Second Level Master in
“Innovation in Cardiac Surgery: advances in Minimally Invasive Therapeutics”
Academic Year
2017/2018
Minimally invasive approach to
aortic root surgery
Author
Dr. Raffaele Gargiulo
Scientific Tutor
Prof. Claudio Passino
Company Tutor
2
Table of contents
page 1. Introduction...3 2. Background...4 3. Methods...6 4. Literature review...74.1 The first decade (1999-2009)...7
4.2 The second decade (2010-2019)...10
5. Discussion………....……...………...………...14
6. Conclusions………...………...………16
7. References………...………...……….17
Abbreviations and acronyms
ARR aortic root replacement MS median sternotomy
MICS minimally invasive cardiac surgery MIARS minimally invasive aortic root surgery CPB cardiopulmonary bypass
MIS ministernotomy AXC aortic cross-clamp ICU intensive care unit
MIARR minimally invasive aortic root replacement AVR aortic valve replacement
VSARR valve-sparing aortic root replacement
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1. Introduction
The aortic root is a complex anatomo-functional unit that connects the hearth with the systemic circulation. It extends from ventriculo-aortic junction to sinotubular junction and contains the aortic valve and the coronary artery ostia. Aortic root aneurysmal dilatation, with or without aortic regurgitation and ascending aorta involvement, acute aortic dissection extending below the sinotubular junction and infective endocarditis with valve and periannular destruction are the most observed pathological conditions requiring surgical correction in this anatomical region1. The traditional surgical treatment of these diseases is the aortic root replacement (ARR) through a median sternotomy (MS). A few different surgical techniques are available and well established; these can be basically classified within two models: the replacement of aortic valve and aortic root en bloc using a composite graft or, in a smaller number of cases a stentless valve as a root, a homograft or a pulmonary autograft, and the reconstruction of the aortic root through a so-called valve sparing operation. These surgical techniques are technically complex, in particular the valve sparing procedures, but despite this, they are nowadays very good standardized and worldwide performed with very good results in terms of survival and freedom from reoperation2,3. The application of the philosophy and of the advances of minimally invasive cardiac surgery (MICS) in this complex type of surgery is still an open challenge and, currently, MICS represents the minority of surgery performed. As soon as the “golden age” of MICS started4, some experience of aortic root surgery with minimal access was described, in particular in the most experienced center in MICS and in high patience volume institutions, but as soon as the results extrapolated from aortic valve surgery demonstrated the potential benefits of the minimal access surgery and the first randomized data was available, these techniques have been more widely applied in aortic root surgery too. As a result of this worldwide spread, many retrospective single-center studies were published on this topic, in particular in the last 10 years. The aim of the present narrative review is to focus on the history, the advances and the state of the art of minimally invasive aortic root surgery (MIARS) and to collect the current evidence in terms of feasibility, safety and clinical outcomes.
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2. Background
Proximal thoracic aortic surgery in the era of cardiopulmonary bypass (CPB) starts with the work of Denton Cooley and Michael Debakey that in 1956 successfully replaced the supracoronary ascending aorta with an aortic homograft5. Some years later, in 1964, Wheat et al.6 reported the first successful replacement of the entire ascending aorta from the aortic annulus to the innominate artery, with reimplantation of the coronary ostia and replacement of the aortic valve6. The ascending aorta was replaced with a woven Teflon graft and the aortic valve with a Starr-Edwards prosthesis.
In 1968 Hugh Bentall and Anthony De Bono described the first aortic valve and aortic root replacement en bloc with re-implantation of the coronary ostia using a composite valve-Dacron graft conduit7. In the decades to follow, numerous innovative surgeons improved on these original procedures to allow for a more reliable and consistent operation8-11. The Bentall procedure is still considered the gold-standard in the treatment of patients who requires ARR and is the most performed operation on the aortic root in the clinical practice with very good long-term results, either with the use of a mechanical or a biologic aortic valve prosthesis12.
Since the early 1990s the desire of minimize the complications related with a prosthetic valve, reduce endocarditis rate and avoid life-long anticoagulant therapy, lead to the introduction of the so-called valve sparing techniques. Two original techniques were proposed, the remodeling of the aortic root13 and the reimplantation of the aortic valve14, also known respectively as Yacoub and David procedure by the names of their inventors, Sir Magdi Yacoub and Tirone David. In the last 30 years these techniques went through numerous variations and interactions15-18 with the aim to correct the main problem of the development of aortic regurgitation19 and are nowadays high standardized and show excellent long term results3 also when additional aortic cusps repair is required.
