Aortic valve replacement through right minithoracotomy: is it really biologically minimally invasive?

Combined Mitral and Aortic Valve Surgery Through a Right Minithoracotomy: A Single-Center Experience

OBJECTIVE

Minimally invasive combined mitral and aortic valve surgery is still uncommon. We report our experience performing multiple valve procedures through a right-sided minithoracotomy.

METHODS

We present an observational case series with a retrospective analysis of 38 patients who underwent double valve surgery through right anterior thoracotomy from November 2013 to November 2023.

RESULTS

The median age of our population was 72 years, and 61% were female patients. The median EuroSCORE II was 2.27. Three patients (7.9%) had redo operations. The median cardiopulmonary bypass (CPB) and cross-clamp times were 98 and 85 min, respectively. No conversion to full sternotomy was necessary. In-hospital mortality was 2.6% (1 patient); the patient died of septic shock and consequent multiorgan failure. Of the patients, 53% required transfusions with packed blood cells. Postoperative atrial fibrillation was observed in 12 patients (32%), and 2 patients (5.2%) required pacemaker implantation due to third-degree atrioventricular block. Also, 1 stroke (2.6%) and 1 rethoracotomy for bleeding were observed. The median ventilation time was 10 h. The median intensive care unit and postoperative length of stay were 2 days and 7.5 days, respectively. Survival at 1, 3, 5, and 10 years was 93.8%, 86.3%, 86.3%, and 77.2%, respectively, with a median follow-up time of 6.5 years. Freedom from reintervention at 1, 3, 5, and 10 years was 96.8%, 89.5%, 85.0%, and 69.5%, respectively, with a median follow-up time of 5.7 years.

CONCLUSIONS

In our experience, a minimally invasive approach for combined aortic and mitral valve surgery is safe and feasible, with acceptable CPB and cross-clamp times and good outcomes. Therefore, it can be an attractive option for patients with double valve diseases.

Right Anterior Minithoracotomy Approach for Aortic Valve Replacement

By sparing the sternum, the right anterior minithoracotomy (RAMT) approach may facilitate a quicker functional recovery when compared with conventional aortic valve replacement (AVR). In the following review, outcomes after RAMT AVR are compared with full sternotomy AVR. The RAMT approach is described, including suggestions for patient selection. The application of the RAMT approach for other cardiac procedures is also discussed.

Eligibility for minithoracotomy aortic valve replacement: from Van Praet classification to complex scanner measurements

Van Praet proposed a classification to predict the ease of minithoracotomy aortic valve replacement (MT-AVR) based on the position of the aorta in the thorax. We have evaluated the relevance of complex computed tomography (CT) scan measurements to predict the ease of performing a MT-AVR. The first 57 patients who underwent MT-AVR from February 2018 to June 2020 were selected prior to surgery using Van Praet's IA and IB classes. We made additional measurements on aorta position related to the chest and the incision on the preoperative CT scan. The main objective was to correlate complex CT measurements with different operating durations. Van Praet criteria were significantly related to the distance from the center of the aorta to the midline (p value < 0.001), the distance from the center of the aortic ring to the midline (p value = 0.013) and aorto-sternal angle (p < 0.001). We did not find a correlation between CT criteria and the different surgical steps durations in patients belonging to Van Praet classes IA and IB. Our cohort of Van Praet class Ia and Ib patients were able to benefit from a MT-AVR without the need for conversion. Complex CT measurements do not provide additional information to predict surgical difficulties. This classification appears to be sufficient to determine a patient's eligibility for MT-AVR, even for a surgeon experienced in sternotomy in his first MT-AVR.

Surgical outcomes of minimally invasive aortic valve replacement via right mini-thoracotomy for hemodialysis patients

OBJECTIVES

Minimally invasive valve surgery has become increasingly accepted as an alternative to conventional median sternotomy in low-risk patients. However, there have been no reports regarding the outcomes of this procedure on high-risk hemodialysis patients. The purpose of this investigation was to assess the surgical outcomes of minimally invasive aortic valve replacement (AVR) via right mini-thoracotomy (MIAVR) in hemodialysis patients compared with those of conventional AVR (CAVR) via full sternotomy.

