Single-Center Experience of mini-invasive Ascending Aortic Surgery via right anterior mini-thoracotomy

Single-Center Experience of mini-invasive Ascending Aortic Surgery via right anterior mini-thoracotomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Center Experience of mini-invasive Ascending Aortic Surgery via right anterior mini-thoracotomy Tao Zhu, Haoran Wang, Chengbin Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8236019/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract Background The right anterior mini-thoracotomy (RAMT) has emerged as a well-established minimally invasive surgical approach in the field of cardiac surgery and is increasingly being utilized for valve-related interventions. However, high-quality clinical evidence supporting its application in ascending aorta surgery remains limited. This study aims to evaluate the safety and feasibility of ascending aortic operations performed via the RAMT approach. Methods A retrospective analysis was conducted on 41 patients who underwent ascending aortic surgery using the RAMT technique at the Cardiac Vascular Center of Northern Jiangsu Province People's Hospital between June 2022 and June 2025. Patient baseline characteristics, perioperative outcomes, and follow-up data were systematically reviewed and analyzed. Results The study cohort comprised 41 patients aged 42 to 83 years. Among them, 27 patients underwent mini-Bentall or mini-Wheat procedures, while 24 underwent ascending aortic replacement. Operative duration ranged from 160.0 to 420.0 minutes. The median aortic cross-clamp time was 88.0 minutes (interquartile range [IQR]: 52.0–147.0), and the median cardiopulmonary bypass (CPB) time was 103.0 minutes (IQR: 68.0–158.0). The median length of intensive care unit (ICU) stay was 3.9 days (IQR: 2.0–7.8), with mechanical ventilation maintained for a median duration of 10.5 hours (range: 5.2–22.7 hours). Median postoperative drainage within the first 24 hours was 220 mL. No deaths or major complications were observed during the follow-up period. Conclusions Ascending aortic surgery performed via the RAMT approach demonstrates favorable safety and procedural feasibility, indicating its potential as a viable and promising minimally invasive technique suitable for wider clinical implementation. ascending aortic surgery right anterior mini-thoracotomy Bentall procedure Wheat procedure perioperative outcomes Figures Figure 1 Figure 2 Figure 3 Introduction Ascending aortic surgery has traditionally been performed via median sternotomy, a technique that offers broad surgical exposure and optimal visualization of the operative field. However, this standard approach is associated with significant limitations, including substantial soft tissue injury, considerable intraoperative blood loss, and prolonged postoperative recovery[ 1 ]. With ongoing advancements in surgical instrumentation and growing operator expertise, minimally invasive cardiac procedures have become increasingly prevalent, offering a means to reduce surgical trauma and improve overall patient outcomes. The right anterior minithoracotomy (RAMT), accessed through the second or third intercostal space, has been well established as a safe and effective approach for aortic valve replacement (AVR), consistently demonstrating advantages such as lower complication rates, accelerated recovery, shorter hospitalization, and superior cosmetic results[ 2 – 5 ]. Despite these benefits and the anatomical continuity between the aortic valve and ascending aorta, the application of RAMT in ascending aortic surgery remains underreported in current literature[ 6 ]. Building on our extensive experience with minimally invasive AVR through the RAMT approach, our center has systematically expanded its procedural scope to include ascending aortic interventions using the same limited access strategy. In this study, we present a retrospective analysis of perioperative data and short-term clinical outcomes from 41 patients who underwent mini-Bentall, mini-Wheat, or isolated ascending aortic replacement via the RAMT approach. The aim was to comprehensively assess the feasibility, safety, technical characteristics, and early efficacy of this minimally invasive technique in the context of ascending aortic pathology. Methods Patients We retrospectively collected and analyzed the baseline, perioperative and follow-up data of 41 patients who underwent the RAMT approach ascending aortic surgery in the Department of Cardiac Vascular Center, Northern Jiangsu Province People's Hospital from June 2022 to June 2025. All patients underwent echocardiography, electrocardiogram, coronary computed tomography angiography (CTA) and aortic CTA before surgery. Patients undergoing ascending aortic surgery via the RAMT approach were required to meet the following criteria: (1) distal ascending aortic diameter ≤ 4.0 cm; (2) aortic-to-chest wall distance at the incision level ≤ 10.0 cm; and (3) rightward displacement of the ascending aorta relative to the sternum. Operative procedure After intubation under anesthesia, a venous catheter (15-17Fr) was inserted into the right internal jugular vein (Fig. 1 B). A small pillow was placed behind the patient's right shoulder, and the upper body was elevated by approximately 30°. After the start of the operation, a 4-cm vertical incision was made in the right groin to expose the right femoral artery and femoral vein (Fig. 1 C). After heparinization (3mg/kg), the appropriate-sized catheters were inserted into the common femoral artery and femoral vein using the Seldinger technique. Cardiopulmonary bypass was established through the femoral artery, femoral vein, and right internal jugular vein. After the initiation of cardiopulmonary bypass, a 6–8 cm incision was made at the second or third intercostal space on the right side of the sternum (Fig. 1 A), depending on whether the aortic valve was to be addressed during the same operation. A sternal retractor was placed in the incision, and a longitudinal incision was made along the pericardium above the aorta, extending to the pericardial fold above the aorta. The pericardium was suspended to fully expose the heart, and a left ventricular drainage tube was inserted into the left ventricle through the right upper pulmonary vein. A 1-cm incision was made laterally at the same intercostal space to place a Chitwood clamp to occlude the ascending aorta near the innominate vein. Cardioplegic solution was directly injected through a transverse incision at the aortic root. The aneurysmal portion of the vessel was excised, and the native aortic valve was explored and excised as needed. The valve conduit was implanted after intermittent suturing (Fig. 2 ). Long-handled instruments and knot pushers are recommended. Holes were made at the openings of the left and right coronary arteries, and continuous suture with 6 − 0 Prolene was used for anastomosis (Fig. 3 ). The distal end of the artificial vessel was anastomosed with 4 − 0 Prolene. The artificial vessel was wrapped with autologous vessels, and a shunt was made to the right atrium. After completing the distal anastomosis, the bypass was opened. After simple hemostasis and postoperative adjustment, the bypass was weaned. The catheters in the internal jugular vein and femoral vein were removed, and protamine was used to neutralize heparin. The femoral artery catheter was removed, and a chest drainage tube was placed after hemostasis was completed. The incision was then closed layer by layer. Study protocol Study protocol Baseline, perioperative, and follow-up data for all patients were retrospectively extracted from the institutional electronic medical records system, with variable definitions and clinical parameters standardized according to the criteria established by the Society of Thoracic Surgeons (STS) Database. Postoperative follow-up was scheduled at one month and six months via outpatient clinic visits or structured telephone interviews, with