Minimally invasive ascending aortic surgery with partial upper sternotomy: Institutional experience and contemporary perspective

Background: Surgical replacement of the ascending aorta remains the gold standard therapy for ascending aortic aneurysm, chronic dissection, and selected aortic root pathologies. Traditionally performed through full median sternotomy, ascending aortic surgery has progressively evolved toward minimally invasive approaches aiming to reduce surgical trauma while preserving procedural safety and durability. Upper partial sternotomy has emerged as the most widely adopted mini-mally invasive access for ascending aortic surgery. This study presents the institutional experience of Acibadem City Clinic Vitosha Hospital with minimally invasive ascending aortic surgery via upper partial sternotomy and places these results in the context of contemporary literature. Methods: A retrospective analysis was conducted of consecutive elective patients undergoing ascending aortic replacement with or without aortic root intervention through an upper partial sternotomy. Demographic characteristics, operative details, and early postoperative outcomes were analyzed. Institutional results were interpreted considering current evidence comparing partial sternotomy with conventional full sternotomy, as well as alternative minimally invasive approaches including transaxillary and totally endoscopic techniques. Results: Minimally invasive ascending aortic surgery via upper partial sternotomy was associated with excellent early outcomes, including absence of early mortality, low neurological complication rates, limited blood transfusion requirements, and short intensive care and hospital stays. Cardiopulmonary bypass and aortic cross-clamp times were within acceptable ranges and comparable to those reported for conventional sternotomy in the literature. Conclusions: Upper partial sternotomy is a safe, reproducible, and effective minimally invasive approach for ascending aortic surgery in carefully selected patients. When performed in experienced centers, this technique provides outcomes comparable to full sternotomy while offering potential advantages in postoperative recovery. It represents a pragmatic and scalable strategy within the expanding fi eld of minimally invasive aortic surgery.