Almost in the same period the desire to reduce the surgical trauma and achieve faster recovery for the patients drove the development of various minimally invasive approaches to cardiac surgery. The techniques of minimally invasive aortic surgery have
5 evolved from the isolated aortic valve surgery, and the first documented minimal access aortic valve replacement through a right thoracotomy20 was reported by Rao and Kumar in 1993. In 1996 Cosgrove and Sabik proposed a right parasternal incision21 with rib cartilage resection, in 1997 Svensson described the “J” hemisternotomy22 and just one year later Doty and colleagues23 proposed a lower half sternotomy. The last two approaches, generally known as upper or lower ministernotomy (MIS) provide several advantages: an adequate exposure, the possibility to use a completely central cannulation, the reduction of postoperative pain and the better thoracic cage stability24. Moreover, they can be extended, if necessary, to provide additional exposure. For these reasons the ministernotomy, using a J, an inverted T or other similar incisions is currently the most common approach to the aortic valve and the aortic root when minimal access is desired.
Another important aspect of MICS is the cannulation and the aorta cross clamp (AXC) strategy. Central cannulation (atrial-aortic, atrial-femoral, atrial-axillary) is generally preferred and can be easily achieved using a MIS, but thoracotomy and parasternal approaches typically require femoral cannulation, although femoral-aortic cannulation is feasible. Depending of the surgical access, the type of cannulation and the preference of the surgeon, different types of aortic cross clamps can be used. Debakey clamp, either straight or angled, and flexible or even deployable aortic cross clamp can be used by MIS access, while a transthoracic aortic clamp is generally required for minithoracotomy.
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3. Methods
A comprehensive electronic literature search was performed using PubMed, Cochrane Library and Google Scholar databases until September 2019. The search terms used and combined were “aortic root” or “Bentall” or “valve sparing” AND “minimally invasive” or “minimal access” or “mini sternotomy”. After the removing of duplicate reports, most articles were excluded based on the title or the abstract.
The studies to be examined in the descriptive analysis were chosen according to the following criteria:
a) studies which compared outcomes between minimally invasive and traditional aortic root surgery;
b) studies including the largest number of patients underwent aortic root surgery; c) studies which referred mostly or exclusively to aortic root surgery;
d) studies with historical or pioneering relevance. Using this method,15 articles were included in this review.
The selected studies were arbitrarily sorted into two groups according to a chronological order (1999-2009 and 2010-2019). In the first group were included 6 retrospective studies and in the second one 7 retrospective studies and 2 meta-analysis.
The primary outcome was early mortality (operative mortality, in-hospital deaths or 30-day mortality according to the study analyzed), the secondary outcomes included CPB duration, AXC time, reoperation for bleeding, intensive care unit (ICU) stay and hospital length of stay.
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3. Literature overview
Before the end of the last century, when the isolated minimally access aortic valve surgery was already supported by randomized evidence25 showing the advantages of MICS procedures, the initial experience of MIARS started to be published.
3.1 The first decade (1999-2009)
In 1999 Byrne et al.26 retrospectively analyzed their initial experience with minimally invasive aortic root replacement (MIARR) through an upper hemi-sternotomy. Between August 1996 and April 1999, they performed 37 cases (31 full root replacement, 4 subcoronary replacement and 2 hemiroot). Valve implants consisted of a homograft in 30 (81%), "Freestyle" bioprosthesis in 4 (11%) and a St Jude valved-conduit in 3 (8%). Mean CPB duration was 193 ± 47 minutes and AXC duration was 157 ± 40 min. Three patients (8%) experienced postoperative low cardiac output syndrome. There was one operative death (3%), one (3%) reoperation for bleeding and 13 patients (35%) required blood transfusions. New onset atrial fibrillation occurred in 7 patients (19%) and there were 3 (8%) minor complications. Hospital length of stay was 6.7 ± 4.3 days. They concluded that MIARR was feasible for a broad range of aortic valve pathology and could be accomplished with acceptable morbidity and mortality. However, the operations through the smaller incision took more time and therefore they recommended more careful attention to myocardial protection.
