Reoperative minimal access aortic valve surgery: Minimal mediastinal dissection and minimal injury risk

Objective: Minimizing surgical access in reoperative cardiac surgery allows limitation of dissection, trauma, and manipulation of patent bypass grafts. We report an 11-year experience with reoperative minimal access aortic valve surgery through an upper hemisternotomy. Methods: From July 1996 to June 2007 at our institution, 146 patients underwent reoperative minimal access aortic valve surgery, 109 of whom had undergone previous coronary artery bypass grafting and 93 of whom had a patent left internal thoracic artery graft. In patients with a patent left internal thoracic artery graft, the graft remained undissected. Myocardial protection was achieved with hypothermia, cold cardioplegia, and systemic hyperkalemia. Early and late outcomes were analyzed. Results: Median age was 76 years, and 43 patients (29%) were 80 years or older. Nineteen patients(13%) underwent concomitant procedures, such as coronary artery bypass grafting, mitral valve repair, and ascending aortic replacement. Median cardiopulmonary bypass and aortic crossclamp times were 150 and 80 minutes, respectively. Four patients (2.8%) had conversion to full sternotomy. Operative mortality was 4.1% (6/146). The incidences of reoperation for bleeding and blood transfusion were 0.7% (1/146) and 83.6% (122/146), respectively. No patient had left internal thoracic artery or aortocoronary graft injury. Median stay was 8 days, and 56% (79/140) were discharged home. Five-year actuarial survival was 85%. Conclusion: An upper hemisternotomy approach for reoperative aortic valve surgery is safe and feasible. This approach minimizes tissue dissection and trauma, thereby reducing the risk of injury to patent grafts and mediastinal organs.