Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients

doi:10.21203/rs.3.rs-1131837/v1

Download PDF

Research Article

Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients

https://doi.org/10.21203/rs.3.rs-1131837/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Excellent partial upper sternotomy (PUS) outcomes have been reported for patients with aortic surgery, but whether this approach is particularly beneficial to obese patients remains to be established. This study was to explore the outcomes of aortic surgery conducted via a PUS or a full median sternotomy (FMS) approach in obese patients.

Methods: Records for 493 patients that had undergone aortic surgery were retrospectively reviewed, leading to the identification of 158 consecutive obese patients and 335 non-obese patients. PUS and FMS group outcomes were compared within and between these two body mass index (BMI) groups.

Results: In total, 88 and 70 obese patients compared to 180 and 155 non-obese patients underwent FMS and PUS, respectively. There were no differences between the FMS and PUS groups within either BMI cohort with respect to preoperative baseline indicators and postoperative complications. Among non-obese individuals, the PUS approach was linked to reduced ventilation time (P = 0.003), shorter intensive care unit (ICU) stay (P = 0.017), shorter hospital duration (P = 0.001), and decreased transfusion requirements (Packed red blood cells: P < 0.001; Fresh frozen plasma: P < 0.001). Comparable findings were also evident among obese patients.

Conclusions: Obese aortic disease patients exhibited beneficial outcomes similar to those achieved for non-obese patients via a PUS approach which was associated with significant reductions in length of ICU residency, duration of hospitalization, ventilator use, and transfusion requirements. This surgical approach should be offered to aortic patients irrespective of their BMI.

Aortic

Obese

BMI

Minimally invasive

Partial upper sternotomy

Aortic root aneurysm and aortic dissection are extremely serious vascular emergencies associated with high morbidity and mortalit^1,2. Appropriate management of aortic arch aneurysm are still being developed and optimized³. The conventional surgical approach for these patients is full median sternotomy (FMS), but minimally invasive partial upper sternotomy (PUS) has been employed as an alternative approach to the aortic valve⁴ since the 1990s, even in obese patients⁵. However, FMS remains the standard approach for complex aortic surgery to ensure exposure and safety ⁶. Even so, recent studies have explored minimally invasive surgical procedures of the aortic root^7–9, ascending aorta¹⁰, or aortic arch^3,11−13. These authors have reported successful surgical outcomes without increasing mortality or major complications. However, few study have explored outcomes in obese patients with aortic disease that underwent treatment via a PUS approach as compared to those treated via conventional FMS.

This study was to compare aortic disease patient outcomes between obese and non-obese patients that underwent treatment via a PUS approach or a FMS approach.

Following approval from the ethics committee of Fujian Medical University, China, the records of patients from January 2015 to January 2021 were reviewed, leading to the identification of 155 consecutive obese (body mass index [BMI] ≧ 30 kg/m²) and 338 consecutive non-obese ([BMI] < 30 kg/m²) patients that underwent aortic surgery for the first time. Preoperative characteristics, operative parameters, and postoperative outcomes were compared between FMS or PUS subgroup in the obese and non-obese cohorts.

PUS was performed at the discretion of the operating surgeon through December 2016. Beginning in January 2017, PUS was the standard approach for all aortic surgical procedures. No additional preoperative assessments were performed for patients undergoing PUS. Expertise of the surgeons were similar and all operations were performed by well-trained surgeons.

A pain chart was also recorded to assess pain sensation level, with this chart having been completed once per day by unmedicated patients and by nursing staff.