In 2000 Sun et al.27 compared 2 groups of patients underwent a Bentall procedure either through a MIS (8 patients - MINI group) or through a MS (21 patients - STD group) between January and September 1999. In the MINI group, the mean operative time was significantly longer than that in the STD group (255.0 ± 27.2 vs. 213.3 ± 47.2 minutes, p < 0.05). The mean postoperative mediastinal drainage in the MINI group was significantly less than in the STD group (456.2 ± 247.4 vs. 1007.6 ± 566.0 mL, p < 0.05). The mean and CPB time (78.1 ± 6.9 vs. 88.6 ± 24.7 minutes), AXT time (58.2 ± 5.2 vs. 63.3 ± 12.2 minutes), intubation time (14.8 vs. 18.4 hours), postoperative blood
8 transfusion (400 vs. 690 mL, range from 0 to 1600 mL), and hospital stay (12.1 vs. 16.1 days) in the postoperative period in the MINI group were less than those in the STD group. They concluded that aortic root replacement by a superior MIS was a safe, reliable procedure with excellent exposure and provided a potential benefit of less trauma, quick recovery, and reduction of mediastinal drainage and reduction of blood transfusion.
Svensson et al.28 in 2001 reported 54 cases of minimal access aortic surgery through an upper MIS with very good early outcomes. Their experience included 36 ascending aortic repairs, 18 ascending aortic and arch repairs, 26 concomitant aortic valve replacements (AVR), 15 concomitant composite valve graft aortic root replacements, and 18 reoperations. In that study, the mean times in minutes were 132 ± 59 for CPB, 91 ± 45 for AXT, and 20 ± 17 for circulatory arrest. Operative mortality and stroke rate were 4% for both outcomes. Intensive care unit (ICU) and postoperative stay were 1.8 ± 1.9 days and 6.7 ± 3.7 days, respectively. The authors concluded that minimal access aortic surgery did not appear to carry a greater risk and, although more demanding technically, was associated with a reasonable ICU and hospital stay.
In 2007 Tabata et al.29 published a retrospective review of 128 consecutive patients, including the 37 patients reported by Byrne and colleagues25 7 years before, who underwent aortic root, ascending aortic, and proximal arch operations through an upper MIS between August 1996 and May 2005. In this study 67 patients received an ARR (57 homograft, 2 stentless bioprosthetic valve, 6 Bentall procedure, 1 aortic reimplantation and 1 aortic remodeling) and 1 patient a patch exclusion of sinus of Valsalva aneurysm. The results, referred to all 128 patients, showed no operative death and an incidence of reoperation for bleeding, perioperative myocardial infarction, deep sternal infection, stroke, and renal failure of 1.6%, 2.3%, 0.8%, 0.8% and 0%, respectively. The median length of hospital stay was 5 days (range, 3 to 21 days). Actuarial survival at 5 years was 97.2%. In the same study they also compared93 patients underwent in the same period ascending aortic, proximal arch and root operations, with or without aortic valve procedures, through a MS, and constructed two matched cohorts, each of 79 patients, between MIS (group A) and MS groups (group B). There was no significant difference either in CPB, AXC and circulatory arrest times or in incidence of blood transfusion,
9 incidence of reoperation for bleeding, perioperative myocardial infarction, deep sternal wound infection, stroke, renal failure and fresh frozen plasma or platelets transfused between the two groups. However, group A received significantly fewer median units of red blood than the group B (p = 0.020). The median length of hospital stay was 5 days in group A and 6 days in group B (p = 0.020). In the conclusions, the authors stated that minimal access ascending aortic and proximal arch surgery through an upper MIS was practical and feasible, with operative times, morbidity, and mortality that were similar to a conventional full sternotomy and shorter length of hospital stay and less blood transfusion. They suggested that this approach could be performed safely in institutions with a large experience both in minimal access as well as in aortic surgery.
Perrotta et al.30 between September 1997 and June 2005 treated 40 patients affected by ascending aorta disease and aortic valve regurgitation using a Bentall procedure through a minimally invasive approach, by means of a reversed T or J MIS. Data were analyzed retrospectively. None of the patients died during the 30-day postoperative period. The mean ICU and hospital length of stay times were 3.3 ± 8.2 and 9.3 ± 7.2 days, respectively. Six patients (15%) had one or more postoperative complications and one patient (2.5%) underwent early reoperation for bleeding. The mean follow-up was 38.4 ± 31 months. Survival at 1, 3 and 5 years was, respectively, 94.1, 90.6 and 90.6%. They concluded that reversed T or J MIS was a feasible and secure alternative to complete sternotomy and that the short incision might enhance the outcome and did not affect the survival, offering proper access to the anatomic structures.
