Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: the Conventional Procedure Performed Through a Smaller Incision

Abstract

Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis

“…Our analysis indicates a potential advantage of ministernotomy over right anterior thoracotomy at 3 years, which is no longer present at 5 years. Despite complications such as injury to the right internal mammary artery and/or intercostal vessels, increased conversion rate to full sternotomy, and increased surgery duration with right anterior thoracotomy, our analysis indicated no difference in major bleeding or blood transfusions, contrasting that reported by Salmasi et al 6,8,9,[60][61][62]…”

Reply to Özahn et al.: “Challenges in sutureless aortic valve implantation with minimal invasive technique”

“…2 Therefore, their concern about the risk of the normothermia use, which has been recently described in other studies, seems to be unjustified. 2,9 Furthermore, we have demonstrated in our results 30-day mortality of only 1% with no perioperative myocardial infarction. 2 Regarding the authors' question about the rate of postoperative permanent pacemaker (PPM) rate in our cohort, it can be read in our results section that the incidence rate of postoperative PPM was 6.9%, while among patients without preoperative atrioventricular block was only 5.4%.…”

Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting

“…The right internal thoracic artery (RITA) is usually divided during the initial incision, although there have been smaller reports of RITA sparing techniques described. 32 RITA-sacrificing incisions must be sure to adequately ligate and/or cauterise the vessels to prevent bleeding complications.…”

“…Usually, a soft-tissue retractor (Edwards Lifesciences, Irvine, Calif, Alexis retractor, applied Medical) is introduced into the incision followed by a small rigid retractor with narrow blades (figure 2). The right internal thoracic artery (RITA) is usually divided during the initial incision, although there have been smaller reports of RITA sparing techniques described 32. RITA-sacrificing incisions must be sure to adequately ligate and/or cauterise the vessels to prevent bleeding complications.…”