Minimally invasive aortic surgery: PUS approach

An 8-12 cm cutaneous incision was generated, after which the sternum was incised in a J-form manner from the sternal notch to the right fourth intercostal space. (Fig.1 A,B,C)

Surgical technique for aortic root reconstruction

Valve-sparing aortic root replacement (VSARR) procedure involved a modified David technique and patch neointima technique ¹⁴, which was performed to repair the aortic valve of patients with severe AR and had been described in detail previously ^{14, 15}. (Fig.1 D)

The Bentall procedure was defned as the replacement of the aortic root with a composite valvegraft device ¹⁶. (Fig.1 E)

Surgical technique for total arch and descending aortic replacement

Procedure details of implantation of modified triple-branched stent-graft had been described previously ¹⁷. Briefly, expose the branching arteries in the aortic arch and implant and release the modified triple-branched stent-graft. (Fig.1 F)

Statistical analysis

Continuous variables are given as means±standard deviations and were compared via Student’s t-tests or Mann-Whitney U-tests, while categorical variables are given as percentages and were compared with chi-squared or Fisher’s exact tests, as appropriate. P < 0.05 was the significance threshold, and SPSS 26.0 (SPSS Inc.) was used for all analyses.

Data

The Shapiro-Wilk test was applied to assess the normal distribution of the continuous variables and they had all been shown normally distributed.

Patient characteristics

155 and 180 of the 335 non-obese patients underwent surgery via PUS and FMS approaches, respectively, while 70 and 88 of the 158 obese patients underwent treatment via these two respective approaches.

Similar risk profiles were observed when comparing these obese and non-obese patient cohorts with respect to their individual comorbidities (Table 1).

Table 1

Preoperative characteristics
		Non-Obese			Obese
	Total	FMS	PUS	P1	FMS	PUS	P2	P3	P4
Patients (n)	493	180(36.5)	155(31.5)	-	88(17.8)	70(14.2)	-
Age (y)	53.9 ± 12.5	54.4 ± 10.4	52.7 ± 9.8	0.126	55.9 ± 10.8	54.0 ± 11.5	0.287	0.275	0.384
BMI	26.99 ± 5.48	25.4 ± 3.9	24.8 ± 4.0	0.166	30.11 ± 3.04	30.56 ± 3.09	0.360	< 0.001	< 0.001
Male (n)	393(79.7)	149(82.8)	119(76.8)	0.171	70(79.5)	55(78.6)	0.881	0.520	0.766
Chronic diseases
Diabetes (n)	81(16.4)	28(15.6)	25(16.1)	0.886	16(18.2)	12(17.1)	0.865	0.586	0.849
Hypertension (n)	402(81.5)	144(80.0)	126(81.3)	0.766	79(89.8)	63(90.0)	0.962	0.044	0.099
Hyperlipidemia (n)	85(17.2)	27(15.0)	23(14.8)	0.967	20(22.7)	15(21.4)	0.845	0.118	0.222
Coronary heart disease (n)	40(8.1)	14(7.8)	14(9.0)	0.679	8(9.1)	4(5.7)	0.426	0.713	0.396
Renal dysfunction ^a (n)	112(22.7)	40(22.2)	33(21.3)	0.837	20(22.7)	19(27.1)	0.523	0.926	0.335
COPD (n)	29(5.9)	8(4.4)	8(5.2)	0.759	7(8.0)	6(8.6)	0.889	0.373	0.495
OSAS	48(9.7)	15(8.3)	14(9.0)	0.821	9(10.2)	10(14.3)	0.436	0.610	0.237
Moderate or severe AR	170(34.5)	60(33.3)	53(34.2)	0.868	30(34.1)	27(38.6)	0.560	0.902	0.525
Malperfusion syndromes	88(17.8)	32(17.8)	29(18.7)	0.826	15(17.0)	12(17.1)	0.987	0.882	0.778
EF (%)	62.7 ± 6.7	63.5 ± 9.9	62.8 ± 7.7	0.468	61.7 ± 8.9	62.5 ± 10.2	0.600	0.150	0.827
Serum creatinine(umol/L)	118.8 ± 98.6	112.6 ± 87.8	113.9 ± 98.4	0.898	119.6 ± 98.6	120.5 ± 88.5	0.953	0.557	0.632
Hb (mg/dl)	12.58 ± 2.05	12.56 ± 2.35	12.86 ± 2.84	0.298	12.66 ± 2.88	12.69 ± 2.01	0.939	0.778	0.608
HCT (%)	41.50 ± 3.96	40.98 ± 3.96	41.80 ± 3.64	0.051	40.94 ± 3.87	41.57 ± 3.88	0.312	0.938	0.260
^a Defined as preoperative creatinine greater than 1.5 mg/dL. AR, aortic valve regurgitation; LVEF, left ventricular ejection fraction; COPD, chronic obstructive pulmonary disease; OSAS, obstructive sleep apnoea syndrome; EF: ejection fraction; Hb: haemoglobin; HCT: haematocrit; SD: standard deviation. Values are n (%) or mean ± SD P1, P2: P value of FMS group versus PUS group in Non-Obese and Obese patients, respectively. P3, P4: P value of Non-Obese patients versus Obese patients in FMS and PUS group, respectively.