subsequent annual evaluations conducted thereafter to monitor long-term outcomes. Statistical analysis Statistical analysis was conducted with SPSS software (version 26.0; IBM SPSS Statistics, Chicago, IL, USA). Normally distributed continuous variables are summarized as mean ± standard deviation and compared using the independent samples t-test. Categorical data are displayed as counts and percentages and evaluated by the chi-square (χ²) test. For continuous variables that deviate from normal distribution, median values and interquartile ranges (IQR) are used to describe central tendency and variability. Statistical significance was defined as a two-tailed P value less than 0.05. Results Baseline characteristics Among the 41 patients (Table 1 ), 37 (90.2%) were male, with a median age of 62.0 years (range: 42.0–83.0 years) and a median body mass index(BMI) of 21.7 kg/m² (range: 16.0–31.6 kg/m²). Comorbidities included hypertension in 22 patients, diabetes in 8, coronary artery disease in 4, and arrhythmia in 5. The median left ventricular ejection fraction was 59.0% (IQR: 47.0–66.0%), with a median left ventricular end-diastolic diameter of 61.0 mm (IQR: 44.0–76.0 mm). The median diameters of the ascending aorta and aortic sinus were 46.0 mm (IQR: 38.0–58.0 mm) and 52.0 mm (IQR: 38.0–63.0 mm), respectively. Aortic valve regurgitation was present in 20 patients, and 4 patients had both aortic stenosis and regurgitation. Underlying valvular pathologies included degenerative aortic valve disease in 18 patients, congenital bicuspid aortic valve in 20, and Marfan syndrome in 3. Table 1 Baseline characteristics Data are presented as number, n (%), or median (IQR). BMI, body mass index; NYHA, New York Heart Association (classification); LVEF, left ventricular ejection fraction; LVEDD, left ventricular endo-diastolic diameter; LVESD, left ventricular endo-systolic diameter; Hb, hemoglobin; BNP, brain natriuretic peptide; ALB, albumin; IQR, interquartile range. Variables Value Number of patients 41.0 (100) Gender (males) 37 (90.2) Age (years) 62.0 [42.0–83.0] BMI (kg/m2 ) 21.7 [16.0-31.6] Smoker 30 (73.2) Drinking 11 (26.8) Concomitant diseases Pulmonary hypertension 1 (2.4) Kidney disease 3 (7.3) Respiratory disease 5 (12.2) Diabetes 8 (19.5) Hypertension 22 (53.7) Cerebrovascular events 1 (2.4) Coronary artery disease 4 (9.8) Arrhythmia 5 (12.2) Aortic valve pathology Degenerative Aortic Valve Disease 18 (43.9) Marfan Syndrome 3 (7.3) Bicuspid aortic valve 20 (48.8) NYHA functional class II 20 (48.8) III 16 (39.0) IV 5 (12.2) Cardiac index LVEF (%) 59.0 [47.0–66.0] Aorta sinus (mm) 46.0 [38.0–58.0] Ascending aorta (mm) 52.0 [38.0–63.0] Area of aortic regurgitation (cm2 ) 11.9 [10.3–16.6] LVEDD (mm) 61.0 [44.0–76.0] LVESD (mm) 45.0 [33.0–56.0] Biochemical index Hb (g/L) 132.0 [120.0-155.0] BNP (pg/mL) 468.0 [225.0-1649.0] ALB (g/L) 38.5 [32.1–47.3] Perioperative characteristics Of the cohort, 15 underwent mini-Bentall procedures, 12 underwent mini-Wheat procedures, and 14 underwent minimally invasive ascending aortic replacement (Table 2 ). Patients who underwent minimally invasive ascending aortic replacement were operated via a second intercostal space incision, whereas the remaining patients underwent surgery through the third intercostal space. The median operative time was 210.0 minutes (IQR: 160.0–420.00 minutes), with a median aortic cross-clamp time of 88.0 minutes (IQR: 52.0–150.0 minutes) and a median cardiopulmonary bypass (CPB) time of 103.0 minutes (IQR: 68.0–158.0 minutes). The sizes of the prosthetic grafts and valves are detailed in Table 2 . All patients undergoing mini-Bentall procedures received aortic root reinforcement and right atrial shunting. The median intraoperative blood loss was 175.0 mL (IQR: 80.0–350.0 mL), and no patient required conversion to open thoracotomy. Table 2 Perioperative characteristics Variables Value Operation Length of surgery (min) 210.0 [160.0–420.0] ACC time (min) 88.0 [52.0–147.0] CPB time (min) 103.0 [68.0–158.0] Blood loss (mL) 175.0 [80.0–350.0] RBC transfusion rate 12 (29.3) Type of surgery Mini-Bentall 15 (36.6) Mini-Wheat 12 (29.3) Minimally Invasive Ascending Aorta Replacement 14 (34.1) Size of prosthetic valve (mm) Bioprosthetic valve 23 23 (85.1) 10 (37.0) 25 13 (48.1) Mechanical valve 4 (14.8) 23 3 (11.1) 25 1 (3.7) Size of graft (mm) 26 10 (24.4) 28 18 (43.9) 30 13 (31.7) Coronary artery anastomosis Left atrial shunt 41 (100.0) Concomitant surgery MVP or TVP 2 (4.9) Conversion to Thoracotomy 0 Data are presented as n (%) or median (IQR). ACC, aortic cross-clamp; CPB, cardiopulmonary bypass; Min, minimum; RBC, red blood cell; MVP, mitral valvuloplasty; TVP, tricuspid valvuloplasty; IQR, interquartile range. Early postoperative data and clinical complications The median duration of mechanical ventilation was 10.5 hours (IQR: 5.2–22.7 hours). Within the first 24 hours postoperatively, the median drainage volume was 220.0 mL (IQR: 60–475 mL). Red blood cell transfusion was administered to seven patients (17.1%), and no patient required re-exploration for hemorrhage. The median intensive care unit length of stay was 3.9 days (IQR: 2.0–7.8 days), while the total hospital stay ranged from 12 to 35 days, with a median of 16 days. Notably, no patients developed major postoperative complications, including postoperative mortality, respiratory failure, myocardial infarction, permanent pacemaker implantation, cerebrovascular events, or acute kidney injury requiring dialysis (Table 3 ). Table 3 Postoperative characteristics Data are presented as n (%) or median [IQR]. ICU, intensive care unit; CRP, C-reactive protein; Hb, hemoglobin; BNP, brain natriuretic peptide; ALB, albumin; RBC, red blood cell; IQR, interquartile range. Variables Value Length of ICU stay (days) 3.9 [2.0-7.8] Hospital stay length (days) 16.0 [12.0–35.0] Ventilation time (h) 10.5 [5.2–22.7] Analgesics 30 (73.2) Anticoagulant drugs 15 (36.6) Vasoactive drugs 32 (78.1) CRP (mg/L) 21.2 [14.3–44.2] Hb (g/L) 113.0 [85.0–128.0] BNP (pg/mL) 320.0 [105.0–1227.00] ALB (g/L) 38.5 [32.1–47.3] Postoperative complications Respiratory failure 0 Postoperative arrhythmia 4 (9.8) Myocardial infarction 0 Pacemaker implantation 0 Cerebrovascular accident 0 Acute kidney failure 0 Reoperation for bleeding 0 Wound infections 0 Pneumothorax/subcutaneous emphysema 0 Pulmonary atelectasis 1 (2.4) Sepsis 0 Rib fracture 0 Pericardial effusion requiring thoracentesis 0 Pleural effusions requiring thoracentesis 0 Paravalvular regurgitation 0 RBC transfusion rate 7 (17.1) Chest tubes drainage at the first 24 h (mL) 220.0 [60.0-475.0] Time of drainage tube (days) 10.0 [5.0–15.0] In-hospital mortality 0 Follow-up results All 41 patients completed follow-up via telephone or outpatient visits (Table 4 ). The median follow-up duration was 11.5 months (IQR: 3.1–30.0 months). All patients remained alive at the time of last follow-up, with sustained improvement in clinical symptoms. One patient experienced delayed chest incision healing, which resolved successfully following debridement and surgical resuturing. Echocardiographic evaluation revealed trace paravalvular leak with mild aortic regurgitation in one patient, and coronary anastomotic fistula in another. Both patients were asymptomatic and are currently under clinical surveillance without intervention (Table 4 ). Table 4 Follow-up results Variables Value Follow-up Number of patients 41 (100) Duration of follow-up(months) 11.5 [3.1–30.0] Reoperation 0 Survival 41 (100) Poor incision healing 1.0 Aortic regurgitation 1.0 Paravalvular leakage 1.0 NYHA functional class I 36 (87.8) II 5 (9.8) Data are presented as n (%) or median (IQR). NYHA, New York Heart Association (classification); IQR, interquartile range. Discussion With the rapid advancement of minimally invasive cardiac surgery, an increasing number of patients have benefited from its clinical application. Currently, common approaches for minimally invasive aortic surgery