Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Minithoracotomy for All Comers With Aortic Valve Disease

Abstract

Objective Right anterior minithoracotomy is a promising technique for aortic valve replacement and has shown excellent results in terms of mortality and morbidity. Against this background, we analyzed our institutional experience in this technique during the last 3 years. Methods Between April 2017 and March 2019, 513 consecutive all comers with aortic valve disease underwent video-assisted minimally invasive aortic valve replacement through a 3-cm skin incision as right anterior minithoracotomy at our institution. A camera and automatic fastener technology were used for the valve implantation in all patients. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 68 ± 24 min and the myocardial ischemic time 38 ± 12 minutes. Thirty-day mortality and overall mortality was 0.4% (2 patients) and 1.4% (7 patients), respectively. Postoperative cerebrovascular events were noted in 8 patients (1.5%). Intensive care stay and hospital stay were 2 ± 2 and 9 ± 7 days, respectively. Pacemaker implantation, injury of the right internal mammary artery, and conversion to full sternotomy were noted in 7 patients (1.4%), 3 patients (0.6%), and 1 patient (0.2%), respectively. Paravalvular leak need to intervention was noted in 2 patients (0.4%). Rethoracotomy rate was 2% (11 patients). Transient postoperative dialysis was necessary for 14 patients (3%). Conclusions Video-assisted minimally invasive aortic valve replacement through the right anterior minithoracotomy is a safe approach and yields excellent outcomes in high-volume centers. The use of a camera and automatic fastener technology facilitates this procedure.

Lessons learned from 10 years of experience with minimally invasive cardiac surgery

“…Elderly patients benefit even from the slightest advantages of endoscopic MICS by decreasing surgical trauma and perioperative pain, blood transfusions, hospital and intensive care unit (ICU) length of stay, ventilation time, wound infections, cost of hospitalization, and rehabilitation when compared to the CS. Moreover, for the young patient group, these techniques improve the cosmetic, quality of life, and patient satisfaction with an earlier return to normal activities ( 3 , 4 , 6 ). Even patients with difficult anatomical conditions, such as pectus excavatum or dextrocardia by situs inversus (DSI), are suitable for an endoscopic MICS when performed at experienced MICS centers.…”

“…Although MICS approaches provide indisputable benefits to the patient, most studies report a correspondingly longer time for extracorporeal circulation and cardiac arrest with the minimally invasive approach. However, MICS benefits both from the utilization of video-thoracoscopic assistance and from advancements in CPB techniques to offer advantages such as a reduction in cross-clamp times, CPB times, and ventilator support, as well as shorter intensive care and total hospital time ( 3 , 4 ).…”

Comparison of Right Anterior Mini-Thoracotomy Versus Partial Upper Sternotomy in Aortic Valve Replacement

“…They justified their results with the learning curve reflected in their studies, since both MIC techniques were performed by all surgeons [ 11 , 20 ]. In our RAMT cohort, the operating times could be reduced by using a 3D camera, long surgical instruments, and an automated suture closure system [ 3 ]. Furthermore, RAMT was performed exclusively by surgeons with excellent surgical skills using minimally invasive surgery.…”

“…For the RAMT group, the access was performed through a 3–5-cm skin incision at the second or third right intercostal space. A detailed description of the surgical technique has been published previously [ 3 ]. Cannulation for CPB was achieved through the common femoral artery in 436 (98.7%) patients and the common femoral vein in all patients in the unmatched cohort.…”

“…Over the past 30 years, cardiac surgery has increasingly used minimally invasive procedures (MIC) with the aim of reducing surgical body trauma and achieving early recovery for the patient [ 1 – 3 ]. The perioperative mortality rate in isolated aortic valve replacement (AVR) has decreased from 3.9 to 1.9% according to the database of the Society of Thoracic Surgeons (STS) [ 4 – 6 ].…”