Operative characteristics

There were no significant differences in total operative duration, cardiopulmonary bypass time, SCP and low body arrest when comparing surgical approaches in the obese and non-obese patient cohorts (Table 2), although the mean cross-clamp time was significantly longer in the PUS group both for non-obese (55.8 ± 26.9 min vs 48.8 ± 17.8 min; P = 0.006) and obese patients (56.0 ± 19.8 min vs 49.0 ± 16.5 min; P = 0.017).

Table 2

Procedural data
		Non-Obese			Obese
	Total	FMS	PUS	P1	FMS	PUS	P2	P3	P4
Patients (n)	493	180(36.5)	155(31.5)	-	88(17.8)	70(14.2)	-
Catogeries of surgery
ASA + hemi-arch	54(11.1)	18(10.0)	18(11.6)	0.635	10(11.4)	8(11.4)	0.990	0.732	0.968
ASA + total arch	52(10.6)	18(10.0)	17(11.0)	0.773	9(10.2)	8(11.4)	0.809	0.954	0.919
root + ASA	80(16.2)	29(16.1)	24(15.5)	0.875	15(17.0)	12(17.1)	0.987	0.846	0.753
root + ASA + hemi-arch	140(28.3)	49(27.2)	45(29.0)	0.713	26(29.5)	20(28.6)	0.894	0.691	0.944
root + ASA + total arch	167(33.8)	66(36.7)	51(32.9)	0.471	28(31.8)	22(31.4)	0.958	0.435	0.827
Operation time (min)	290.5 ± 87.5	288.5 ± 97.8	292.8 ± 100.8	0.693	290.9 ± 99.8	295.8 ± 105.8	0.766	0.851	0.839
Cardiopulmonary bypass (min)	139.8 ± 35.8	138.4 ± 43.9	142.6 ± 41.8	0.373	139.9 ± 45.6	144.4 ± 50.6	0.558	0.796	0.795
Cross-clamp time (min)	48.9 ± 18.7	48.8 ± 17.8	55.8 ± 26.9	0.006	49.0 ± 16.5	56.0 ± 19.8	0.017	0.930	0.950
SCP and low body arrest (min)	14.1 ± 4.1	13.8 ± 4.8	14.5 ± 6.9	0.290	14.1 ± 8.8	14.8 ± 7.7	0.601	0.766	0.771
ASA, ascending aorta; SCP, selective cerebral perfusion. Values are n (%) or mean ± SD P1, P2: P value of FMS group versus PUS group in Non-Obese and Obese patients, respectively. P3, P4: P value of Non-Obese patients versus Obese patients in FMS and PUS group, respectively.

