title: Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery.
abstract: OBJECTIVE
  We developed techniques for 'inverted T' partial upper re-sternotomy for aortic valve replacement (AVR) or re-replacement (AVreR) after previous cardiac surgery. We previously reported on decreased blood loss, transfusion requirements and total operative duration when compared to conventional full re-sternotomy. This report updates our series, one of the few to document a substantial benefit from a 'minimally-invasive' approach, refines a number of technical aspects of this new approach and reports follow-up.
  
  
  METHODS
  Between November 1996 and December 1999, we performed 34 AVRs or AVreRs after previous cardiac surgery by use of an 'inverted T' partial upper re-sternotomy. There were 25 (74%) men. Median ejection fraction was 54%, range 15-80%. Median age was 72, range 38-93. All were New York Heart Association functional class (NYHA) functional class II or III. Twenty-one (62%) had previous coronary artery bypass grafts (CABG) while 14 (41%) had previous valve surgery. Follow-up was 100% complete for a total of 593 patient months (median 19 months).
  
  
  RESULTS
  Twenty-three (66%) underwent AVR of the native aortic valve while 11 (33%) underwent AVreR of a prosthetic aortic valve. There were no intraoperative or valve-related complications, and no conversion to full re-sternotomy was necessary. There were two (5.9%) operative deaths from an arrhythmia on postoperative day 4 and a large stroke during surgery, respectively. Twenty-four (75%) patients were free of major complications. There was no need for reoperation for bleeding and patients required a median of two units of packed red blood cells. Complications included new atrial fibrillation (n=3, 9%), pacemaker implantation (n=3, 9%) and deep sternal wound infection (n=2, 6%). Median lengths of stay in the intensive care unit (ICU) and in the hospital were 1 and 7 days, respectively. There was one (3%) late deep sternal wound infection and 2/32 (6%) late deaths due to congestive heart failure at 22 months and myocardial infarction at 23 months, respectively.
  
  
  CONCLUSIONS
  Partial upper re-sternotomy presents a safe and effective alternative approach to AVR and AVreR after previous cardiac surgery, and is associated with low morbidity and mortality.
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA. jgbyrne@partners.org
authors.forename: J G
authors.initials: JG
authors.lastname: Byrne
authors.forename: A N
authors.initials: AN
authors.lastname: Karavas
authors.forename: D H
authors.initials: DH
authors.lastname: Adams
authors.forename: L
authors.initials: L
authors.lastname: Aklog
authors.forename: S F
authors.initials: SF
authors.lastname: Aranki
authors.forename: G S
authors.initials: GS
authors.lastname: Couper
authors.forename: R J
authors.initials: RJ
authors.lastname: Rizzo
authors.forename: L H
authors.initials: LH
authors.lastname: Cohn
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods* / Q000401:mortality; D011475:Prosthesis Failure; D012086:Reoperation; D012189:Retrospective Studies; D013249:Sternum / Q000601:surgery*; D015996:Survival Rate