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Chapter 33
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Minimally Invasive Aortic Surgery:
Mini-Bentall Procedure and Beyond
Campbell D. Flynn1, Tristan D. Yan
1
University of Sydney, Sydney, NSW, Australia; 2Macquarie University, Sydney, NSW, Australia
1,2
Chapter Outline
Introduction 383
Etiology of Thoracic Aortic Aneurysm 383
Marfan Syndrome 383
Nonsyndromal Familial Thoracic Aortic Aneurysm 384
Bicuspid Aortic Valve 384
Pathophysiology of Thoracic Aortic Aneurysm 384
Indications for Surgery 384
Evolution of Proximal Thoracic Aortic Surgery 385
Evolution of Minimally Invasive Cardiac Surgery 385
Mini-Bentall and Hemiarch Procedure 386
Preparation 386
Mini-Sternotomy 386
Cannulation and Cardiopulmonary Bypass 386
Preparation of the Aortic Root 387
Aortic Root Replacement 388
Hemiarch Replacement 388
Graft-to-Graft Anastomosis 390
Completion of Procedure 390
Discussion 390
Conclusions and Future Directions 391
References 391
INTRODUCTION
Thoracic aortic aneurysm is a lethal condition and has an annual incidence of 10.4 aneurysms per 100,000 population
[1]. It necessitates prompt surgical intervention to prevent potentially deadly complications such as aortic rupture
or aortic dissection. Thoracic aortic aneurysm is known as a “silent killer,” as only 5%–10% of patients experience
symptoms. Symptoms suggestive of thoracic aortic aneurysm include dysphonia, dysphagia, dyspnea, cough, and
very rarely musculoskeletal pain due to erosion of the ribs. Patients presenting acutely may experience severe, tearing
pain as a result of aortic dissection or impending rupture [2].
ETIOLOGY OF THORACIC AORTIC ANEURYSM
The majority of thoracic aneurysmal disease is sporadic and degenerative in etiology with risk factors including
hypertension, hypercholesterolemia, and diabetes [1]. A number of connective tissue disorders with characteristic
extra-aortic manifestations represent approximately 5% of patients with thoracic aortic aneurysm. The most common syndromal aortopathy is Marfan syndrome. Other aggressive, genetically mediated connective tissue disorders
with associated aortopathy include Loeys–Dietz syndrome, Ehlers–Danlos syndrome, and the more recently identified aneurysm osteoarthritis syndrome and arterial tortuosity syndrome. In particular, the proximal thoracic aorta is
commonly affected in Marfan syndrome, nonsyndromal familial thoracic aortic aneurysm, and bicuspid aortic valve
associated aortopathy.
MARFAN SYNDROME
Marfan syndrome is a genetic disorder displaying autosomal dominant inheritance. The features of Marfan syndrome
result from mutation in the gene, FBN1. It affects 1:5000 individuals and is diagnosed using the Ghent-2 criteria, which is
based on clinical features, family history, and presence of FBN1 mutation [3]. Ascending aortic pathology is a prominent
feature with ascending aortic dilatation present in 53% of Marfan patients at 30 years and 96% at 60 years. The probability
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00033-X
Copyright © 2018 Elsevier Inc. All rights reserved.
383
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of having an aortic dissection or requiring aortic surgery for Marfan patients at an age of 30 years is 16%; by the age of
60 years this reaches 74% [4]. Previously, Marfan patients had a median life expectancy of 49 years. However, with prompt
cardiovascular surgical intervention, these individuals now have a near normal life expectancy [5].
NONSYNDROMAL FAMILIAL THORACIC AORTIC ANEURYSM
In patients with no diagnosed syndromal connective tissue disorder, family history remains an important risk factor for
thoracic aortic aneurysm. Twenty percent of thoracic aortic aneurysms occur in individuals with strong family history of
aneurysm. Nonsyndromal familial thoracic aortic aneurysm demonstrates autosomal dominant inheritance with incomplete
penetrance. Patients with a familial thoracic aortic aneurysm have an earlier age of aneurysm diagnosis than sporadic aneurysms (55.4 vs. 58.2 years old, respectively) and a faster rate of aneurysm growth [6].