Postoperative outcomes

For full details regarding the postoperative outcomes for patients included in this study, see Table 3. Rates of deep surgical site infection (DSSI) requiring revision, re-exploration, postoperative myocardial infarction, neurological dysfunction, renal dysfunction, hepatic insufficiency, pulmonary complications, and in-hospital mortality were also comparable between FMS and PUS subgroups in both the obese and non-obese cohorts. Among obese patients, PUS treatment was associated with decreases in ventilation time 106.2 ± 60.0 vs 129.8 ± 77.8 h; P = 0.033], ICU stay length [5.5 ± 3.5 days vs 7.8 ± 4.7 days; P = 0.001], hospitalization duration [17.2 ± 9.9 days vs 21.5 ± 10.5 days; P = 0.010], and transfusion requirements (Packed red blood cells: 4.76 ± 3.08 units vs 6.88 ± 4.66 units, P = 0.001; Fresh frozen plasma: 435.8 ± 108.5 ml vs 511.9 ± 174.9 ml, P = 0.001). Similar trends were also evident for non-obese patients.

Table 3

Postoperative event rates of clinical outcomes
Events	Total	Non-Obese			Obese
Events	Total	FMS	PUS	P1	FMS	PUS	P2	P3	P4
Patients (n)	493	180(36.5)	155(31.5)	-	88(17.8)	70(14.2)	-
Infections
SSI	38(7.7)	11(6.1)	13(8.4)	0.421	7(8.0)	7(10.0)	0.653	0.571	0.694
DSSI	18(3.7)	5(2.8)	5(3.2)	1.000	4(4.5)	4(5.7)	1.000	0.694	0.607
Cardiac
Resternotomy for major bleeding	21(4.3)	7(3.9)	6(3.9)	0.983	4(4.5)	4(5.7)	1.000	1.000	0.786
Cardiac arrest	15(3.0)	5(2.8)	4(2.6)	1.000	3(3.4)	3(4.3)	1.000	1.000	0.789
MI	10(2.0)	3(1.7)	3(1.9)	1.000	2(2.3)	2(2.9)	1.000	1.000	1.000
Neurologic dysfunction	18(3.7)	6(3.3)	6(3.9)	1.000	3(3.4)	3(4.3)	1.000	1.000	1.000
Temporary	12(2.4)	4(2.2)	4(2.6)	1.000	2(2.3)	2(2.9)	1.000	1.000	1.000
Permanent	6(1.0)	2(1.1)	2(1.3)	1.000	1(1.1)	1(1.4)	1.000	1.000	1.000
Renal
Acute kidney injury ^a	157(31.8)	57(31.7)	55(35.5)	0.460	25(28.4)	20(28.6)	0.982	0.587	0.309
Dialysis (%)	107(21.7)	37(20.6)	32(20.6)	0.984	20(22.7)	18(25.7)	0.663	0.683	0.397
Hepatic insufficiency ^b	145(29.4)	50(27.8)	46(29.7)	0.701	26(29.5)	23(32.9)	0.655	0.763	0.632
Pulmonary
Pneumonia ^c	335(68.0)	125(69.4)	92(59.4)	0.054	70(79.5)	48(68.6)	0.115	0.081	0.187
Reintubation	97(19.7)	36(20.0)	28(18.1)	0.653	19(21.6)	14(20.0)	0.525	0.762	0.730
Tracheotomy	67(13.6)	24(13.3)	20(12.9)	0.907	14(15.9)	9(14.3)	0.589	0.570	0.992
Ventilation time (h)	108.2 ± 82.3	107.2 ± 62.2	90.2 ± 40.6	0.003	129.8 ± 77.8	106.2 ± 60.0	0.033	0.019	0.045
Multiple organ dysfunction syndrome	16(3.2)	6(3.3)	5(3.2)	0.956	2(2.3)	3(4.3)	0.794	0.923	0.993
Transfusion requirements
Packed red blood cells (units)	5.77 ± 4.96	6.75 ± 4.73	4.34 ± 2.99	< 0.001	6.88 ± 4.66	4.76 ± 3.08	0.001	0.832	0.335
Fresh frozen plasma (ml)	470.8 ± 150.8	480.6 ± 188.6	410.0 ± 99.6	< 0.001	511.9 ± 174.9	435.8 ± 108.5	0.001	0.193	0.082
Platelets (units)	9.18 ± 5.50	9.66 ± 6.50	8.96 ± 6.70	0.333	10.03 ± 5.32	8.88 ± 5.56	0.188	0.620	0.926
Length of stay
ICU (days)	5.8 ± 3.7	6.3 ± 3.5	5.5 ± 2.6	0.017	7.8 ± 4.7	5.5 ± 3.5	0.001	0.080	1.000
Hospital (days)	18.9 ± 14.8	20.0 ± 10.8	16.2 ± 9.8	0.001	21.5 ± 10.5	17.2 ± 9.9	0.010	0.282	0.481
In-hospital mortality	25(5.1)	10(5.6)	7(4.5)	0.666	5(5.7)	3(4.3)	0.974	1.000	1.000
^a Defined as 50% rise in baseline creatinine or new need for dialysis. ^b Defined as bilirubin greater than 5 mg/dL persisting for more than 5 days postoperatively. ^c Defined as chest roentgenogram diagnosing pneumonia after cardiac surgery. DSSI: deep surgical site infection requiring revision; MI: myocardial infarction; SSI: surgical site infection. Values are n (%) or mean ± SD. P1, P2: P value of FMS group versus PUS group in Non-Obese and Obese patients, respectively. P3, P4: P value of Non-Obese patients versus Obese patients in FMS and PUS group, respectively.

