full sternotomy or minimally invasive

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May 26, 2024
full sternotomy or minimally invasive

Hello everyone, I hope you are all well. I am 25 years old and I recently discovered by chance that I have Marfan syndrome. When I consulted with cardiology, it was found that my aortic root is 56mm. I need surgery and I plan to have it in the coming days. I have consulted with 3-4 professors. One of them suggested the mini Bentall procedure, saying that it involves a smaller incision and my recovery would be faster. When I spoke with the others, it seems that my entire chest would need to be opened. Do you have any opinions on this matter? Which option do you think is better for this condition? Have you had any experiences like this? How large was your incision? Can you help me? I'm a bit nervous about surgery. Do you have any recommendations?
well if they are saying mini sternotomy then go for it; however don't be surprised if you wake up and find that "they needed to go full"

I've had 3 standard sternotomies in my life (one at 10, 28 and then 48) and I'm not showing any sign of that. Well of course my dream of bikini modelling career was thrown to the wild but hey...

Also I want to emphasise "who fckken cares how large your scar is" ... we're dealing with being alive vs being dead. Sure as a kid of 12 I was self conscious but by the time I grew up I found it more of a talking point than anything.

"Primitive" societies deliberately scar themselves as a rite of passage into adulthood ... now we all whinge if we get our beautiful bodies "mutilated" ... I'm betting "anxiety" wasn't an issue back then either.



you can be sure these men were tough as nails. Heck it may even be part of your culture too.

Best Wishes
full sternotomy or minimally invasive <snip>>> Do you have any opinions on this matter? Which option do you think is better for this condition? Have you had any experiences like this? How large was your incision?
Whatever the surgeon who is cutting you open thinks is best. They know what they are doing. You and I don't know what they are doing.

I had a full sternotomy. My surgeon said that was best because he repaired my mitral valve, and he installed an On-X mechanical aortic valve. My incision is about 8 inches (20 cm) long. The incision is not very visible. The 2 drain tube scars are more visible. Recovery from a full sternotomy does take several months before you can even start to lift weight with your arms. But that recovery is trivial compared to having excellent quality heart surgery.

Good luck! Please keep us informed as you have surgery and during your recovery!
I fully understand your concerns and don’t want to minimize them. They are your concerns.

I will add a few thoughts since I have endured two full open heart surgeries. First off, having Marfan syndrome you probably know by now that connective tissue disorders are quite common. But you will now live a long healthy life managing yourself and being diligent about health concerns. So glad you discovered this early. That being said, you may want to consider the surgeon(s) ability to capture a full uninhibited view of your aorta beyond the root, the aortic root itself, and the space where the aorta and aortic root are connected to your heart during a full open heart surgery. The trade off is invaluable in my opinion. During full open heart surgery your surgeons will have full complete access to your entire ascending aorta and root. Plus, full access for the restenosis of coronary arteries, which by itself is not trivial and it may potentially buy you options in the future, if (big if with Bentall) you may need future valve procedures. MRI’s and CT’s are amazing images but a full “eyes on” via open heart surgery is the best option and just think of 2-4 hands doing their magic in your chest easily rather than working in a tight space via less invasive procedures. The time under anesthesia will be longer but trivial concerns at your age and if no other significant medical concerns.

Secondly, you are young and sternum recovery will be quick and over before you know it. I mean this sincerely and speaking from experience.

Lastly, regarding the scar, you will forget about it sooner than you may think. I am not trivializing a permanent change to your body and each of us have our own thoughts about this topic. But it’s a small price to pay for a longer, safer life. You may find that explaining the scar and your surgical journey somewhat therapeutic. There is a reason why some of us joined this forum.

I wish you good luck and I’m here if I can be of help.
Which option do you think is better for this condition?
IMO the best option is the one practiced by the surgeon with most experience and best results. The minimally-invasive and full sternotomy variants require different tools and training. You probably want the surgeon to do what they do "all the time".

It sounds like you have a choice, which is excellent! Ideally one of the surgeons actually specializes in aortic valve and/or aneurisms. Would be even better if they had a lot of Marfan cases before.

That said, @Survived03 mentioned important points specifically for Marfan cases.

Have you had any experiences like this?
Yes, but not with the aortic surgery.

I'm a bit nervous about surgery. Do you have any recommendations?
First, you are in a very good position of knowing your issue and being able to address it!

Apart of selecting the surgeon and proceeding to the surgery, there is not much you can do about the procedure itself. (But the medical establishment practiced a lot of heart surgeries, and they really know how to take care of this situation.)

You can prepare for the procedure and recovery afterwards. I described my experience and pointed to a previous thread with a lot more information HERE. Although, frankly, at 25 years old you are very likely to have a fast and easy recovery for any of the surgical options!
My surgeon said he was going to try minimal incision for aortic valve replacement. After I was taken into surgery, a TEE was done. I am told it showed heart was larger than thought and deeper in the chest. So, surgeon decided it was best to do a full incision.

