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\begin{document}

\title{Outcomes in partial sternotomy for aortic root surgery: the new routine
procedure?}



\author[1]{Amer Harky}%
\author[2]{Runzhi Chen}%
\author[1]{Ahmed Othman}%
\affil[1]{Liverpool Heart and Chest Hospital NHS Foundation Trust}%
\affil[2]{Imperial College London}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\textbf{Outcomes in partial sternotomy for aortic root surgery: the new
routine procedure?}

Running Head: Partial sternotomy for aortic root repair

\textbf{Amer Harky\textsuperscript{1,2} MRCS, Runzhi
Chen\textsuperscript{3} BSc, Ahmed Othman FRCS-CTh}

\begin{enumerate}
\tightlist
\item
  University of Liverpool, Liverpool, UK
\item
  Department of Cardiothoracic Surgery, Liverpool Heart and Chest,
  Liverpool, UK
\item
  Faculty of Medicine, Imperial College London, London, UK
\end{enumerate}

\textbf{Corresponding author}

Amer Harky MRCS, MSc

Department of Cardiothoracic Surgery

Liverpool Heart and Chest

Liverpool, UK

E-mail: aaharky@gmail.com

Tel: +44-151-600-1616

\textbf{Funding} : none obtained

\textbf{Conflict of interest} : none declared

\textbf{Key words} : minimally invasive surgery, partial sternotomy,
aortic root

Dear Editor,

We read with great interest the article by Elghannam \emph{et
al.}{[}1{]} in which they concluded that partial upper sternotomy (PUS)
for aortic root surgery could be a safe alternative to full median
sternotomy (FMS), albeit requiring longer operative times and greater
operative skills.

Whilst we agree with some of the conclusions, there are aspects of this
study that would benefit from further clarification. In our recent
meta-analysis, we evaluated eight comparative studies for aortic root
replacement with a total of 2,765 patients (n=1974 for PUS and n=1,791
for FMS) {[}2{]}. PUS was associated with shorter cardiopulmonary bypass
times, lower operative mortality, and shorter stays at intensive care
and at hospital (p\textless{}0.05). However, no differences in aortic
cross-clamp or total operation times were observed (76.1\selectlanguage{ngerman}±24.7 versus
109.6±52.9 minutes, WMD -4.17, 95\% CI {[}-11.70, 3.37{]}, p=0.28 and
252.8±56.3 versus 249.7±54.1 minutes, p=0.31 respectively). Similarly,
no differences in re-exploration rates for bleeding were observed
between PUS and FMS (OR 0.81, 95\% CI {[}0.55, 1.19{]}, p=0.28). It is
also important to note that dialysis was more frequently required
following FMS procedures (n=2,217 patients, 2.78\% versus 3.36\%,
p=0.001).

Thus, it would have been robust for the authors to include a
patient-matched FMS group in order to facilitate direct comparison
between the techniques. Moreover, the authors reported much higher mean
cardiopulmonary bypass and cross-clamp times for PUS in comparison to
results from our meta-analysis (101±33.5 versus 174±54.8 minutes and
76.1±24.7 versus 133±33.1 minutes, respectively) {[}2{]}. Prolonged
operative parameters are established risk factors for adverse
perioperative outcomes {[}3{]}. Furthermore, it would be of interest to
know if any patients required dialysis due to post-operative renal
failure. This is important factor for quality of life and thus patient
contentment, and useful for predicting long-term mortality.

Taken together, it would be pertinent to directly compare these results
with an FMS control group to conclude whether PUS is indeed superior to
FMS for aortic root surgery, an area which lacks robust evidence.



\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Elghannam M, Aljabery Y, Naraghi H, Moustafine V, Bechte M, Strauch J,
  Haldenwang P. Minimally invasive aortic root surgery: Midterm results
  in a 2-year follow-up. \emph{J Card Surg} . 2020;1-8. doi:
  https://doi.org/10.1111/jocs.14628
\item
  Harky A, Al-Adhami A, Chan JSK, Wong C, Bashir M. Minimally Invasive
  Versus Conventional Aortic Root Replacement -- A Systematic Review and
  Meta-analysis. \emph{Heart Lung Circ.} 2019;28(12):1841-1851. doi:
  https://doi.org/10.1016/j.hlc.2018.10.023
\item
  Harky A, Roberts N, Oo A\emph{.} Minimal Access Techniques in Aortic
  Root Surgery.~\emph{Int J Cardiovasc Res} . 2018;7(4). doi:
  10.4172/2324-8602.1000357
\end{enumerate}

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