The postoperative daily percentage of patients who were either free of pain or experienced only minor pain were similar across groups (Fig. 2).

Surgical procedures of the ascending aorta with or without total arch replacement and aortic root reconstruction have traditionally been performed via an FMS approach to ensure a good exposure. Recent advances in MIS techniques in combination with different partial sternotomy approaches have been employed as an alternative to FMS ^{12,18–20,21}, being used to conduct isolated heart valve disease, Bentall procedure, hemi-arch replacement, and ascending aorta repair. These less invasive approaches have been linked to superior cosmetic and postoperative outcomes, including an overall reduction in surgical trauma, ventilator use, ICU stay duration, transfusion requirements, respiratory failure, and sternal stability as compared to FMS ^18,22,23.

Although the Bentall technique and valve-paring aortic root surgery are complex procedures which necessitate a good overview, the value of PUS as an alternative access strategy for these complex procedures has been a topic of recent interest. ^9–11 Hillebrand et al. ² evaluated outcomes for 33 patients undergoing aortic root replacement with the Bentall procedure through a J-shaped PUS access and thereby confirmed the safety of PUS when conducting complex aortic surgery. Wachter et al. ²⁴ also demonstrated the safety of valve-sparing aortic root replacement procedures with the David procedure performed via PUS.

The degree of obesity is correlated with increased certain adverse outcomes including renal failure, sternal and wound infections, hospitalization duration, and prolonged mechanical ventilation^25–28. To determine whether the benefits of PUS were reduced due to obesity when undergoing aortic surgery, we herein compared PUS and FMS outcomes for obese and non-obese patients and explored the answer. This study is the most detailed analysis of this topic to date so far as we are aware.

Comorbidities, operative duration, and major complication rates

In our study, we observed comparable preoperative risk profiles and operative duration for both obese and non-obese patients when comparing the PUS and FMS groups. Although PUS was associated with a longer cross-clamp duration, we do not believe that this difference, on the scale of minutes of ischemic time, is likely to be clinically relevant.

Rates of mortality and major complications were comparable among PUS and FMS groups irrespective of BMI, indicating that obese patients are good candidates for PUS treatment.

Pulmonary complications

Obesity has been tied to the prolongation of ventilation and increase hypoxemia after acute aortic dissection (AAD) surgical procedures ²⁹. MIS approaches better preserve the integrity of the chest wall and thus have the potential to decrease the length of postoperative ventilator use. While obese patients did exhibit prolonged ventilator use relative to non-obese patients when comparing the PUS patient cohorts, PUS treatment was nonetheless associated with reductions in ventilator use for both obese and non-obese patients as compared to FMS treatment. We additionally observed no significant differences in rates of pneumonia, reintubation, or tracheotomy in the PUS group for obese or non-obese patients, suggesting that limited surgical access does not result in unfavorable pulmonary outcomes even among obese patients.