include partial sternotomy, upper J-shaped incision, upper T-shaped incision, and right parasternal incision[ 7 – 10 ]. While the right parasternal approach is frequently employed in minimally invasive aortic valve replacement, its use in minimally invasive ascending aortic procedures remains less reported[ 11 , 12 ]. Ji[ 13 ] et al. retrospectively analyzed clinical data from 15 patients who underwent Bentall procedure via the RAMT approach. The study demonstrated that none of the patients required conversion to full median sternotomy, and no severe postoperative complications occurred. All patients were discharged uneventfully, with no mortality observed during the 6-month follow-up period. He[ 14 ] et al. reported the clinical data of 27 male patients who underwent Bentall procedure via the RAMT approach. The results demonstrated that no patient experienced severe perioperative complications or in-hospital mortality. During the follow-up period, which ranged up to 21 months, all patients showed improvement in cardiac function, with no deaths or reoperations observed. Careful patient selection is essential for this approach, and preoperative aortic computed tomography angiography (CTA) is mandatory. If CTA reveals significant dilation of the ascending aorta in close proximity to the brachiocephalic artery, the parasternal approach is contraindicated. In our practice, the second intercostal space is typically preferred for isolated ascending aortic procedures, whereas the third intercostal space is selected when concomitant aortic valve intervention is required. Previous studies have demonstrated that, compared with conventional aortic valve replacement via median sternotomy, minimally invasive aortic valve replacement through a small right anterior thoracotomy at the second intercostal space is associated with prolonged aortic cross-clamping, cardiopulmonary bypass (CPB), and operative times[ 3 , 15 , 16 ]. Similarly, our experience indicates that minimally invasive ascending aortic surgery via the same approach may involve longer aortic cross-clamping and CPB durations than conventional sternotomy-based procedures, primarily due to the limited operative field, increased technical complexity, and dependence on surgeon expertise. However, in this cohort, these time intervals were not significantly prolonged compared to those typically observed with median sternotomy, likely attributable to the high surgical volume, advanced technical proficiency, and extensive experience of the primary surgeon. Notably, although the main procedural phase may require additional time under minimally invasive conditions, the duration of chest closure and hemostasis is substantially reduced, resulting in comparable overall operative times. Consistent with previous reports[ 8 , 17 ], our findings show that minimally invasive approaches shorten mechanical ventilation duration, ICU length of stay, and postoperative hospitalization, thereby accelerating patient recovery. This benefit was observed even in our cohort, which underwent more complex procedures such as minimally invasive Bentall, Wheat, and ascending aortic replacements. The advantages may be explained by several factors: preservation of sternal integrity maintains thoracic stability, reduces the risk of postoperative hypoxemia, and facilitates earlier extubation; additionally, the smaller incision minimizes surgical trauma and avoids sternal bleeding, leading to less postoperative drainage, earlier removal of drains, and earlier mobilization. These factors collectively contribute to enhanced recovery, earlier discharge, and reduced economic burden on patients. Minimally invasive ascending aortic surgery through the RAMT approach has a relatively high technical difficulty. Based on our center's experience, having accumulated rich experience in median incision ascending aortic surgery and routinely performing minimally invasive aortic valve surgery through the RAMT approach, attempting minimally invasive ascending aortic surgery through this approach can achieve twice the result with half the effort. Complete exposure of the aortic root is the key to the success of the surgery. Good pericardial traction, especially on the left side, can provide more adequate exposure of the aortic root. Coronary artery anastomosis remains the main challenge in Bentall surgery. The exposure and anastomosis of the left coronary artery are relatively simple, while those of the right coronary artery are more difficult and require certain skills. End-to-end anastomosis is a common surgical technique with high clinical efficacy, especially for aortic root-right atrial shunt[ 18 , 19 ]. Another buttonhole anastomosis technique is beneficial for the exposure of coronary arteries; however, patients treated with this method are more prone to bleeding at the root and coronary artery anastomosis sites, leading to surgical failure[ 20 ]. In this study, all patients underwent end-to-end anastomosis and right atrial shunt, which ensured the successful completion of the surgery and provided more experience for the surgeons. This study has several limitations. First, it is a single-center observational study involving only 41 patients and lacking a control group, which limits the ability to draw definitive conclusions. Nevertheless, this investigation represents an exploratory clinical observation, and prior reports on minimally invasive ascending aortic surgery via the RAMT approach remain scarce in the literature. Therefore, our findings warrant validation through large-scale, multicenter studies with rigorous design. Second, the postoperative follow-up duration is limited; longer-term follow-up data are required to fully assess the durability and long-term outcomes of this minimally invasive surgical technique. Conclusions In conclusion, minimally invasive ascending aortic surgery via the RAMT approach is associated with reduced surgical trauma, faster postoperative recovery, and favorable safety and feasibility, making it a viable and promising technique worthy of clinical promotion and broader application. Declarations Ethical Statement The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Northern Jiangsu People's Hospital (No. 2024ky275). Informed consent was obtained from all participants involved in the study. Disclosure All authors read and approved the final manuscript. Conflicts of Interest The authors declare no conflicts of interest. Funding This study was supported by the Youth Fund of Northern Jiangsu People's Hospital, research project no. SBQN24002. Author Contribution All authors contributed to the study conception and design. Tao zhu: conceptualization, writing–original draft preparation, and writing–review and editing. Haoran Wang: data curation, conceptualization, and project administration. Chenbin Tang: formal analysis, investigation and resources. All co-authors take full responsibility for the integrity and accuracy of all aspects of the work. References Shah VN, et al. The mini-Bentall approach: Comparison with full sternotomy. JTCVS Tech. 2021;7:59–66. Bonacchi M, et al. Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery. J Thorac Cardiovasc Surg. 2023;165(3):1022–32. e2. Glauber M, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg. 2013;145(5):1222–6. Miceli A, Ferrarini M, Glauber M. Right anterior minithoracotomy for aortic valve replacement. Ann Cardiothorac Surg. 2015;4(1):91–3. Vohra HA et al. Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting. Open Heart, 2023. 10(1). Johnson CA Jr., et al. Right Mini-thoracotomy Bentall Procedure. Innovations (Phila). 2018;13(5):328–31. Elghannam M, et al. Minimally Invasive versus Conventional Aortic Root Surgery: Results of an Intermediate-Volume Center. Thorac Cardiovasc Surg. 2024;72(2):118–25. Glauber M et al. Right anterior minithoracotomy for aortic valve replacement: 10-year experience of a single center. J Thorac Cardiovasc Surg, 2015. 150(3): p. 548 – 56 e2. Karadzha A, et al. Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach. Asian Cardiovasc Thorac Ann. 2024;32(5):285–93. Totaro P et al. Minimally invasive approach for complex cardiac surgery procedures. Ann Thorac Surg, 2009. 88(2): pp. 462-6; discussion 467. Glauber M, et al. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early outcomes and midterm follow-up. J Thorac Cardiovasc Surg. 2011;142(6):1577–9. Lim MH, et al. Right anterior mini-thoracotomy as first-line strategy for isolated aortic valve replacement: a retrospective study. J Thorac Dis. 2024;16(10):6664–76. Ji Q, et al. Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing. Front Cardiovasc Med. 2022;9:841472. He X, et al. The safety and feasibility of mini-invasive Bentall surgery via right anterior mini-thoracotomy. J Thorac Dis. 2024;16(5):2918–26. Abud B, et al. Outcomes of Aortic Valve Replacement Via Right Anterior Minithoracotomy and Central Cannulation Versus Conventional Aortic Valve Replacement in Obese Patients. Braz J Cardiovasc Surg. 2022;37(6):875–82. Chang C, et al. Minimally Invasive Approaches to Surgical Aortic Valve Replacement: A Meta-Analysis. Ann Thorac Surg. 2018;106(6):1881–9. Bowdish ME, et al. A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients. Eur J Cardiothorac Surg. 2016;49(2):456–63. Huang LC, et al. Clinical outcomes of the cuff wrapping technique in the modified Bentall procedure: a propensity score-matched study. J Thorac Dis. 2023;15(8):4337–45. Kourliouros A, et al. Evolution and current applications of the Cabrol procedure and its modifications. Ann Thorac Surg. 2011;91(5):1636–41. Sivakumar K, Sagar P. Post-Bentall Ascending Aortic Pseudoaneurysm Due to Coronary Button Dehiscence. Ann Thorac Surg. 2021;111(3):e161–4. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 20 Mar, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 03 Feb, 2026 Reviews received at journal 01 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers invited by journal 27 Jan, 2026 Editor assigned by journal 02 Dec, 2025 Submission checks completed at journal 02 Dec, 2025 First submitted to journal 29 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8236019","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581434039,"identity":"435f5306-9165-464d-81ef-1dc80473d993","order_by":0,"name":"Tao Zhu","email":"","orcid":"","institution":"Northern Jiangsu People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Zhu","suffix":""},{"id":581434042,"identity":"1927717d-9503-40f1-9dc6-469b23bf623b","order_by":1,"name":"Haoran Wang","email":"","orcid":"","institution":"Northern Jiangsu People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haoran","middleName":"","lastName":"Wang","suffix":""},{"id":581434049,"identity":"c348633f-429a-45d0-a52b-9e7a32437156","order_by":2,"name":"Chengbin Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYLCCBAMbHn725gMHPvwgQjUPiHhQkCYj2XMs8eDMHiK1MD74cNjGYEaO8WEONiK02LOfPfwiweAwj4FEzofDQBPk+cUOELCFJy/NIsEgncec5+2GwwUWDIYzZycQcliOmUGCgTWPZXvuhsMzeIBBcZuQFv43IC3MPAYHch4c5mEjRotEjvGDBANnHoMTOQxEarnxxgyoLI0HGMgGwECWIOwX9v4c448//tjYA6Py8YcPP2zk+aUJaAECNgkkjgROZciA+QNRykbBKBgFo2DkAgChc0XY1sIz0AAAAABJRU5ErkJggg==","orcid":"","institution":"Northern Jiangsu People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chengbin","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-11-29 09:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8236019/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8236019/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-026-04127-4","type":"published","date":"2026-04-17T15:57:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101459858,"identity":"1f33efc9-d2c6-4a4c-bdb8-18de403c25a5","added_by":"auto","created_at":"2026-01-30 01:33:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45773281,"visible":true,"origin":"","legend":"\u003cp\u003eThe surgical incision is located in the second or third intercostal space adjacent to the sternum (A). Superior vena cava drainage is established via the catheter inserted into the right internal jugular vein (B). Arterial perfusion and inferior vena cava drainage were established via cannulation of the right femoral artery and vein (C).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8236019/v1/4d7b3604fc6426d90627f910.png"},{"id":101459856,"identity":"1eaca16d-d86e-43b2-ab29-24e2e03a21d0","added_by":"auto","created_at":"2026-01-30 01:33:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1844150,"visible":true,"origin":"","legend":"\u003cp\u003ePosition of the suture.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8236019/v1/3864df3a6cf5e712d58eebd0.png"},{"id":101459855,"identity":"880c0e2a-6e4e-4ac7-bee3-1559565c7c90","added_by":"auto","created_at":"2026-01-30 01:33:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1830097,"visible":true,"origin":"","legend":"\u003cp\u003eAn opening was created in the prosthetic graft and directly anastomosed to the right coronary ostium.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8236019/v1/cf661bda0297fdc72250efd1.png"},{"id":107350775,"identity":"85224926-b178-498e-8cef-77a2d5b04bd7","added_by":"auto","created_at":"2026-04-20 16:03:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":42897576,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8236019/v1/50558c61-2ab3-4d1b-9a8f-09ca80035410.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Center Experience of mini-invasive Ascending Aortic Surgery via right anterior mini-thoracotomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAscending aortic surgery has traditionally been performed via median sternotomy, a technique that offers broad surgical exposure and optimal visualization of the operative field. However, this standard approach is associated with significant limitations, including substantial soft tissue injury, considerable intraoperative blood loss, and prolonged postoperative recovery[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With ongoing advancements in surgical instrumentation and growing operator expertise, minimally invasive cardiac procedures have become increasingly prevalent, offering a means to reduce surgical trauma and improve overall patient outcomes. The right anterior minithoracotomy (RAMT), accessed through the second or third intercostal space, has been well established as a safe and effective approach for aortic valve replacement (AVR), consistently demonstrating advantages such as lower complication rates, accelerated recovery, shorter hospitalization, and superior cosmetic results[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite these benefits and the anatomical continuity between the aortic valve and ascending aorta, the application of RAMT in ascending aortic surgery remains underreported in current literature[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Building on our extensive experience with minimally invasive AVR through the RAMT approach, our center has systematically expanded its procedural scope to include ascending aortic interventions using the same limited access strategy. In this study, we present a retrospective analysis of perioperative data and short-term clinical outcomes from 41 patients who underwent mini-Bentall, mini-Wheat, or isolated ascending aortic replacement via the RAMT approach. The aim was to comprehensively assess the feasibility, safety, technical characteristics, and early efficacy of this minimally invasive technique in the context of ascending aortic pathology.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWe retrospectively collected and analyzed the baseline, perioperative and follow-up data of 41 patients who underwent the RAMT approach ascending aortic surgery in the Department of Cardiac Vascular Center, Northern Jiangsu Province People's Hospital from June 2022 to June 2025.