The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis

Antonia van Kampen; Christian D Etz; Josephina Haunschild; Martin Misfeld; Piroze Davierwala; Sergey Leontyev; Michael A Borger

doi:10.3390/life13112204

The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis

Life (Basel). 2023 Nov 13;13(11):2204. doi: 10.3390/life13112204.

Authors

Antonia van Kampen^{1

2}, Christian D Etz^{1

3}, Josephina Haunschild^{1

3}, Martin Misfeld^{1

4

5

6

7}, Piroze Davierwala^{1

8}, Sergey Leontyev¹, Michael A Borger¹

Affiliations

¹ Leipzig Heart Center, University Clinic for Cardiac Surgery, Struempellstr. 39, 04289 Leipzig, Germany.
² Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA.
³ Department of Cardiac Surgery, Rostock University Hospital, Schillingallee 35, 18057 Rostock, Germany.
⁴ Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd., Camperdown, NSW 2050, Australia.
⁵ Sydney Medical School, Anderson Stuart Buidling, The University of Sydney, Camperdown, NSW 2050, Australia.
⁶ Institute of Academic Surgery, Royal Prince Alfred Hospital, 145 Missenden Rd., Camperdown, NSW 2050, Australia.
⁷ The Baird Institute of Applied Heart and Lung Surgical Research, 100 Carillon Ave., Newtown, NSW 2042, Australia.
⁸ Division of Cardiac Surgery, Toronto General Hospital, University of Toronto, 585 University Ave., Toronto, ON M5G 2N2, Canada.

Abstract

Objective: Minimally invasive approaches are being used increasingly in cardiac surgery and applied in a wider range of operations, including complex aortic procedures. The aim of this study was to examine the safety and feasibility of a partial upper sternotomy approach for isolated elective aortic root replacement (a modified Bentall procedure).

Methods: We performed a retrospective analysis of 768 consecutive patients who had undergone isolated Bentall surgery between January 2000 and January 2021 at our institution, with the exclusion of re-operations, endocarditis, acute aortic dissections, and root replacement with major concomitant procedures such as multi-valve or coronary bypass surgery. A total of 98 patients were operated on via partial sternotomy (PS) and were matched 2:1 to 196 patients operated on via full sternotomy (FS).

Results: The procedure time was 12 min longer in the PS group (205 min vs. 192.5 min in the FS group, p = 0.002), however, cardiopulmonary bypass and aortic cross-clamp times were comparable between groups. Eight PS-procedures were converted to full sternotomy, predominantly for bleeding complications (n = 6). Re-exploration for acute bleeding was necessary in 11% of the PS group and 4.1% of the FS group (p = 0.02). Five FS patients and none in the PS group required emergency coronary bypass grafting for postoperative coronary obstruction (p = 0.2). PS patients were hospitalized for a significantly shorter period (9.5 days vs. 10.5 days in the FS group, respectively). There were no significant differences regarding in-hospital (p = 0.4) and mid-term mortality (p = 0.73), as well as for other perioperative complications.

Conclusions: Performing Bentall operations via partial upper sternotomy is associated with similar perfusion and cross-clamp times, as well as overall mortality, when compared to a full sternotomy approach. A low threshold for conversion to full sternotomy should be accepted if limited access proves insufficient for the handling of intraoperative complications, particularly bleeding.

Keywords: Bentall procedure; aortic aneurysm; aortic root replacement; minimally invasive aortic surgery.

Grants and funding

This research received no specific external funding. A.v.K. is supported by an American Heart Association Postdoctoral Fellowship Award (Funder: American Association. Grant number: 905880).