Transfusion requirements

Patients in the present study that underwent treatment via a PUS approach exhibited reduced transfusion requirements as compared to patients treated via an FMS approach irrespective of whether or not they were obese. These results are in line with those of Wu et al. ³⁰ and Xie et al. ^13,19,31,32. Previous evidence suggested that transfusions was associated with a negative impact on outcomes following cardiac surgery³³^–³⁶. Obese patients in the present study that underwent PUS procedures did not exhibit any differences in transfusion requirements as compared to non-obese patients, further supporting the fact that this procedure does not expose obese individuals to greater risk.

Length of stay

MIS approaches are associated with decreased length of hospitalization and duration of ICU stay ³⁷. Consistently, we found that both obese and non-obese patients in PUS group exhibited shorter durations of hospitalization and ICU stay as compared to FMS group. These findings are also consistent with previous meta-analyses^13,22,24,25. We did not observe any differences in the length of ICU or hospital stays for obese patients in this study relative to non-obese patients in the PUS cohort, indicating that this MIS approach is not associated with increased risk for obese individuals.

Sternal infections

We did not observe any protective benefits with respect to the odds of postoperative sternum infection in PUS cohort, which may contradict subjective clinical expectations. This might because the pathogenesis of sternal infections is likely multifactorial, and as such the improved integrity of the sternum alone is not sufficient to reduce the risk of sternum infection. Notably, we did not observe increased risk of postoperative sternal infections among obese patients in PUS cohort in this study, suggesting that PUS does not expose obese patients to additional risk of sternal infection.

Postoperative pain levels

Our results suggest that the PUS approach was associated with better postoperative pain levels. While these results do not align with those of a pooled analysis performed by Lim et al. ³², they are consistent with a meta-analysis conducted by Brown et al. ¹⁸ Overall, relatively limited data are available pertaining to this operative outcome, potentially explaining these contradictory results. We additionally found that obese and non-obese patients in PUS cohort experienced comparable levels of postoperative pain.

Limitations

The present study was a retrospective analysis which is subject to inherent bias. In addition, the study period was relatively long and changes in perioperative therapeutic regimens over this period may have impacted these findings. Propensity score matching could not be performed, given that the inclusion criteria for the PUS group shifted over the course of the study period from being at the discretion of the operating surgeon to the standard departmental approach.

The results of this study indicate safe and efficacious for obese patients to routinely undergo aortic root reconstruction or extensive total arch replacement via a PUS approach. This limited access strategy did not adversely impact the safety of obese patients while still conferring them benefits including reductions in postoperative ventilator use, ICU stay length, duration of hospitalization, and transfusion requirements. However, further prospective randomized trials will be necessary to confirm and expand upon these data.

PUS, partial upper sternotomy; FMS, full median sternotomy; BMI, body mass index; MIS, minimally invasive surgery; VSARR, valve-sparing aortic root replacement; AAD, acute aortic dissection; ARDS, acute respiratory disease syndrome; ICU, intensive care unit.

Acknowledgement

We highly acknowledge the contribution by the participators: Han-Fan Qiu, Liang-Liang Yan, Xiao-Dong Chen, Xue-Shan Huang, Xiao-Fu Dai, Dao-Zhong Chen, Dong-Shan Liao, Feng-Lin, Qi-Min Wang.

Ethical Approval and Consent to participate

The present study was approved by the ethics committee of Fujian Medical University, China and adhered to the tenets of the Declaration of Helsinki.

Consent for publication

Not applicable

Availability of Data and Materials

The data that support the findings of this study are available from Fujian Cardiac Medical Center but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Fujian Cardiac Medical Center.

Funding

This research was funded by the National Natural Science Foundation of China (81670438) and (81700418).

Competing interests

All authors declare that they have no competing interests.