In 2009 Totaro et al.31 reported their experience of 1126 procedures performed through an upper MIS between February 1997 and December 2007. In this period 67 patients underwent a mini-Bentall procedure (5.9%) at their institution. The outcomes of these patients were described in a group that included 354 patients underwent complex cardiac surgery procedures (double valve replacement/repair, ascending aorta and aortic arch replacement, aortic dissection, AVR combined with coronary surgery and complex redo procedures). In this group, in-hospital mortality was 6.7% (24/354), 18 patients (5.1%) underwent reoperation for bleeding, mean ICU stay was 3.6 ± 6.7 days and total hospital stay was 12 ± 8 days. Cumulative CBP duration was 100 ± 45 minutes and AXC time was 70 ±26 minutes. The authors concluded that an upper MIS approach
10 was feasible and safe not only for isolated AVR but also for a variety of complex surgical procedures, including aortic root surgery.
3.2 The second decade (2010-2019)
Between April 2011 and March 2014, Shresta et al.32 performed a pilot study with the aim to assess the safety and feasibility of valve sparing aortic root replacement (VSARR) via an upper MS up to the third intercostal space. Their cohort were composed of 40 patients between two groups (MIS in 26 patients - group A and MS in 14 patients - group B). They had no significant differences in the operating time (280.3 ± 78.9 vs. 248.6 ± 32.3 minutes), CPB time (175.8 ± 41.9 vs. 163 ± 24.5 minutes) and AXC time (115.6 ± 30.3 vs. 114.1 ± 19.9 minutes). Although ICU stay was longer in group B (2.1 ± 1.5 vs. 1.3 ± 0.6 days respectively), total hospital stay was shorter in the same group (9.1 ± 2.7
vs. 10.4 ± 6.8 days respectively). This pilot project showed the feasibility and safety of
minimally invasive VSARR in carefully selected patients. The same group presented in 201833 another study in which the outcomes between 2 groups (MIS and MS) in different aortic procedures were analyzed. In the MIS group there were 210 patients divided in 4 sub-groups: 41 patients underwent isolated ascending aortic replacement and 64 patients AVR with supra-commissural ascending aortic replacement, 55 patients underwent Bentall procedure and 46 patients underwent valve sparing David procedure. There were two intra-operative conversions to full sternotomy (one in Bentall group and one in AVR with supracommissural aortic replacement group). Re-thoracotomy for bleeding was necessary in 10 patients (4.8%). Eight patients had a perioperative stroke (3.8%) and one patient with acute renal failure required temporary dialysis (Bentall group). The post-operative ventilation time was 0.6 ± 0.6 days. One patient died within the 30 days (Bentall group). In the post-operative echocardiography in the David subgroup only one patient (1/46) had aortic valve insufficiency grade >1 (2.2%), while the rest had either no or trivial insufficiency. Based on their reported outcomes, they recommended MIS as safe alternative technique to MS in carefully selected patients. They also stated that the key to success was a ‘step by step’ technique of moving from minimally invasive AVR to more demanding MIARR.
11 In 2016 Levack et al.34 published the largest single-center study of reporting outcomes between MIS vs. MS in aortic root surgery. Their study was based on 966 propensity matched patients (483 patients in each group) underwent proximal aortic operations between January 1995 and January 2014. Average AXC time was shorter after a J incision (55 ± 21 vs. 70 ± 30 minutes, p < 0.0001), as was CPB time (70 ± 26 vs. 87 ± 36 minutes, p < 0.0001). There was no difference in the post-operative rate of stroke (0.625, p = 1.0), renal failure (p = 0.3), sternal wound infection (0% in both) and operative mortality (0.415% vs. 0%, p = 0.16). Intra- operatively, there was no difference in the rate of blood transfusion (p = 0.08), and no difference during postoperative period (p = 0.6). Finally, ICU and total hospital stay were much shorter in MS patients (p < 0.0001 in both cases). They concluded that J mini-sternotomy was a safe and feasible technique for isolated primary elective proximal aortic surgeries, but they underlined that the choice of the technique should be carefully planned for each patient based on several pre-operative parameters.