BICUSPID AORTIC VALVE
Bicuspid aortic valve condition represents the most common congenital cardiac defect and is present in 2% of the population. The clinical sequelae of aortic valve insufficiency and dilatation of the ascending aorta are common. Twenty-five
percent of individuals require surgery on the ascending aorta and 53% require surgery on the aortic valve within 25 years
of the diagnosis of bicuspid aortic valve [7]. Aneurysm of the proximal aorta is common with aneurysmal ascending aorta
developing in 57% of individuals and aneurysmal aortic root developing in 14% of individuals [8].
PATHOPHYSIOLOGY OF THORACIC AORTIC ANEURYSM
The aorta has a complicated geometry that gradually tapers as it continues distally, the maximum normal aortic diameter
is 4 cm, anything above this is considered aneurysmal. The normal aorta is known to dilate with age, the rate of dilation
for males is 0.9 mm per decade of life and 0.7 mm for females [9]. The risk of complication, in particular aortic rupture,
has been shown to markedly increase when the aneurysm size is greater than 6 cm in diameter [10]. As the human aorta
dilates, the wall stress increases and distensability decreases. Koullias et al. developed a model suggesting that wall stress
for aneurysm >6 cm was 857 ± 290.8 kPa at a transient blood pressure of 220 mmHg exceeding the tensile strength of aortic
tissue [11]. This explains the markedly increased risk of rupture of aneurysm greater than 6 cm.
INDICATIONS FOR SURGERY
The etiology of thoracic aortic aneurysm is an important determinant for timing of intervention. Current indication for surgical intervention on the proximal thoracic aorta is guided by the size criteria and patient-related factors (Table 33.1). There
is lower threshold for surgical intervention for patients with a connective tissue disorder, family history, or bicuspid aortic
valve as they are at higher risk of aortic dissection or rupture than patients with sporadic aneurysm [12,13]. As surgical
TABLE 33.1 Indications for Intervention on the Aortic Root and Ascending Aorta [12,13]
Indication for Operative Intervention on Aortic Root or Ascending Aortic
Patient Group
Any patient
Marfan syndrome
Loeys–Deitz syndrome
Ehler–Danlos syndrome
Bicuspid aortic valve disease
Coronary artery or valve disease requiring
operative management
Aneurysm
l
≥55 mm
l
Growth rate >0.5 cm/year
l
Symptomatic
l
Aneurysm ≥50 mm (Loeys–Deitz consider intervention if aneurysm >44–46 mm)
l
Aneurysm diameter ≥45 mm if family history of dissection
l
Aneurysm dilatation of >3–5 mm/year
l
≥50 mm
l
Symptomatic
l
Aneurysm dilation >5 mm/year
l
Consider if aneurysm ≥45 mm
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techniques and patient outcomes improve, it is quite possible that a lower threshold for surgical intervention would be justifiable. Novel predictors for aneurysm-related complications are under investigation that may allow individualized patient
care to be based on aneurysm morphology, aneurysm wall stress, and shear stress analysis in the future [14].
EVOLUTION OF PROXIMAL THORACIC AORTIC SURGERY
Prior to the development of reliable cardiopulmonary bypass, the management of proximal thoracic aortic aneurysm
was limited to excision and aortorrhaphy of saccular aneurysms [15]. In 1956, Cooley and Debakey performed the
first proximal aortic replacement, replacing the supracoronary ascending aorta using a frozen aortic homograft [16].
The first documentation of aortic root surgery is in 1964 when Wheat et al. reported a repair of the aortic root and
ascending aortic by anastomosing a Teflon conduit to the aortic annulus with the coronary ostia kept in continuity
with the aortic annulus by a tongue of aortic tissue [17]. In 1968, Bentall and De Bono documented the next evolution
in the management of aortic root pathology with the use of a composite valve—Dacron graft conduit [18]. The original procedure describes an “inclusion method,” whereby a longitudinal incision was made in the ascending aorta and
a composite valve graft was secured to the aortic annulus. The coronary ostia, still in continuity with the native aorta,
was anastomosed to orifices created in the Dacron graft and the longitudinal incision in the aneurysmal native aorta
was closed over the graft. This approach was necessary due to the porous nature of the Dacron conduit that would
otherwise have led to exsanguination.
