Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy

Midterm Outcomes of Minimally Invasive Aortic Valve Replacement via Right Lateral Minithoracotomy

OBJECTIVE

Minimally invasive aortic valve replacement (MIAVR) procedures have been found to have good short-term results. However, no known reports regarding outcomes of MIAVR via a right lateral minithoracotomy (LT) approach over longer terms have been presented. The aim of the present study was to analyze the midterm outcomes of the use of MIAVR with the right LT approach over an 8-year period.

METHODS

Between September 2014 and February 2023, MIAVR was performed for 348 patients with severe aortic valve stenosis and regurgitation at our hospital. Operative mortality, all-cause mortality, and valve-related events were retrospectively examined.

RESULTS

The mean patient age was 72.3 ± 10.9 years, while 78 patients (22.4%) were more than 80 years old. Surgical, cardiopulmonary bypass, and cross-clamp times were 194.7 ± 43.2, 118.6 ± 28.7, and 89.4 ± 23.3 min, respectively. The 30-day mortality rate was 0.3%. The mean follow-up period was 35.6 ± 25.9 months. Overall survival shown by Kaplan-Meier analysis at 1, 3, and 5 years was 96.4%, 90.3%, and 83.2%, respectively, and freedom from valve-related events at those time points was noted in 100%, 99.5%, and 96.9% of the cases, respectively.

CONCLUSIONS

MIAVR via a right LT approach was found to be associated with excellent short-term and midterm outcomes and is considered to have the potential to become an established surgical option.

Y Incision and Roof Technique for Aortic Root Enlargement: A Minimally Invasive Approach

The Y incision and roof technique for aortic valve replacement enable implantation of a large prosthetic valve and extensive enlargement of the sinotubular junction. Surgeons have been reluctant to adopt a minimally invasive approach for this procedure because of its complexity and risk. The Stonehenge technique was designed to achieve an ideal surgical view of the aortic root through a small right thoracotomy. Herein, we report implementing a Y incision and roof technique for aortic valve replacement through a minimally invasive approach facilitated by the Stonehenge technique.

Sutureless Aortic Valve Replacement Through Lateral Mini-Thoracotomy - Feasibility and Effectiveness

BACKGROUND

Minimally invasive sutureless aortic valve replacement with the Perceval bioprosthetic heart valve (MISUAVR) is commonly performed through a right anterior thoracotomy (AT). However, a lateral thoracotomy (LT) may be superior as it does not require rib and right internal thoracic artery (RITA) cutting.

METHODS AND RESULTS

In total, 38 MISUAVRs performed from May 2019 to approximately August 2021 were retrospectively reviewed; 21 through LT (Group L), and 17 through AT (Group A). In Group L, the skin incision was made on the right anterior axillary line and third intercostal space, and in group A, on the right anterior chest and second or third intercostal space. All other surgical techniques were the same. Age, body surface area, EuroSCORE II, and ejection fraction were similar between the patients. Cardiopulmonary bypass (L: 82±19 vs. A: 93±28 min, P=0.19) and cross-clamp times (L: 57±13, vs. A: 64±23 min, P=0.19) were similar. Rib and/or RITA cutting were required in 94.6% of patients in group A and in none of group L (P<0.001). Surgical visualization score was better in group L (L: 1.19±0.40 vs. A: 1.94±0.69, P<0.01). Total amount of intraoperative bleeding was lower in group L (L: 623±141 vs. A: 838±316 mL, P<0.01). Duration of hospital stay was similar (P=0.30).

CONCLUSIONS

MISUAVR through LT has multiple advantages over AT.

Updates on the Latest Surgical Approach of the Aortic Stenosis

Over the last twenty years, we marked significant progresses in the field of tissue engineering and the development of new aortic valve structural and delivery systems. These continuous iterations on the field, have completely changed the surgical indications and approaches for AVR. Nowadays, therapeutic decisions are endorsed by international guidelines; however, new technical advances need a new integrated approach. The clinical scenarios issued from the interaction between the Guidelines and the newest approaches and technologies are regularly on debate by the Heart Team. We will present some of our most encountered situations and the pattern of our therapeutic decisions. To easily navigate through Guidelines and clinical scenarios, we reported in this review a simplified and easy to use Clinical decision-making algorithm that may be a valuable tool in our daily practice.

Aortic valve approaches in the era of minimally invasive cardiac surgery

The concept of minimally invasive cardiac surgery has been gradually adopted world-wide since its inception more than 2 decades ago. Recently, catheter intervention has been used in the treatment of structural heart disease. Most notably, minimally invasive transcatheter aortic valve implantation is now an established treatment option for aortic valve stenosis. There are three major approaches for minimally invasive aortic valve surgery: via median sternotomy, via the parasternal approach, and via the thoracotomy approach. All these approaches allow for a small skin incision and/or avoid full sternotomy. Moreover, several advanced variations with additional aortic procedures or totally endoscopic management have been developed. When considering each approach, low invasiveness must be balanced with safety, as surgeons broaden their insight of advanced medicine. Physical invasiveness is largely related to the surgical approach in minimally invasive surgery. We review the history and evolution of the different surgical approaches for minimally invasive aortic valve replacement.

Superior trans-septal approach for minimally invasive mitral valve surgery via right small thoracotomy

Minimally invasive mitral valve surgery (MIMVS), despite its challenges, is not a rare procedure. However, MIMVS via a right small thoracotomy must be performed using long-shafted surgical instruments and thoracotomy instruments specialized for minimally invasive cardiac surgeries. We have performed 12 cases of MIMVS via right small thoracotomy using the superior trans-septal approach and secured a surgical visual field that easily allows a finger to reach the mitral valve annulus without using special instruments for minimally invasive cardiac surgery. We named this technique the "drawer-case technique." In conclusion, MIMVS via right thoracotomy using the superior trans-septal approach can be performed easily and safely, similar to mitral valve surgery performed via median sternotomy.