\u003c/p\u003e \u003cp\u003eAll patients underwent echocardiography, electrocardiogram, coronary computed tomography angiography (CTA) and aortic CTA before surgery. Patients undergoing ascending aortic surgery via the RAMT approach were required to meet the following criteria: (1) distal ascending aortic diameter\u0026thinsp;\u0026le;\u0026thinsp;4.0 cm; (2) aortic-to-chest wall distance at the incision level\u0026thinsp;\u0026le;\u0026thinsp;10.0 cm; and (3) rightward displacement of the ascending aorta relative to the sternum.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOperative procedure\u003c/h3\u003e\n\u003cp\u003eAfter intubation under anesthesia, a venous catheter (15-17Fr) was inserted into the right internal jugular vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). A small pillow was placed behind the patient's right shoulder, and the upper body was elevated by approximately 30\u0026deg;. After the start of the operation, a 4-cm vertical incision was made in the right groin to expose the right femoral artery and femoral vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). After heparinization (3mg/kg), the appropriate-sized catheters were inserted into the common femoral artery and femoral vein using the Seldinger technique. Cardiopulmonary bypass was established through the femoral artery, femoral vein, and right internal jugular vein.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter the initiation of cardiopulmonary bypass, a 6\u0026ndash;8 cm incision was made at the second or third intercostal space on the right side of the sternum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), depending on whether the aortic valve was to be addressed during the same operation. A sternal retractor was placed in the incision, and a longitudinal incision was made along the pericardium above the aorta, extending to the pericardial fold above the aorta. The pericardium was suspended to fully expose the heart, and a left ventricular drainage tube was inserted into the left ventricle through the right upper pulmonary vein. A 1-cm incision was made laterally at the same intercostal space to place a Chitwood clamp to occlude the ascending aorta near the innominate vein. Cardioplegic solution was directly injected through a transverse incision at the aortic root. The aneurysmal portion of the vessel was excised, and the native aortic valve was explored and excised as needed. The valve conduit was implanted after intermittent suturing (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Long-handled instruments and knot pushers are recommended. Holes were made at the openings of the left and right coronary arteries, and continuous suture with 6\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene was used for anastomosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The distal end of the artificial vessel was anastomosed with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene. The artificial vessel was wrapped with autologous vessels, and a shunt was made to the right atrium. After completing the distal anastomosis, the bypass was opened. After simple hemostasis and postoperative adjustment, the bypass was weaned. The catheters in the internal jugular vein and femoral vein were removed, and protamine was used to neutralize heparin. The femoral artery catheter was removed, and a chest drainage tube was placed after hemostasis was completed. The incision was then closed layer by layer.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eStudy protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eStudy protocol\u003c/div\u003e \u003cp\u003eBaseline, perioperative, and follow-up data for all patients were retrospectively extracted from the institutional electronic medical records system, with variable definitions and clinical parameters standardized according to the criteria established by the Society of Thoracic Surgeons (STS) Database. Postoperative follow-up was scheduled at one month and six months via outpatient clinic visits or structured telephone interviews, with subsequent annual evaluations conducted thereafter to monitor long-term outcomes.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted with SPSS software (version 26.0; IBM SPSS Statistics, Chicago, IL, USA). Normally distributed continuous variables are summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and compared using the independent samples t-test. Categorical data are displayed as counts and percentages and evaluated by the chi-square (χ\u0026sup2;) test. For continuous variables that deviate from normal distribution, median values and interquartile ranges (IQR) are used to describe central tendency and variability. Statistical significance was defined as a two-tailed P value less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eAmong the 41 patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 37 (90.2%) were male, with a median age of 62.0 years (range: 42.0\u0026ndash;83.0 years) and a median body mass index(BMI) of 21.7 kg/m\u0026sup2; (range: 16.0\u0026ndash;31.6 kg/m\u0026sup2;). Comorbidities included hypertension in 22 patients, diabetes in 8, coronary artery disease in 4, and arrhythmia in 5. The median left ventricular ejection fraction was 59.0% (IQR: 47.0\u0026ndash;66.0%), with a median left ventricular end-diastolic diameter of 61.0 mm (IQR: 44.0\u0026ndash;76.0 mm). The median diameters of the ascending aorta and aortic sinus were 46.0 mm (IQR: 38.0\u0026ndash;58.0 mm) and 52.0 mm (IQR: 38.0\u0026ndash;63.0 mm), respectively. Aortic valve regurgitation was present in 20 patients, and 4 patients had both aortic stenosis and regurgitation. Underlying valvular pathologies included degenerative aortic valve disease in 18 patients, congenital bicuspid aortic valve in 20, and Marfan syndrome in 3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics Data are presented as number, n (%), or median (IQR). BMI, body mass index; NYHA, New York Heart Association (classification); LVEF, left ventricular ejection fraction; LVEDD, left ventricular endo-diastolic diameter; LVESD, left ventricular endo-systolic diameter; Hb, hemoglobin; BNP, brain natriuretic peptide; ALB, albumin; IQR, interquartile range.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41.0 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (males)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (90.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62.0 [42.0\u0026ndash;83.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.7 [16.0-31.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (73.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (26.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (19.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (53.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic valve pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDegenerative Aortic Valve Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (43.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarfan Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicuspid aortic valve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (48.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA functional class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (48.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (39.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59.0 [47.0\u0026ndash;66.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAorta sinus (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.0 [38.0\u0026ndash;58.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscending aorta (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.0 [38.0\u0026ndash;63.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea of aortic regurgitation (cm2 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.9 [10.3\u0026ndash;16.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEDD (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61.0 [44.0\u0026ndash;76.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVESD (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.0 [33.0\u0026ndash;56.