A significant complication of the original Bentall and De Bono procedure was the formation of tense hematoma
between the Dacron graft and the aortic wall putting tension on the coronary anastomoses. Interposition grafts were used
to improve the reliability and reduce tension on this anastomosis. Blanco et al. employed saphenous vein interposed
between the coronary ostia and the Dacron graft or distal aortic tissue [19]. Cabrol et al. developed an alternative interposition graft solution using a single tube of 8 mm Dacron graft anastomosed on one end to the right coronary ostium
and the other to the left with a side-to-side anastomosis fashioned between the 8 mm graft and the aortic graft, thus
perfusing the coronaries.
In 1986, Kouchoukos et al. modified the procedure described by Bentall and De Bono by preclotting the Dacron conduit, making it immediately hemostatic. This signaled the end of the inclusion techniques. The aneurysmal aortic tissue
was completely excised with coronary buttons fashioned, which were reimplanted to the aortic root graft [20,21]. Ongoing
modification to the Bentall procedure has been subsequently undertaken with the primary objective of improving hemostasis and reducing transfusion requirement [22–24]. The improvements in hemostasis put aortic surgery within the reach of
minimally invasive techniques.
EVOLUTION OF MINIMALLY INVASIVE CARDIAC SURGERY
A desire to reduce the surgical trauma associated with cardiac surgery has driven the development of various minimally
invasive approaches. The techniques of minimally invasive aortic surgery have evolved from the valve surgery, with the
first documented minimal access aortic valve replacement being performed in 1993 [25] via right anterior thoracotomy. By
the late 1990s, approaches via right parasternal incision [26] and hemisternotomy [27] were described. As the technique
became refined, an increasing complexity of procedures was undertaken including aortic root replacement [28], ascending
aorta, and arch replacements [29].
Currently, minimally invasive cardiac surgery represents the minority of surgery performed. However, an increasing
evidence base may encourage more surgeons to pursue these techniques to improve the outcomes for our patients [30].
Conclusive data from minimal access aortic surgery are limited but results extrapolated from valve surgery demonstrate
the potential benefits of minimally invasive surgery. Experienced centers have demonstrated significantly shorter hospital
length of stay [31–35] and an increase in discharge home as opposed to rehabilitation facilities [34]. A reduction in major
complication rates has been observed with high volume centers reporting decreased rates of postoperative myocardial
infarction, stroke [34], and atrial fibrillation [36]. Patients undergoing minimally invasive procedures had a reduced transfusion requirement [36]. As could be expected, patients required less postoperative opiate analgesia [37] reported less pain
and have improved patient satisfaction [38] with minimally invasive incisions.
A concern of minimally invasive surgery is the increase in procedure time and in particular increase in cardiopulmonary
bypass and cross-clamp times [35–37]. However, minimally invasive surgery obliges surgeons to pay ultimate respect to
tissue handling and hemostasis. This likely contributes to the improved patient outcomes reported in the literature. The
fundamental principles of the traditional surgical approaches must be respected, it cannot be emphasized enough that circulatory control, organ protection, and meticulous surgical technique are of utmost importance in minimal access surgery.
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MINI-BENTALL AND HEMIARCH PROCEDURE
Here, we describe the technical approach to perform proximal aortic surgery. This approach provides sufficient access to
safely perform currently accepted methods of proximal aortic repair with minimal modification while reducing surgical
trauma. Should the need arise, it is possible to rapidly convert to a conventional midline sternotomy.
PREPARATION
After induction of anesthesia, left- and right-sided arterial, central venous, and pulmonary artery monitoring lines are sited.
The patient is positioned supine. For patients with a short neck or significant adiposity, exposure to the sternum can be
improved by placing a 1L bag of saline between the scapulae. The suprasternal notch, the xiphoid process, the manubriosternal junction, the mid-line of the sternum, the second to fourth intercostal spaces, and both femoral arteries are marked
before the skin is prepped and draped.
