) vs. one patient (1.5%; MiniAVR) (p = 0.506). The 30-day mortality was similar in both groups (2.9%, p = 1.000). Survival at 1, 5, and 10 years was 94.1 ± 3% (FS and MiniAVR), 80.3 ± 5% vs. 75.7 ± 5%, and 45.3 ± 6% vs. 43.8 ± 6%, respectively (p = 0.767). There were two (2.9%) reoperations in each group and two thrombo-embolic events (2.9%) vs. one (1.5%) thrombo-embolic event in the MiniAVR and FS groups, respectively (p = 0.596). Conclusions: In comparison to FS, MiniAVR provided similar short- and long-term outcomes in a higher-risk elderly population receiving biological prostheses. In particular, long-term survival, freedom from reoperation, and the incidence of endocarditis were comparable. These results clearly advocate for the routine use of MiniAVR as a standard procedure for AVR, even in a high-risk population.

Introduction: This study reports of the use of a rigid-plate fixation (RPF) system designed for sternal closure after minimally invasive cardiac surgery (MICS). Methods: This retrospective analysis included all patients undergoing MICS with RPF (Zimmer Biomet, Jacksonville, FL, USA) at our institution. We analyzed in-hospital complications, as well as sternal complications and sternal pain at discharge and at follow-up 7 to 14 months after surgery. Results: Between June and December 2023, 12 patients underwent RPF during MICS, of which 9 patients were included in the study. The median (IQR) age was 64 years (63 to 71) and two patients (22%) were female. All patients underwent aortic valve replacement, with two patients (22%) undergoing concomitant aortic surgery. RPF was successfully performed in all patients. ICU and in-hospital stay were 1 day (1 to 1) and 9 days (7 to 13), respectively. Patients were first mobilized in the standing position on postoperative day 2 (2 to 2). Four patients (44%) required opiates on the general ward. In-hospital mortality was 0%. At discharge, rates of sternal pain, sternal instability or infection were 0%. After a follow-up time of 343.6 days (217 to 433), median pain intensity using the Visual Analog Scale was 0 (0 to 2). Forty-four percent (n = 4) of patients reported pain at rest. No sternal complications (sternal dehiscence, sternal mal-union, sternal instability, superficial wound infections and deep sternal wound infections) were reported. Conclusions: In the evolving landscape of cardiac therapies with incentives to reduce surgical burden, RPF showed safety and feasibility. It might become an important tool for sternal closure in minimally invasive cardiac surgery.

The main goal of minimally invasive surgery is to reduce the perioperative trauma, accelerate patient mobilization and reduce the length of hospital stay. Due to the development of modern technology, these treatments can be offered to a wider group of patients. For many years, aortic root surgery consisted of mechanical conduit implantation and, therefore, necessitated life-long anticoagulation. At present, in patients with aortic root aneurysm and significant aortic valve regurgitation, it is possible to perform minimal-access valve sparing surgical procedures. The current paper is a brief description of the surgical technique for aortic root aneurysm surgery with preservation of the patient's own valve using the David procedure.