Wachter et al.35 in 2016 analyzed the outcomes of 192 patients that underwent elective VSRR between February 2007 and February 2012 and reported no difference in 30-day mortality rates (p =0.562), CPB duration (p = 0.659), AXC time (p = 0.576), ICU stay (p = 0.07) and total hospital stay (p = 0.17) between matched group of MIS vs. MS group. However, they reported a higher rate of additional cardiac procedures in MS patients (57.4% vs. 13.9%, p < 0.001), and, consequently, shorter length of operations in MIS patients (p = 0.008). Finally, they recommend J-upper mini-sternotomy for patients undergoing elective VSRR, if operated on by experienced surgeon.
In 2018 Lamelas et al.36 presented the world’s first report series of patients underwent MIARS through a minimally invasive right thoracotomy (MIRT) incision. This study included 177 patients who required circulatory arrest for the treatment of an ascending aortic pathology, with or without aortic valve involvement, between January 2009 and November 2014. Seventy-four surgeries were performed by using a MIARS approach, and the remaining 103 were performed by using a MS. They performed a propensity score-matched analysis to assess any potential benefits of the sternal-sparing, MIRT approach. In the propensity score-matched cohort, 30-day mortality was 3.2% in both groups. In terms of intraoperative variables, the minimally invasive group had longer
12 median circulatory arrest times than the sternotomy group (37.00 vs. 25.00 minutes, p < 0.0001) but had similar median CPB (183.00 vs. 78.00 minutes, p = 0,49) and AXC times (141.0 vs. 128.0 minutes, p = 0.008). In addition, the median number of red blood cell units transfused was significantly lower for the minimally invasive group than for the sternotomy group (1 vs. 3, respectively, p < 0.0001). Furthermore, the median ventilation time was significantly shorter for the minimally invasive group than for the sternotomy group (9.30 vs. 17.58 hours, p = 0.01). The median ICU (30.44 vs. 52.15 hours, p < 0.0001) and total hospital (5 vs. 7 days, p < 0.0001) length of stay were also significantly shorter in the minimally invasive group. The conclusion was that sternal-sparing aortic surgery was safe and could be learned in a stepwise fashion to treat a variety of proximal aortic pathologies, with patient outcomes that were better than those observed when using the gold-standard sternotomy approach.
In 2017 Mikus et al.37 described their experience with Mini-Bentall procedure in 53 patients underwent surgery between January 2010 and November 2015 and compared the outcomes between this group and a group of 112 patients underwent a Bentall through a MS in the same period. The two groups showed similar results in terms of postoperative outcomes with a slightly superiority of minimally invasive group mainly regarding CPB time (p = 0.004), AXC time (p = 0.04), incidence of atrial fibrillation (p = 0.04) and prolonged postoperative ventilation times (p < 0.01).
Monsefi et al.38 performed in 2018 a propensity-matched comparison in patients underwent a David procedure through MIS (n = 103) or MS (n = 103) from 1991 to 2016. The MIS group had shorter CPB duration (p < 0.01) and AXC time (p < 0.01), shorter ICU stay (p = 0.02) and received less blood transfusion (p < 0.01). No differences were found in reoperation for bleeding (p = 0.4) and in-hospital death (p = 0.5)
Harky et al.39 presented in 2018 the results of a meta-analysis of the articles that compared minimally invasive versus conventional sternotomy in ARR. A total of 2,765 patients were analyzed from across 8 studies that fulfilled the criteria for meta-analysis. ARR through a MIS was associated with significantly shorter cardiopulmonary bypass time (p = 0.009), lower rate of blood transfusion (p = 0.01). additionally, they had lower operative mortality (p = 0.02), and shorter stay at intensive care and at hospital (p =
13 0.0009, p = 0.03 respectively). However, there was no difference between MIS and conventional ARR in terms of aortic cross-clamp time (p = 0.28), total operation time (p = 0.31), re-exploration rate for bleeding (p = 0.28), stroke rate (p = 0.90), wound infection rate (p = 0.96), and length of mechanical ventilation (p = 0.10). In the conclusion they stated that MIS was a safe and feasible alternative option to MS in aortic root repair, but the significant heterogeneity in data pointed to the need for a larger trial to support the currently limited literature evidences.