MINI-STERNOTOMY
A skin incision is created extending from the manubriosternal junction to the third rib interspace, usually measuring approx-
imately 5–7 cm. Diathermy dissection of the subcutaneous tissues to define the midline of the sternum. A flap is raised bilaterally in the prepectoral plane 3–4 cm lateral to the sternal edge to allow adequate retraction; this plane is then continued
superiorly to the suprasternal notch and the intraclavicular ligament is divided. The flap is raised inferiorly to the fourth
rib interspace. A small skin incision is made parasternally on the left in the third or fourth interspace through which a 14Fr
Jackson Pratt drain is sited (Cardinal Health, McGaw Park, IL, USA) and this drain is used during the case to flood the
operative field with carbon dioxide at 4 L/min to reduce the risk of air embolism and is left in situ to act as a subcutaneous
drain postoperatively.
The mini-sternotomy is created using a pneumatic or electric hand saw commencing at the suprasternal notch to the
fourth interspace. The sternotomy can be terminated in either the left or right parasternal space. However, for surgery
on the aorta, we favor a “reverse J-hemisternotomy,” whereby the sternotomy is terminated in the left fourth intercostal
space. Time spent on hemostasis at this point is essential; bleeding edges of periosteum are managed with diathermy
and hemostasis of the cut surface of the sternum is achieved using a small amount of bone wax. The thymic tissue is
mobilized and excised to the level of the innominate vein. The pericardium is opened superiorly to the pericardial reflection on the aorta and inferiorly to the fourth interspace. The pericardium is retracted with three stay sutures on each side
that are secured to the skin. The aorta is examined for calcified plaque and the cannulation and cross-clamping sites are
identified. A Semb dissecting forceps is used to create a plane behind the mid-ascending aorta taking care not to damage
the delicate right pulmonary artery posteriorly and the main pulmonary trunk medially and a nylon tape is slung around
the aorta.
CANNULATION AND CARDIOPULMONARY BYPASS
Systemic heparinization is administered to achieve an activated clotting time of greater than 450 s prior to cannulation. The
right femoral vein is accessed under ultrasound guidance, a wire is passed up the femoral vein and into the superior vena
cava with the position being confirmed on transesophageal echocardiogram (TOE). A Seldinger technique is used to insert a
23Fr or 25Fr dual-stage venous cannula. The cannula is advanced into the inferior vena cava and then right atrium at which
point the introducing trocar is retracted into the cannula to reduce the chance of atrial injury. Traction must be applied to
the wire whenever the cannula is being advanced to ensure that kinking does not occur. The final position of the cannula tip
is confirmed in the superior vena cava on TOE.
Attention is then focused on arterial cannulation. If hemiarch replacement is required, the arterial line is “split” into two
lines, one line for systemic perfusion and the other for unilateral antegrade selective cerebral perfusion. Central aortic or
peripheral femoral arterial cannulation can be performed. Central arterial cannulation permits antegrade arterial flow and
is preferred for elective surgery. The cannulation site is at the level of the pericardial reflection on the aorta. Exposure of
the distal ascending aorta is improved by applying gentle inferior traction to the nylon tape that is slung around the aorta
or inferior traction to an artery forcep grasping the adventitia of the mid-ascending aorta. Two 2-0 Ti-cron (Medtronic Inc.,
Minneapolis, MN, USA) purse string sutures are sited in the adventitia surround the cannulation site. The aorta is punctured
and an elongated one-piece arterial cannula (Medtronic Inc, Minneapolis, MN, USA) is sited and advanced approximately
3 cm into the vessel.
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Cardiopulmonary bypass is commenced and the patient is cooled to 32°C for aortic root replacement or 25°C for
hemiarch replacement. An atraumatic cross-clamp is applied across the distal ascending aorta and cardiac arrest is
achieved using antegrade cardioplegia delivered via a dual lumen aortic root cannula (Medtronic Inc, Minneapolis, MN,
USA). The left ventricle is not well visualized in hemisternotomy so the heart is closely watched on TOE to ensure that
ventricular distension does not occur. If distension occurs direct coronary ostial cardioplegia can be administered to
achieve arrest. Cold blood cardioplegia can be used; however, Custodiol histidine-tryptophan-ketoglutarate cardioplegia
(Essential Pharmaceuticals, Ewing, NJ, USA) is an attractive alternative in minimal access surgery providing equivalent
myocardial protection with a single dose of cardioplegia [39].
