Page 94 - Read Online

Chiu Modified parasternal approach for aortic valve surgery

A B

C D

Figure 4: The three-dimensional distance consisting of the root of square sum of simplified two parameters (A: depth from skin to the
level of annulus; B-D: oblique distance from the projection of 3rd rib to annulus) which could be acquired from both axial and frontal
reconstruction of computed tomography scan. The distance offers surgeons the feasibility and difficulty of this approach

cardioplegic or de-airing needle and reasonable room cases. Most surgeons prefer upper partial sternotomy
for aortotomy and prosthesis manipulation. Shorter rather than anterior thoracotomy. Conversely, the
distance usually indicates limited or shorter exposure parasternal approach offers better exposure to the
of ascending aorta which necessitates peripheral aortic root, annulus, and is technically easier for
cannulation and very low aortotomy. Farer distance beginners initiating sternum-sparing approaches. It
clearly indicates difficulty in exposure, suturing is more anatomically oriented and could be a good
and knot tying. Exposure may be acceptable after alternative for aortic valve surgery, especially for
commencement of CPB and aortic cross-clamp. patients with the need for better exposure. Additionally,
However, care should be given for meticulous suturing this approach offers opportunity for multi-valve surgery
and hemostasis for aortotomy, especially at both ends. (including mitral and tricuspid).
For those with limited exposure, additional stitches for
overt bleeding may not be easy once CPB is weaned Our parasternal approach carries additional benefits.
off and the heart is fully loaded. Complex procedures, Wound complications are rare, mainly due to the
like remodeling procedure, reimplantation procedure, stability and muscle flap coverage. It maintains the
Bentall operation, annular enlargement, peri-annular integrity of sternum, manubrium, and sternoclavicular
abscess patch repair for infective endocarditis and redo joints. From anatomical experience, upper extremities
aortic valve replacement have been performed using (UE) are connected to axial skeleton through clavicles,
two-rib parasternal approach in our series. Hemostatic sternoclavicular joints and chest cage. Our approach
products would be helpful for those suture lines without reduces pain from UE movement. Early return of full
second chance of hemostasis. range of UE motility improves post-operative lung
function and quality of life.
Compared with anterior thoracotomy, similarly, both
approaches may need peripheral CPB and have With the availability of sutureless aortic prostheses,
divided or torn right internal mammary artery, broken the aortic valve replacement could be facilitated. [16,17]
costal cartilage, lower conversion rate, and limited High transverse aortotomy is easily achieved.
lung herniation. The advantage of “so-called” intact Decalcification of the annulus and nadir sutures could
chest cage often counteracts by its limited exposure. be easily accomplished. The parasternal approach
Therefore, its application is limited to highly selected offers a versatile platform for wide-range of aortic valve

Mini-invasive Surgery ¦ Volume 1 ¦ June 30, 2017 87