Author Contributions

Zeng-Rong Luo and Liang-Wan Chen designed the study. Zeng-Rong Luo and Yi-Xing Chen collected and analyzed data together. Zeng-Rong Luo drafted the article and submitted the manuscript. Liang-Wan Chen supervised this study. All authors read the final version of this article and approved for publication.

Mikus E, Micari A, Calvi S, et al. Mini‐Bentall: an interesting approach for selected patients. Innovations. 2017;12(1):41‐45.
Hillebrand J, Alshakaki M, Martens S, Scherer M. Minimally invasive aortic root replacement with valved conduits through partial upper sternotomy. Thorac Cardiovasc Surg. 2018;66(4):295‐300.
Yoshiyuki Tokuda, Hideki Oshima, Yuji Narita, et al. Extended total arch replacement via the L-incision approach: single-stage repair for extensive aneurysms of the aortic arch. Interact Cardiovasc Thorac Surg. 2016;22(6):750-5.
Bakir I, Casselman FP, Wellens F, et al. Minimally invasive versus standard approach aortic valve replacement. Ann Thorac Surg. 2006; 81:1599‐1604.
Henryk A Welp, Isabell Herlemann, Sven Martens, et al. Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients. Interact Cardiovasc Thorac Surg. 2018;27(4):481-486.
Roselli EE. Interventions on the aortic valve and proximal thoracic aorta through a minimally invasive approach. Ann Cardiothorac Surg. 2015;4(1): 81–4.
Totaro P, Carlini S, Pozzi M, et al. Minimally invasive approach for complex cardiac surgery procedures. Ann Thorac Surg. 2009;88:462‐467.
Shrestha M, Krueger H, Umminger J, et al. Minimally invasive valve sparing aortic root replacement (David procedure) is safe. Ann Cardiothorac Surg. 2015;4(2):148‐153.
Monsefi N, Risteski P, Miskovic A, Moritz A, Zierer A. Midterm results of a minimally invasive approach in David procedure. Thorac Cardiovasc Surg. 2018;66(4):301‐306.
Perrotta S, Lentini S. Ministernotomy approach for surgery of the aortic root and ascending aorta. Interact CardioVasc Thorac Surg. 2009 Nov;9(5):849-58.
Ahmad A, Risteski P, Papadopoulos N, Radwan M, Moritz A, Zierer A. Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique. Eur J of Cardio‐Thoracic Surr. 2016;50:140‐144.
Oishi Y, Sonoda H, Tanoue Y, et al. Advantages of the L-incision approach comprising a combination of left anterior thoracotomy and upper halfmedian sternotomy for aortic arch aneurysms. Interact Cardiovasc Thorac Surg. 2011;13:280–3.
Xian-Biao Xie, Xiao-Fu Dai, Guan-Hua Fang, et al. Extensive repair of acute type A aortic dissection through a partial upper sternotomy and using complete stent-graft replacement of the arch. J Thorac Cardiovasc Surg. 2020; 24;S0022-5223(20)32885-3.
Liang-Wan Chen, Xi-Jie Wu, Qian-Zhen Li, Xiao-Fu Dai. A modifed valve-sparing aortic root replacement technique for acute type A aortic dissection:the patch neointima technique. Eur J Cardiothorac Surg. 2012;42:731–3.
Xiao-Fu Dai, Guan-Hua Fang, Liang-Liang Yan, et al. Patch neointima technique in acute type A aortic dissection: mid-term results of 147 cases. Ann Thorac Surg. 2021;112(1):75-82.
Bentall H, DeBono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23(4):338–9.
Zhi-Huang Qiu, Liang-Wan Chen, Lian-Ming Liao, et al. Efficiency of Modifified Triple-Branched Stent Graft in Type I Aortic Dissection: Two-Year Follow-up. Ann Thorac Surg. 2020 Sep;110(3):925-932.
Brown ML, McKellar SH, Sundt TM, et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009;137:670–9.e5.
Scarci M, Young C, Fallouh H. Is ministernotomy superior to conventional approach for aortic valve replacement? Interact CardioVasc Thorac Surg. 2009;9:314‐317.
