Eugenio Caradonna

ABSTRACT                                                                             BIBLIOGRAFY

 

Method

Two patients with ascending aortic aneurysm and severe aortic valve incompetence underwent replacement of the aortic valve and of the ascending aorta with direct reimplantation of the coronary ostia. Nuclear magnetic resonance showed the presence of 8 and 10 cm. aneurysms.

Surgical manual

Skin incision is 8 cm. Partial L-sternotomy is performed with an ocillating saw from the sternal notch to the 3rd./4rd. intercostal space towards the right avoiding to damage the right internal thoracic artery. Extracorporeal circulation is connected to the patient through the femoral vessels. The pericardium is opened in a standard way. The exposition of the ascending aorta obtained is excellent. A catheter placed in the pulmonary artery is used to vent the heart. The operations were performed as described (7). In these instances cardioplegia was given directly in the coronary ostia (St.Thomas type 2).

There were no surgical complications. No inotropic support was needed in the early post operatory period. The patients stay in the intensive care was two days. The quality of life during Hospital stay was better if compared with quality of life of patients operated with standard sternotomy. Post -operative pain has been less. This resulted in:

1)Improved respiratory function

2)early mobilization

3)reduced pain treatment.

The patients were discharged in the seventh posr-operative day. The post operative follow-up showed a rapid recovery to normal life.

Comment

Nowadays aortic valve replacement is usually performed through conventional sternotomy. Nevertheless, partial sternotomy is used with increasing rate with the aim to obtain a less invasive surgery. In cardiac surgery the concept of invasivness is strictly related to:

1)the surgical approach

2)the extracorporeal circulation.

The possibility to perform an operation with a minimal incision and without the use of extracorporeal circulation is the less invasive approach possible. The increasing interest towards mini invasive cardiac surgery should not determine a prolonged time of cardiac arrest and extracorporeal circulation. Post operative mortality and morbidity being strictly related to the variable described. For these reasons tecniques that imply an increased time of extracorporeal perfusion cannot be considered mini-invasive. In the surgery on the aorta and particolarly in the cases here reported therewere no increased time related to the surgical approach. In fact the surgical exposition was excellent. The advantage obtained are:

1) increased sternal stability

2) a reduced probability of infections

3) minor blood loss

Point 2,3 as consequences of reduced exposition. The general sensation of well being of the patients operated with a mini invasive approach is due to the sum of the factors previously described. This is of particular importance for the patients that must undergo complex surgical operations. In our experience mini invasive surgery is the preferred option for routine operations on the ascending aorta and the aortic valve excluding patients obese and reoperations.

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