The Arrowhead Ministernotomy with Rigid Sternal Plate Fixation: A Minimally Invasive Approach for Surgery of the Ascending Aorta and Aortic Root

Background. Ministernotomy incisions have been increasingly used in a variety of settings. We describe a novel approach to ministernotomy using arrowhead incision and rigid sternal fixation with a standard sternal plating system. Methods. A small, midline, vertical incision is made from the midportion of the manubrium to a point just above the 4th intercostal mark. The sternum is opened in the shape of an inverted T using two oblique horizontal incisions from the midline to the sternal edges. At the time of chest closure, the three bony segments are aligned and approximated, and titanium plates (Sternalock, Jacksonville, Florida) are used to fix the body of the sternum back together. Results. This case series includes 11 patients who underwent arrowhead ministernotomy with rigid sternal plate fixation for aortic surgery. The procedures performed were axillary cannulation (), aortic root replacement (), valve sparing root replacement (), and replacement of the ascending aorta () and/or hemiarch (). Thirty-day mortality was 0%; there were no conversions, strokes, or sternal wound infections. Conclusions. Arrowhead ministernotomy with rigid sternal plate fixation is an adequate minimally invasive approach for surgery of the ascending aorta and aortic root. 1. Introduction Ministernotomy incisions have been increasingly used in a variety of cardiac surgery settings in an attempt to reduce surgical trauma and hasten patient recovery [1–5]. One of the first described ministernotomy techniques was the T incision [6]. However, despite offering superior exposure, that technique has been avoided after reports of poor healing of the transverse portion [7]. Currently, the J incision technique is the most widely used, although this technique limits exposure. Other less common techniques, such as the “upper V-type” ministernotomy in the second intercostal space, also involve limited exposure [8]. Here we describe a novel approach to ministernotomy by employing two simple but, in our experience, important modifications to the T incision technique. Firstly, the horizontal limb of the inverted T sternotomy is altered to an arrowhead shape. Secondly, rigid sternal fixation by a standard sternal plating system is used to maximize exposure, while limiting risk of sternal complications. 2. Methods 2.1. Preoperative Assessment Preoperatively, a CT scan is obtained to assess relative location of the aorta to the sternum. If the aortic root is lower than the 4th intercostal space, we favor a full sternotomy. 2.2. Procedure A small vertical skin incision is made from the