Skripochnik E, Michler RE, Hentschel V, Neragi‐Miandoab S. The efficacy and outcome of ministernotomy compared to those of standard sternotomy for aortic valve replacement. ISRN Minim. Invasive Surg. 2014;2014:254084.
Morisaki A, Hattori K, Kato Y, et al. Evaluation of aortic valve replacement via the right parasternal approach without rib removal. Ann Thorac Cardiovasc Surg. 2015;21:139–45.
Minoru Tabata, Zain Khalpey, Sary F Aranki, et al. Minimal access surgery of ascending and proximal arch of the aorta: a 9-year experience. Ann Thorac Surg. 2007; 84:67–72.
Filip G, Bryndza MA, Konstanty-Kalandyk J, et al. Ministernotomy or sternotomy in isolated aortic valve replacement? Early results. Kardiochir Torakochirurgia Pol. 2018;15(4):213–8.
Wachter K, Franke UF, Yadav R, et al. Feasibility and clinical outcome after minimally invasive valve‐sparing aortic root replacement Interact Cardiovasc Thorac Surg. 2017;24(3):377‐383.
Birkmeyer NJ, Charlesworth DC, Hernandez F, et al. Obesity and risk of adverse outcomes associated with coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation 1998;97:1689–94.
Tolpin DA, Collard CD, Lee VV, Elayda MA, Pan W. Obesity is associated with increased morbidity after coronary artery bypass graft surgery in patients with renal insuffificiency. J Thorac Cardiovasc Surg 2009;138: 873–9.
Roberts WC, Roberts CC, Vowels TJ, et al. Effect of body mass index on survival in patients having aortic valve replacement for aortic stenosis with or without concomitant coronary artery bypass grafting. Am J Cardiol 2011;108:1767–71.
Smith RL 2nd, Herbert MA, Dewey TM, et al. Does body mass index affect outcomes for aortic valve replacement surgery for aortic stenosis? Ann Thorac Surg 2012;93:742–6; discussion 746–7.
Wei Sheng, Hai-Qin Yang, Yi-Fan Chi, Zhao-Zhuo Niu, Ming-Shan Lin, Sun Long. Independent risk factors for hypoxemia after surgery for acute aortic dissection. Saudi Med J. 2015 Aug;36(8):940-6.
Yang Wu, Wei Jiang, Dong Li, et al. Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy. J Cardiothorac Surg. 2020 Apr 7;15(1):57.
Murtuza B, Pepper JR, Stanbridge RD, et al. Minimal access aortic valve replacement: is it worth it? Ann Thorac Surg 2008;85:1121–31.
Lim JY, Deo SV, Altarabsheh SE, et al. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg 2015;30:125–34.
Ghanta RK, Lapar DJ, Kern JA, et al. Minimally invasive aortic valve replacement provides equivalent outcomes at reduced cost compared with conventional aortic valve replacement: a real-world multi-institutional analysis. J Thorac Cardiovasc Surg. 2015;149:1060–5.
Bhaskar B, Dulhunty J, Mullany DV, Fraser JF. Impact of blood product transfusion on short and long-term survival after cardiac surgery: more evidence. Ann Thorac Surg 2012;94:460–7.
Reeves BC, Murphy GJ. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Curr OpinCardiol. 2008;23:607–12.
von Heymann C, Kaufner L, Sander M, et al. Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery? J Thorac Cardiovasc Surg. 2016;152:1412–20.
Santana O, Reyna J, Grana R, Buendia M, Lamas GA, Lamelas J. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011;91:406–10.

Download PDF

Reviews received at journal
28 Apr, 2022
Reviewers invited by journal
28 Apr, 2022
Editor assigned by journal
02 Dec, 2021
First submitted to journal
01 Dec, 2021

You are reading this latest preprint version

Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients

Status:

Version 1

Abstract

Figures

Introduction

Patients And Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Status:

Version 1