PREPARATION OF THE AORTIC ROOT
A transverse aortotomy is completed and the aneurysmal aortic tissue of the ascending aorta is excised leaving a
sufficient cuff of tissue proximal to the aortic clamp. Sufficient left ventricular venting can be achieved by placing a
pediatric drop vent through the aortic valve into the left ventricular outflow tract negating the need to site a vent in the
superior pulmonary vein. The proximal resection ends approximately 1 cm distal to the sinotubular junction, the coronary ostia are identified and the aortic root is mobilized. Resection of the aortic root tissue begins at the noncoronary
sinus; tissue is excised leaving an 8 mm rim of aortic tissue above the aortic annulus that makes part of the hemostatic
layer of closure. The coronary buttons are fashioned by creating a vertical incision in the aortic tissue on either side
of the coronary ostium; these incisions are then connected inferiorly. A 4-0 Prolene suture (Ethicon, Somerville, NJ,
USA) is placed in the flap of aortic tissue superior to the ostium to allow gentle retraction and the coronary button is
mobilized a short distance. The aortic tissue of the left and right coronary sinuses is now resected as was performed
for the noncoronary sinus.
With the aortic root prepared, exposure of the aortic annulus is addressed by siting 3X pledgetted 2-0 Ethibond
(Medtronic Inc, Minneapolis, MN, USA) above the commissures of the aortic valve. The suture place above the noncoronary cusp/left coronary cusp commissure is secured on the drapes at the 10 o’clock position, above the left coronary
cusp/right coronary cusp commissure it is secured in the 2 o’clock position, and above the right coronary cusp/noncoronary cusp commissure it is secured at the 7 o’clock position. Traction on these sutures moves the aortic root cephalad
(Fig. 33.1). The aortic valve leaflets are excised and the annulus is meticulously debrided of calcium deposits.
Pledgetted or nonpledgetted annular sutures can be sited; we favor pledgetted sutures to minimize tissue stress when
securing the valve. When siting annular sutures attention is paid to equal spacing between sutures and ensuring that
the need is driven perpendicularly to the tissue of the aortic annulus from the ventricular side to the aortic side thus
leaving the pledget in a subannular position (Fig. 33.2).
FIGURE 33.1 Three pledgetted sutures are sited above commissures, traction elevates the aortic root cephalad improving the exposure. Reproduced
from Yan TD. Mini-Bentall procedure. Ann Cardiothorac Surg 2015;4(2):182–90. With permission from Medical Illustrxator, Beth Croce.
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FIGURE 33.2 Plegetted sutures are sited in the aortic annulus in a horizontal mattress fashion leaving the pleget in a subannular position. Reproduced
from Yan TD. Mini-Bentall procedure. Ann Cardiothorac Surg 2015;4(2):182–90. With permission from Medical Illustrator, Beth Croce.
AORTIC ROOT REPLACEMENT
With annular sutures in situ, an appropriately sized valve is selected. A Valsalva graft (Vascutek Ltd, Renfrewshire, Scotland)
is subsequently selected according to the formula:
The Valsalva graft and prosthetic aortic valve are incorporated into the aortic root using a double layer anastomosis—the
French cuff technique [40]. The proximal portion of the Valsalva graft is trimmed to 8 mm; this cuff is then folded back on
itself giving a double layer of fabric, it is this double layer of fabric that gives the technique the moniker the French cuff
technique. The valve is sited in the Valsalva graft and the annular sutures are passed first through the sewing ring of the
valve and the needle then continues to pass through the folded double layer of fabric of the Valsalva graft. When all the
annular sutures are sited, the Valve-conduit is parachuted into position and sutures tied. The second layer of the anastomosis
is completed with a continuous, running 4-0 Prolene suture (Ethicon, Somerville, NJ, USA), which secures the remaining
supra-annular cuff of aortic tissue to the everted edge of the Valsalva graft. The assistant must apply adequate tension to the
suture as it is placed to ensure a hemostatic closure the first time.
