title: Minimally invasive approach for complex cardiac surgery procedures.
abstract: BACKGROUND
  A minimally invasive approach through an upper ministernotomy (UMS) has been used in our Division since 1997. On the basis of favorable outcome we have gradually extended this approach from isolated aortic valve replacement (AVR) to more complex cardiac surgery procedures and it is currently our first choice for a variety of procedures. Here we report our 11 years experience.
  
  
  METHODS
  From 1997 to December 2007, 1,126 procedures were performed at our department, using UMS. Isolated procedures on the aortic valve were performed in 695 patients (61%). Isolated procedures on the aortic valve as redo operation were performed in 77 patients (7%). Complex cardiac surgery procedures (including double valve replacement-repair, ascending aorta-aortic arch replacement, aortic root replacement, aortic dissection, AVR combined with coronary surgery, and complex redo procedures) were performed in 354 patients (32%). Early postoperative outcome was evaluated considering three different groups according to the surgical procedure (first time AVR, redo AVR, and complex procedure).
  
  
  RESULTS
  Overall conversion to full sternotomy was required in 16 patients (1.4%) with no significant differences between isolated AVR (9 patients, 1.3%) and complex or redo procedures (1 patient [1.2%] and 6 patients [1.6%], respectively). Forty-seven patients died in hospital (cumulative in-hospital mortality of 4.1 %). Mortality according to the procedure was 6.7, 3.8, and 2.8% for complex, redo AVR, or isolated AVR procedures, respectively, with a significant difference only for the complex procedures. Similarly, early postoperative outcome in terms of incidence of prolonged mechanical ventilation and ICU stay was significantly different only in the complex procedure group. Incidence of surgical revision (5.1, 2.9, and 2.7% for complex, redo, or isolated AVR procedures, respectively) showed no statistically significant differences regardless the type of procedures.
  
  
  CONCLUSIONS
  Our experience clearly shows that a minimally invasive approach through upper ministernotomy is feasible and safe not only for isolated AVR but that it can also be utilized for a variety of complex surgical procedures. Minimizing surgical access may be helpful in patients undergoing complex surgical procedures, especially redo procedures, without compromising the surgical result.
authors.affiliation: Division of Cardiac Surgery, Istituto Di Ricovero e Cura a Carattere Scientifico University Hospital Foundation San Matteo, Pavia, Italy. ptotaro@yahoo.com
authors.forename: Pasquale
authors.initials: P
authors.lastname: Totaro
authors.forename: Simone
authors.initials: S
authors.lastname: Carlini
authors.forename: Matteo
authors.initials: M
authors.lastname: Pozzi
authors.forename: Francesco
authors.initials: F
authors.lastname: Pagani
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Zattera
authors.forename: Andrea Maria
authors.initials: AM
authors.lastname: D'Armini
authors.forename: Mario
authors.initials: M
authors.lastname: Vigano
mesh_terms: D000368:Aged; D001011:Aorta / Q000601:surgery; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013249:Sternum / Q000601:surgery