The last article of this review was published just a few months ago by Rayner et al.40 and is a meta-analysis of the studies that compared minimally invasive (including MIRT)
versus conventional surgery of the ascending aorta and root. Thirteen observational
studies were included comparing 1101 patient underwent a minimally invasive procedure and 1405 patients underwent MS. Mortality and the incidence of stroke were similar between the 2 cohorts. Meta-analysis demonstrated increased length of CPB time for patients undergoing MS (p = 0.001). Patients receiving MS had a longer ICU and hospital (p < 0.001 for both outcomes) stay, more reoperation for bleeding (p = 0.024) and renal impairment (p = 0.019). There was no significant difference in AXC time between patient groups, but the heterogeneity between studies was substantial. The conclusions of this meta-analysis are that just very low-quality non-randomized evidence suggests that minimally invasive surgery of the aorta may be associated with improved early clinical outcomes when compared to MS and for that reason randomized controlled trials are essential to confirm these findings.
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4. Discussion
Aortic root surgery is traditionally performed through a full sternotomy to have adequate exposure of the heart and great vessels. However, as with any other surgical specialty, the era of practice is diverting toward minimally invasive surgery with the aim to provide better postoperative outcomes, mainly potential shorter ICU and hospital stay, lower healthcare costs, less chance of sternal wound infection, less pain and finally better cosmetic results for the patient. It is about 20 years that MIARS has been performed but the practice of minimal access technique has evolved dramatically over the last 10 years, as shown by the large number of studies available on this topic.
In the first decade the research question was focused on the safety and the feasibility of the minimally invasive procedures. Very low operative death rate, comparable or lower than the same procedures conducted with a traditional full sternotomy, was described in all reports of MIARS in this period, although initially the patients were high selected and mostly low-risk. Many authors emphasized the need for prolonged experience either with aortic root surgery or with minimally invasive AVR as well as the careful patient selection in the early stages of a minimally invasive programme to minimize the learning-curve. It is particularly interesting to underline that in the early reports the total duration of the surgical operations and the AXC times were longer in the patients underwent MIS but this difference was no more observed in the following studies. In particular the reports of the Boston group26,29,41 demonstrate that in a short period of time no statistically significant difference in the length of the procedures, CBP and AXC times was evident anymore.
By the end of the first decade many original articles, published from institutions in almost every continent were available on MIARS, and the minimal access procedures started to be standard surgery for many institutions. However, a significant limitation to the studies of this period is that they all are single-center, retrospective reviews with limited statistical power.
In the second decade analyzed in the present literature overview, leading up to the present time, the available data are growing exponentially. When the mini-Bentall
15 operation had almost become a standardized procedure42, many surgeons started with the more challenging aortic valve-sparing procedures, in particular the reimplantation of the aortic valve. The number of the studies and of the patients analyzed in the studies increases constantly, and gives continuously the research community new evidence of the excellent outcomes associated with MIARS. Moreover, many propensity score-matched studies are published with the aim to reduce selection bias, which is mostly due to the high selection of the patients underwent minimally invasive techniques. The MIRT access started to be used also in aortic root surgery when a previously report43 had stated that, compared with the use of a MIS for AVR, using a minithoracotomy significantly reduced the incidence of postoperative atrial fibrillation, ventilator time, as well as ICU and hospital length of stay. This approach, although well-developed44, is currently used by very few surgeons, but it seems to be a feasible alternative when sternal-sparing MIARS is desired.
The most interesting data currently available are probably coming from the two recent systematic reviews and meta-analysis, but the results, as they come from all the studies within a 20 years period, are significant heterogeneous and this limits the power of the statistical evidence, as the outcomes of the second decade are consistently better than the ones of the first decade.
The aortic root is one of the last fields where the surgical treatment is the only available therapeutic choice within cardiac and great vessels diseases; for that reason, the advances in MIARS are particularly important to keep up with the times and to give an answer to the constant demand of procedures that can offer reduced surgical trauma, improved quality of life and allow for a faster return to normal activities.
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5. Conclusions
Minimally invasive aortic root surgery seems to be feasible and safe either through an upper sternotomy or through a right minithoracotomy; it is moreover associated, when compared with traditional surgery, with shortened cardiopulmonary bypass time, reduced rates of reoperations for bleeding, shorter ICU and hospital length of stay, but the overall quality of all evidence is very low. A properly designed prospective randomized control study is essential to confirm these findings, but minimally invasive procedures can be already considered as a valid alternative to traditional aortic root surgery.
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