The coronary buttons are prepared by trimming the flap of surrounding aortic tissue to a 3 mm rim around the coronary
ostium. The site of the coronary ostium anastomosis is determined by filling the heart and allowing the coronary button to
rest in a natural position; the Valsalva graft is marked at this point. A small hole is created on the Valsalva graft using a thermocautery pen and the coronary button is secured to the graft using a 5-0 Prolene suture (Ethicon, Somerville, NJ, USA).
The left coronary button is anastamosed followed by the right (Fig. 33.3). Care must be taken to ensure accurate suture
placement and that a full thickness bite of the aortic tissue is taken to ensure hemostasis as this is a particularly difficult
anastomosis to repair off bypass. On completion, the anastomosis is checked for hemostasis by pressurizing the aortic root
by delivering a dose of antegrade cardioplegia via the aortic root.
HEMIARCH REPLACEMENT
For patients with aneurysmal distal ascending aorta or proximal arch, which precludes repair under cross-clamp, a hemiarch
replacement is completed with open distal anastomosis. Neuroprotection is afforded by moderate hypothermic circulatory
arrest with antegrade cerebral perfusion. The patient is cooled to 25°C and the head is packed in ice. The patient’s blood is
drained into the bypass reservoir and total circulatory arrest is commenced. The cross-clamp is removed and the aneurysmal
segment of the ascending aorta and proximal aortic arch is excised. The ostium of the innominate artery and left common
carotid is inspected for atheromatous disease. The innominate is cannulated with a 17Fr manual balloon inflation catheter
(Fig. 33.4), and cerebral perfusion is continuously monitored using bilateral near-infrared spectroscopy; a significant drop
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FIGURE 33.3 The coronary button is trimmed leaving a 3 mm cuff of aortic tissue around the coronary ostium; the anastomosis is completed with a
continuous suture with 5-0 Prolene. Reproduced from Yan TD. Mini-Bentall procedure. Ann Cardiothorac Surg 2015;4(2):182–90. With permission from
Medical Illustrator, Beth Croce.
FIGURE 33.4 Unilateral antegrade cerebral perfusion is delivered by cannulating the innominate artery. Bilateral cerebral near infrared spectroscopy
(NIRS) is monitored to ensure that adequate cerebral protection is achieved using unilateral antegrade perfusion. A drop in left-sided NIRS could prompt
the placement of a left common carotid perfusion catheter or cooling to achieve deep hypothermia. Reproduced from Yan TD. Mini-Bentall procedure.
Ann Cardiothorac Surg 2015;4(2):182–90. With permission from Medical Illustrator, Beth Croce.
in left-sided cerebral saturation prompts the insertion of a left cerebral perfusion catheter. If there is difficulty in inserting
the cerebral perfusion catheter or significant atherosclerotic disease antegrade cerebral perfusion is abandoned and the
patient is cooled to achieve deep hypothermia rather than risk a catheter-related embolic stroke.
With neuroprotection secured, the open distal anastomosis of an appropriately sized Vascutek Ante-Flo graft (Vascutek
Ltd, Renfrewshire, Scotland) is undertaken using a double arm, 3-0 Prolene suture (Ethicon, Somerville, NJ, USA) starting with the posterior wall, furthest from and stitching toward the surgeon (Fig. 33.5). When the posterior aspect of the
anastomosis is complete, a nerve hook is used to ensure that an adequate, hemostatic tension is achieved. The other arm of
the suture is taken and the anterior wall of the anastomosis is completed. The suture line is reinforced as necessary using
pledgetted 4-0 Prolene sutures (Ethicon, Somerville, NJ, USA). The arterial cannula is secured in the side arm of the AnteFlo graft and the graft deaired. Systemic antegrade perfusion can be resumed and the patient rewarmed to 37°C.
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FIGURE 33.5 The posterior wall of the open distal anastomosis is completed first using a 3-0 continuous Prolene suture. When the posterior wall
is completed, a nerve hook is used to tighten the suture prior to completing the anterior wall. Reproduced from Yan TD. Mini-Bentall procedure. Ann
Cardiothorac Surg 2015;4(2):182–90. With permission from Medical Illustrator, Beth Croce.