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiochemical index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132.0 [120.0-155.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBNP (pg/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e468.0 [225.0-1649.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALB (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.5 [32.1\u0026ndash;47.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerioperative characteristics\u003c/h3\u003e\n\u003cp\u003eOf the cohort, 15 underwent mini-Bentall procedures, 12 underwent mini-Wheat procedures, and 14 underwent minimally invasive ascending aortic replacement (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Patients who underwent minimally invasive ascending aortic replacement were operated via a second intercostal space incision, whereas the remaining patients underwent surgery through the third intercostal space. The median operative time was 210.0 minutes (IQR: 160.0\u0026ndash;420.00 minutes), with a median aortic cross-clamp time of 88.0 minutes (IQR: 52.0\u0026ndash;150.0 minutes) and a median cardiopulmonary bypass (CPB) time of 103.0 minutes (IQR: 68.0\u0026ndash;158.0 minutes). The sizes of the prosthetic grafts and valves are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All patients undergoing mini-Bentall procedures received aortic root reinforcement and right atrial shunting. The median intraoperative blood loss was 175.0 mL (IQR: 80.0\u0026ndash;350.0 mL), and no patient required conversion to open thoracotomy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of surgery (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e210.0 [160.0\u0026ndash;420.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACC time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.0 [52.0\u0026ndash;147.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPB time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103.0 [68.0\u0026ndash;158.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175.0 [80.0\u0026ndash;350.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBC transfusion rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMini-Bentall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMini-Wheat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimally Invasive Ascending Aorta Replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (34.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of prosthetic valve (mm) Bioprosthetic valve\u003c/p\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (85.1)\u003c/p\u003e \u003cp\u003e10 (37.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (48.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical valve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (14.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of graft (mm) 26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (43.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (31.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery anastomosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft atrial shunt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMVP or TVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to Thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as n (%) or median (IQR). ACC, aortic cross-clamp; CPB, cardiopulmonary bypass; Min, minimum; RBC, red blood cell; MVP, mitral valvuloplasty; TVP, tricuspid valvuloplasty; IQR, interquartile range.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEarly postoperative data and clinical complications\u003c/h3\u003e\n\u003cp\u003eThe median duration of mechanical ventilation was 10.5 hours (IQR: 5.2\u0026ndash;22.7 hours). Within the first 24 hours postoperatively, the median drainage volume was 220.0 mL (IQR: 60\u0026ndash;475 mL). Red blood cell transfusion was administered to seven patients (17.1%), and no patient required re-exploration for hemorrhage. The median intensive care unit length of stay was 3.9 days (IQR: 2.0\u0026ndash;7.8 days), while the total hospital stay ranged from 12 to 35 days, with a median of 16 days. Notably, no patients developed major postoperative complications, including postoperative mortality, respiratory failure, myocardial infarction, permanent pacemaker implantation, cerebrovascular events, or acute kidney injury requiring dialysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative characteristics Data are presented as n (%) or median [IQR]. ICU, intensive care unit; CRP, C-reactive protein; Hb, hemoglobin; BNP, brain natriuretic peptide; ALB, albumin; RBC, red blood cell; IQR, interquartile range.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of ICU stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 [2.0-7.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay length (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.0 [12.0\u0026ndash;35.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentilation time (h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.5 [5.2\u0026ndash;22.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (73.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticoagulant drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVasoactive drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (78.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.2 [14.3\u0026ndash;44.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113.0 [85.0\u0026ndash;128.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBNP (pg/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e320.0 [105.0\u0026ndash;1227.00]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALB (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.5 [32.1\u0026ndash;47.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative arrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePacemaker implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute kidney failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation for bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumothorax/subcutaneous\u003c/p\u003e \u003cp\u003eemphysema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary atelectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRib fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericardial effusion requiring\u003c/p\u003e \u003cp\u003ethoracentesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusions requiring thoracentesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParavalvular regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBC transfusion rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest tubes drainage at the first 24 h (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e220.0 [60.0-475.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime of drainage tube (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 [5.0\u0026ndash;15.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up results\u003c/h2\u003e \u003cp\u003eAll 41 patients completed follow-up via telephone or outpatient visits (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The median follow-up duration was 11.5 months (IQR: 3.1\u0026ndash;30.0 months). All patients remained alive at the time of last follow-up, with sustained improvement in clinical symptoms. One patient experienced delayed chest incision healing, which resolved successfully following debridement and surgical resuturing. Echocardiographic evaluation revealed trace paravalvular leak with mild aortic regurgitation in one patient, and coronary anastomotic fistula in another. Both patients were asymptomatic and are currently under clinical surveillance without intervention (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFollow-up results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of follow-up(months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.5 [3.1\u0026ndash;30.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor incision healing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParavalvular leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA functional class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (87.