Minimal-invasive Zugänge in der Aortenklappenchirurgie und andere Zugangsmethoden // Minimally invasive Aortic Surgery and other Accesses

Journal für Kardiologie - Austrian Journal of Cardiology 2016; 23 (9-10): 225-228

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Keywords: alternativer Zugangsweg,  Herzchirurgie,  minimal-invasive Aortenklappenchirurgie,  alternative approach,  cardiac surgery,  minimally invasive aortic surgery

For decades full median sternotomy has been the non-plus-ultra-access for cardiac surgery. In the last few years, the demand for smaller incisions, resulting in faster recovery increased and the clinical interest for alternative approaches is constantly rising. Keeping in mind the goal of not compromising safety and efficacy of the procedure and achieving equal operative quality by introducing minimal access surgery, patient selection is essential. For aortic valve (and in selected cases, even ascending aorta) procedures partial upper sternotomy and right-anterior thoracotomy proved to offer the same operative results as conventional sternotomy, however minimizing tissue trauma and pain and enhancing cosmetics. Further on, for high-risk patients an elimination of support of cardiopulmonary bypass during the procedure via transapical or direct aortic transcatheter aortic valve intervention brought additional advantage and decrease in mortality. Likewise, minimally invasive concepts for coronary artery disease have been introduced, but did not gain as much popularity as compared to valve programs. As endovascular strategies for pathologies of the descending aorta evolved, major access surgery via clamshell- incision or left thoracotomy has become rare.
It is the responsibility of the surgeon to ensure that the important basic principles of valvular and coronary surgery are not compromised by adapting minimal access strategies. If operating through smaller skin incision provides equal operative quality, these innovative approaches should be of priority.

Kurzfassung: Gerade für den Aortenklappen- Ersatz bieten sich mehrere Zugänge an, die in Zusammenhang mit den verwendeten Aortenklappen- Prothesen zu sehen sind. Die Langzeitergebnisse mit den verschiedenen minimal-invasiven Methoden sind mit jenen der medianen Sternotomie gleichwertig, aber schon wenige Wochen postoperativ sind die verschiedenen Patientenkollektive mit klinischen Methoden nicht mehr unterscheidbar. Gemeinsam mit den kosmetisch guten Ergebnissen bei den verschiedenen, minimal-invasiven, aortalen Zugängen, wenn auch das Patientenkollektiv meist älter ist als bei den Mitraleingriffen, ist die hohe Zuweiserzufriedenheit. Die Vollsternotomie im Fall des Aortenklappenersatzes sollte bald der Vergangenheit angehören.