So things can change. I had no issues from the full cut.
I had both types about 6 months apart about a decade ago when I was 50. Here's a link to a few of my personal anecdotes from a couple years ago. My summary is to repeat what others have said:
a) access (from the surgeon's perspective) should be the priority and b)at your age (if you are in reasonably good condition) I suspect you wouldn't experience marked recovery differences between the two approaches. When pressed I tend to say the full sternotomy took a week longer to recover but for me, that likely had as much to do with the summer/winter aspect of my surgeries as the technique!

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Welcome to the forum.

I have consulted with 3-4 professors. One of them suggested the mini Bentall procedure, saying that it involves a smaller incision and my recovery would be faster.
When I spoke with the others, it seems that my entire chest would need to be opened
First of all, good for you for seeking more than one opinion. In my view this is always a good idea.

By mini, I believe you are referring to what would be called a mini-sternotomy. In that your surgeon will be doing a Bentall Procedure, I don't believe that the other minimally invasive procedures, such as the J incision, allow enough access for a Bentall. I could be wrong about that and if someone has had a Bentall with one of the procedures that is even more minimal than the mini-sternotomy, hopefully they will share.

I did, in fact, have a Bentall Procedure and it was with a mini-sternotomy. Getting a Bentall was not the original plan. The plan was to just do a standard aortic valve replacement. In our pre-surgery consults, my surgeon explained that his preferred method is the mini-sternotomy. He has decades of experience as a surgeon and has done thousands of mini-sternotomies. When he explained to me the quicker recovery it sounded good.

As I indicated, the origninal plan was to just replace my aorta, however, when my surgeon got his eyes on my aorta, he determined that it looked as if I had the connective tissue disorder which would lead to me requiring another OHS down the road. So, he opted to shift to a Bentall and replaced my aortic root, as well as my ascending aorta. He did not switch to a full sternotomy when he did this. All of the work was done through the small opening of the mini-sternotomy.

To this day I find his skill set in being able to do all that through only a 3.5 inch opening in my chest remarkable. I think if we lived in a Groundhog Day world and I had 1,000 years to practice, I would never aquire the skills needed to be able to do such a thing. In my consult with my cardiologist after the surgery he shared with me that very few are skilled enough to accomplish this.

One thing thing which I did not think to ask my surgeon in our after surgery consult: If he knew going in that it would be a Bentall, would he still opt for the mini-sternotomy, or would he do a full sternotomy, given the better access the full sternotomy allows.

-If I had to do another OHS and knew beforehand that it would be another Bentall, I would probably lean towards the full sternotomy to give the surgeon better access, to the extent that I had a choice in the matter.
-The benefits of the mini are short term. Yes, the recovery is quicker, but there is no evidence that it leads to any superior long term outcomes.
-There is a reason why the other consults are telling you that you should get the full sternotomy. Better access is an advantage.
-If you feel that the surgeon who is recommending the mini is the one whom you feel the most comfortable with, I guess I would want to have another consult with him and ask more questions. 1) Why does he feel so strongly about doing a mini, given that it will be a Bentall Procesure? 2) How many mini-sternotomies has he done in total? 3) How many times has he completed a Bentall using a mini-sternotomy.
In order for me to feel comfortable, as to his answers to these quesitons: I would want to hear a very good reason why he prefers the mini as it relates to long term outcomes, not just short term recovery. I would want to hear that he's done thousands of mini-sternotomies and at least hundreds of those were Bentall Procedures.

Best of luck with your decision.
I wanted to come back to you with an additional question which hasn’t been touched upon. Do you happen to have pectus excavatum (sunken chest) or any other muscle skeletal considerations common with Marfans? Perhaps this is an added piece to the mini recommendation.
Thank you all for your answers. I will take everything you said into consideration when making my decision.
pectus excavatum (sunken chest) or any other muscle skeletal considerations common with Marfans?
Yes I have pectus carinatum.

This situation makes me think because of my connective tissue weakness. Actually, I felt good for the doctor who recommended mini. After all, when the doctor says he is thinking of doing it with an incision like this, it is not my duty to go and tell him to make me open. I don't really care about the looks, actually.It just makes me feel good to think that I will have less pain and heal faster. And when I think of my chest being split open, I get a little goosebumps.

I don't trust my own body more than the surgery itself, wondering if something might go wrong.
Anyway, I asked the surgeon to do whatever it takes to have better access to the heart. After the surgery, I asked him why he chose a full sternotomy and he replied that the anatomy of my chest did not allow a mini sternotomy, so there was no other option.
I have the cut on my chest as a sign of a battle I won

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