Upper hemisternotomy vs. full sternotomy for hemiarch and proximal aortic replacement

Hemiarch replacement with proximal aortic replacement is seldom performed via upper hemisternotomy (UHS). We report our surgical technique and postoperative outcomes in 11 patients who underwent UHS for hemiarch and proximal aortic replacement, compared with 15 patients who underwent the procedure via full sternotomy (FS).

A UHS was performed at the right third or fourth intercostal space. Cardiopulmonary bypass (CPB) was established via the distal ascending aorta or right axillary artery and right common femoral vein. After aortic cross-clamping (ACC), the heart was arrested with single-dose antegrade crystalloid cardioplegia. After proximal aortic replacement, hypothermic circulatory arrest (HCA) between 20 and 24 °C was initiated with bilateral antegrade or retrograde cerebral perfusion, and hemiarch replacement performed.

Between February and December 2010, 15 patients (median age 67 yr) underwent hemiarch repair with proximal aortic replacement using FS. From April 2015 to February 2019, 11 patients (median age 74 yr) underwent the same procedure via UHS. Median CPB, ACC, and HCA times were 192 min vs. 185 min (P = 0.72), 105 min vs. 157 min (P  = 0.03), and 5 min vs. 15 min (P = 0.95) for UHS and FS, respectively. There were no in-hospital deaths. Survival at 1 and 5 yr was 100% and 72.7% in the UHS group, and 100% and 80% in the FS group (P = 0.13, P = 1.0).

Low morbidity and mortality demonstrate that UHS for combined hemiarch and proximal aortic replacement is safe and feasible. Larger studies are needed to confirm these findings.