GRAFT-TO-GRAFT ANASTOMOSIS
The valve conduit is trimmed to just above the “sinus” of the Valsalva graft and the Ante-Flo graft is placed under gentle
tension and cut to the correct length. The graft-to-graft anastomosis is completed in a similar fashion to the open distal
anastomosis using a 3-0 continuous running suture; however, suture placement is narrower on synthetic graft than aortic
tissue with bites being not more than a few millimeters apart. Once the anastomosis is complete, an aortic root needle is
inserted to allow vent any residual entrained air. The proximal anastomosis can be reinforced with pledgetted 4-0 Prolene
(Ethicon, Somerville, NJ, USA) sutures as needed.
COMPLETION OF PROCEDURE
In preparation to wean from bypass, an assessment for intracardiac air is on transesophageal echo with venting achieved via
the aortic root. Absolute hemostasis is essential and a hemostatic pause must be a routine component of closing minimal
access surgery. Topical hemostatic agents such as Flo-seal or Tisseal Fibrin sealant (Baxter Healthcare, Zurich, Switzerland)
can be applied to suture lines as required.
Ventricular pacing wires are sited and the sternum is closed over a 28Fr Blake drain. This completes the minimally
invasive Bentall procedure and hemiarch replacement.
DISCUSSION
Conventionally, surgery on the proximal aorta has been performed through a midline sternotomy; the majority of surgery
is elective and the most common indication for surgery on the proximal aorta is for aneurysmal disease. Techniques have
continued to evolve that afford patients durable, reliable, and hemostatic repairs. Contemporary data on outcomes for
proximal aortic surgery demonstrate an overall mortality of 4.2%–6.1% for aortic root surgery [41–43]. Major morbidity in
aortic root replacement is significant. Stroke is seen in 2.11%–3.92% [41,43], whereas reoperation for bleeding/tamponade
occurs in 5.80%–7.13% of cases [41–43]. As expected elective surgery is associated with lower in-hospital mortality than
emergency surgery 2.72% versus 13.74% for aortic root surgery [43]. A recent propensity-matched study suggests that
the addition of hemiarch replacement to aortic root replacement did not significantly increase mortality or major adverse
outcomes, despite significantly longer cardiopulmonary bypass times, cross-clamp times, and the need for hypothermic
circulatory arrest in patients requiring hemiarch replacement [44].
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Minimally invasive cardiac surgery is a natural evolution in the management of aortic disease. Surgeons are increasingly managing complicated proximal aortic disease as well as valvular disease via minimal access incision [28,33,45–48].
Outcome data demonstrate analogous results to conventional aortic surgery in terms of major morbidity and mortality,
although as yet, these data come from case series and nonrandomized, retrospective analysis [48]. High-volume centers
have indeed reported remarkably low morbidity and mortality; however, it is important to recognize that this may be a
reflection of overall expertise and minimally invasive surgery alone may not fully explain these outcomes.
The technique of “reverse-J” upper hemi-sternotomy is our favored method of exposure. It allows excellent access to the
aortic root and ascending aorta, permits central aortic cannulation, and does not require any modification to accepted proximal
aortic surgical procedures. Alternative access techniques use peripheral femoral arterial cannulation to provide retrograde
systemic perfusion. Although convenient, retrograde arterial perfusion has been associated with an increased risk of stroke,
postoperative delirium, and aortic dissection [49]. This exposure has been used to perform a wide range of aortic procedures
on the aortic root, ascending aorta and also arch replacement [50] and total arch replacement with frozen elephant trunk [51].
CONCLUSIONS AND FUTURE DIRECTIONS
The surgical access in the chapter also allows repair of complex aortic pathologies involving the arch and descending aorta.
Hybrid procedures with debranching of the epiaortic vessels, endoluminal management of thoracic aortic aneurysm, and
frozen elephant trunk procedures with antegrade deployment of a stented graft may be possible in selected cases.
Minimally invasive aortic surgery has been demonstrated to be a safe and effective alternative to conventional aortic surgery. However, one must never be tempted to deviate from the cornerstones of cardiac surgery of ensuring adequate organ
protection and meticulous surgical technique for the sake of a smaller incision. The technique described herein respects all
of these principles, maximizing patient safety while achieving the goal of minimizing surgical trauma.
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