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as n (%) or median (IQR). NYHA, New York Heart Association (classification); IQR, interquartile range.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWith the rapid advancement of minimally invasive cardiac surgery, an increasing number of patients have benefited from its clinical application. Currently, common approaches for minimally invasive aortic surgery include partial sternotomy, upper J-shaped incision, upper T-shaped incision, and right parasternal incision[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While the right parasternal approach is frequently employed in minimally invasive aortic valve replacement, its use in minimally invasive ascending aortic procedures remains less reported[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Ji[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] et al. retrospectively analyzed clinical data from 15 patients who underwent Bentall procedure via the RAMT approach. The study demonstrated that none of the patients required conversion to full median sternotomy, and no severe postoperative complications occurred. All patients were discharged uneventfully, with no mortality observed during the 6-month follow-up period. He[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] et al. reported the clinical data of 27 male patients who underwent Bentall procedure via the RAMT approach. The results demonstrated that no patient experienced severe perioperative complications or in-hospital mortality. During the follow-up period, which ranged up to 21 months, all patients showed improvement in cardiac function, with no deaths or reoperations observed.\u003c/p\u003e \u003cp\u003eCareful patient selection is essential for this approach, and preoperative aortic computed tomography angiography (CTA) is mandatory. If CTA reveals significant dilation of the ascending aorta in close proximity to the brachiocephalic artery, the parasternal approach is contraindicated. In our practice, the second intercostal space is typically preferred for isolated ascending aortic procedures, whereas the third intercostal space is selected when concomitant aortic valve intervention is required.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated that, compared with conventional aortic valve replacement via median sternotomy, minimally invasive aortic valve replacement through a small right anterior thoracotomy at the second intercostal space is associated with prolonged aortic cross-clamping, cardiopulmonary bypass (CPB), and operative times[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, our experience indicates that minimally invasive ascending aortic surgery via the same approach may involve longer aortic cross-clamping and CPB durations than conventional sternotomy-based procedures, primarily due to the limited operative field, increased technical complexity, and dependence on surgeon expertise. However, in this cohort, these time intervals were not significantly prolonged compared to those typically observed with median sternotomy, likely attributable to the high surgical volume, advanced technical proficiency, and extensive experience of the primary surgeon. Notably, although the main procedural phase may require additional time under minimally invasive conditions, the duration of chest closure and hemostasis is substantially reduced, resulting in comparable overall operative times. Consistent with previous reports[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], our findings show that minimally invasive approaches shorten mechanical ventilation duration, ICU length of stay, and postoperative hospitalization, thereby accelerating patient recovery. This benefit was observed even in our cohort, which underwent more complex procedures such as minimally invasive Bentall, Wheat, and ascending aortic replacements. The advantages may be explained by several factors: preservation of sternal integrity maintains thoracic stability, reduces the risk of postoperative hypoxemia, and facilitates earlier extubation; additionally, the smaller incision minimizes surgical trauma and avoids sternal bleeding, leading to less postoperative drainage, earlier removal of drains, and earlier mobilization. These factors collectively contribute to enhanced recovery, earlier discharge, and reduced economic burden on patients.\u003c/p\u003e \u003cp\u003eMinimally invasive ascending aortic surgery through the RAMT approach has a relatively high technical difficulty. Based on our center's experience, having accumulated rich experience in median incision ascending aortic surgery and routinely performing minimally invasive aortic valve surgery through the RAMT approach, attempting minimally invasive ascending aortic surgery through this approach can achieve twice the result with half the effort. Complete exposure of the aortic root is the key to the success of the surgery. Good pericardial traction, especially on the left side, can provide more adequate exposure of the aortic root. Coronary artery anastomosis remains the main challenge in Bentall surgery. The exposure and anastomosis of the left coronary artery are relatively simple, while those of the right coronary artery are more difficult and require certain skills. End-to-end anastomosis is a common surgical technique with high clinical efficacy, especially for aortic root-right atrial shunt[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another buttonhole anastomosis technique is beneficial for the exposure of coronary arteries; however, patients treated with this method are more prone to bleeding at the root and coronary artery anastomosis sites, leading to surgical failure[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In this study, all patients underwent end-to-end anastomosis and right atrial shunt, which ensured the successful completion of the surgery and provided more experience for the surgeons.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, it is a single-center observational study involving only 41 patients and lacking a control group, which limits the ability to draw definitive conclusions. Nevertheless, this investigation represents an exploratory clinical observation, and prior reports on minimally invasive ascending aortic surgery via the RAMT approach remain scarce in the literature. Therefore, our findings warrant validation through large-scale, multicenter studies with rigorous design. Second, the postoperative follow-up duration is limited; longer-term follow-up data are required to fully assess the durability and long-term outcomes of this minimally invasive surgical technique.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, minimally invasive ascending aortic surgery via the RAMT approach is associated with reduced surgical trauma, faster postoperative recovery, and favorable safety and feasibility, making it a viable and promising technique worthy of clinical promotion and broader application.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical Statement\u003c/h2\u003e \u003cp\u003e The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Northern Jiangsu People's Hospital (No. 2024ky275). Informed consent was obtained from all participants involved in the study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eDisclosure\u003c/h2\u003e \u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflicts of Interest\u003c/strong\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by the Youth Fund of Northern Jiangsu People's Hospital, research project no. SBQN24002.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Tao zhu: conceptualization, writing\u0026ndash;original draft preparation, and writing\u0026ndash;review and editing. Haoran Wang: data curation, conceptualization, and project administration. Chenbin Tang: formal analysis, investigation and resources. All co-authors take full responsibility for the integrity and accuracy of all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShah VN, et al. The mini-Bentall approach: Comparison with full sternotomy. JTCVS Tech. 2021;7:59\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonacchi M, et al. Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery. J Thorac Cardiovasc Surg. 2023;165(3):1022\u0026ndash;32. e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlauber M, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg. 2013;145(5):1222\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiceli A, Ferrarini M, Glauber M. Right anterior minithoracotomy for aortic valve replacement. Ann Cardiothorac Surg. 2015;4(1):91\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVohra HA et al. Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting. Open Heart, 2023. 10(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson CA Jr., et al. Right Mini-thoracotomy Bentall Procedure. Innovations (Phila). 2018;13(5):328\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElghannam M, et al. Minimally Invasive versus Conventional Aortic Root Surgery: Results of an Intermediate-Volume Center. Thorac Cardiovasc Surg. 2024;72(2):118\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlauber M et al. Right anterior minithoracotomy for aortic valve replacement: 10-year experience of a single center. J Thorac Cardiovasc Surg, 2015. 150(3): p. 548\u0026thinsp;\u0026ndash;\u0026thinsp;56 e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaradzha A, et al. Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach. Asian Cardiovasc Thorac Ann. 2024;32(5):285\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTotaro P et al. \u003cem\u003eMinimally invasive approach for complex cardiac surgery procedures.\u003c/em\u003e Ann Thorac Surg, 2009. 88(2): pp. 462-6; discussion 467.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlauber M, et al. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early outcomes and midterm follow-up. J Thorac Cardiovasc Surg. 2011;142(6):1577\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim MH, et al. Right anterior mini-thoracotomy as first-line strategy for isolated aortic valve replacement: a retrospective study. J Thorac Dis. 2024;16(10):6664\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJi Q, et al. Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing. Front Cardiovasc Med. 2022;9:841472.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe X, et al. The safety and feasibility of mini-invasive Bentall surgery via right anterior mini-thoracotomy. J Thorac Dis. 2024;16(5):2918\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbud B, et al. Outcomes of Aortic Valve Replacement Via Right Anterior Minithoracotomy and Central Cannulation Versus Conventional Aortic Valve Replacement in Obese Patients. Braz J Cardiovasc Surg. 2022;37(6):875\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang C, et al. Minimally Invasive Approaches to Surgical Aortic Valve Replacement: A Meta-Analysis. Ann Thorac Surg. 2018;106(6):1881\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowdish ME, et al. A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients. Eur J Cardiothorac Surg. 2016;49(2):456\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang LC, et al. Clinical outcomes of the cuff wrapping technique in the modified Bentall procedure: a propensity score-matched study. J Thorac Dis. 2023;15(8):4337\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKourliouros A, et al. Evolution and current applications of the Cabrol procedure and its modifications. Ann Thorac Surg. 2011;91(5):1636\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSivakumar K, Sagar P. Post-Bentall Ascending Aortic Pseudoaneurysm Due to Coronary Button Dehiscence. Ann Thorac Surg. 2021;111(3):e161\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ascending aortic surgery, right anterior mini-thoracotomy, Bentall procedure, Wheat procedure, perioperative outcomes","lastPublishedDoi":"10.21203/rs.3.rs-8236019/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8236019/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe right anterior mini-thoracotomy (RAMT) has emerged as a well-established minimally invasive surgical approach in the field of cardiac surgery and is increasingly being utilized for valve-related interventions. However, high-quality clinical evidence supporting its application in ascending aorta surgery remains limited. This study aims to evaluate the safety and feasibility of ascending aortic operations performed via the RAMT approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 41 patients who underwent ascending aortic surgery using the RAMT technique at the Cardiac Vascular Center of Northern Jiangsu Province People's Hospital between June 2022 and June 2025. Patient baseline characteristics, perioperative outcomes, and follow-up data were systematically reviewed and analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study cohort comprised 41 patients aged 42 to 83 years. Among them, 27 patients underwent mini-Bentall or mini-Wheat procedures, while 24 underwent ascending aortic replacement. Operative duration ranged from 160.0 to 420.0 minutes. The median aortic cross-clamp time was 88.0 minutes (interquartile range [IQR]: 52.0\u0026ndash;147.0), and the median cardiopulmonary bypass (CPB) time was 103.0 minutes (IQR: 68.0\u0026ndash;158.0). The median length of intensive care unit (ICU) stay was 3.9 days (IQR: 2.0\u0026ndash;7.8), with mechanical ventilation maintained for a median duration of 10.5 hours (range: 5.2\u0026ndash;22.7 hours). Median postoperative drainage within the first 24 hours was 220 mL. No deaths or major complications were observed during the follow-up period.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAscending aortic surgery performed via the RAMT approach demonstrates favorable safety and procedural feasibility, indicating its potential as a viable and promising minimally invasive technique suitable for wider clinical implementation.\u003c/p\u003e","manuscriptTitle":"Single-Center Experience of mini-invasive Ascending Aortic Surgery via right anterior mini-thoracotomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 01:33:36","doi":"10.21203/rs.3.rs-8236019/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-20T12:33:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T12:19:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-03T12:46:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-01T18:54:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238449744695635433576457697389918521102","date":"2026-02-01T18:25:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113303998857719532776747187679133293759","date":"2026-02-01T17:56:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205095987383915784484151528023550985436","date":"2026-01-31T16:21:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67163136348445629786169527695193062608","date":"2026-01-28T00:16:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T16:55:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-02T05:14:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-02T05:12:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-11-29T09:28:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2a60b12-a5c9-42bd-bde4-f144e04c72fc","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-8236019","link":"https://doi.org/10.1186/s13019-026-04127-4","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-17 15:57:27","publishedOnDateReadable":"April 17th, 2026"},"versionCreatedAt":"2026-01-30 01:33:36","video":"","vorDoi":"10.1186/s13019-026-04127-4","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04127-4","workflowStages":[]},"version":"v1","identity":"rs-8236019","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8236019","identity":"rs-8236019","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}