METHODS

Two hundred and seventy-four patients underwent isolated AVR for severe AS, and 42 hemodialysis patients were included in this study. MIAVR was performed in 17 cases and CAVR in 25 cases. We compared the short-term surgical outcome among the two groups.

RESULTS

There was no difference in the aortic cross-clamp or cardiopulmonary bypass time. However, the procedure time was significantly shorter in the MIAVR group. Patients in the MIAVR group had less bleeding and a smaller amount of transfused red blood cells. There were four hospital deaths (18.2%) in the CAVR group. For postoperative complications, there were 2 (9.1%) cerebrovascular incidents, 2 (9.1%) cases of respiratory failure, 1 (4.5%) re-exploration for bleeding in CAVR group. The postoperative ventilation time was significantly shorter in the MIAVR group. There was no difference in the length of postoperative intensive care unit stay or of postoperative hospital stay.

CONCLUSION

The surgical outcomes of MIAVR in hemodialysis patients were acceptable, with a low incidence of morbidity, reasonable lengths of hospital stay, and no mortality among the patients studied.

Minimally invasive aortic valve surgery

Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intra- and post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.

Clinical study of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision: The first Chinese experience

BACKGROUND

There is an increasing demand for minimally invasive aortic valve replacement. This study aimed to investigate the safety and feasibility of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision.

METHODS

This was a retrospective study, and we collected information from 111 patients who underwent isolated aortic valve replacement surgery performed by the same surgeon from January 2018 to December 2019. According to the operative approach, the patients were divided into a sternotomy aortic valve replacement (SAVR) group (n = 62) and a minimally invasive aortic valve replacement (Mini-AVR) group (n = 49). We compared the intraoperative and postoperative data between the two groups.

RESULT

There was no difference in preoperative data between the Mini-AVR and SAVR. The postoperative ventilator-assisted time, CSICU time and postoperative hospital stay of the Mini-AVR were shorter than those of the SAVR [(15.45 ± 5.75) VS (18.51 ± 6.71) h; (1.77 ± 0.31) VS (2.04 ± 0.63) d; (8.69 ± 2.75) VS (10.77 ± 2.94) d], and the difference was statistically significant (P < 0.05). Mini-AVR had lower postoperative drainage and blood transfusion rates in the first 24 h than SAVR [(109.86 ± 125.98) VS (508.84 ± 311.70) ml; 22.4% VS 46.8%], and the differences were statistically significant (P < 0.05). The incidence of postoperative AF in the Mini-AVR group was also lower than that in the SAVR group (10.2% VS 30.6%), and the differences were statistically significant (P < 0.05).

CONCLUSION

Mini-AVR has the advantages of less ventilator time, a reduced need for blood transfusion, less AF and a faster recovery. Mini-AVR is a safe and feasible surgical technique that is worthy of clinical application.

Is it safe to move away from a full sternotomy for aortic valve replacement?

BACKGROUND

Minimally invasive surgical approaches have gained popularity among patients and surgeons. The aim of this project was to assess the safety of initiating aortic valve replacement via an anterior right thoracotomy program.

METHODS

Between May 2015 and May 2019, data of all isolated primary aortic valve replacements were extracted retrospectively from our prospectively collected database and categorized into conventional median sternotomy, hemisternotomy, and anterior right thoracotomy cases. In total, 661 patients underwent isolated primary aortic valve replacement, of whom 429 (65%) had a median sternotomy, 126 (19%) had a hemisternotomy, and 106 (16%) had an anterior right thoracotomy. Preoperative characteristics were similar in each of the three groups. Statistical testing of the surgical groups was undertaken using the chi-square test for categorical variables and one-way analysis of variance with Tukey post-hoc pairwise tests (where appropriate) for continuous variables, to identify differences between pairs of data.

RESULTS

Cardiopulmonary bypass and crossclamp times were significantly longer in the anterior right thoracotomy group compared to the hemisternotomy and median sternotomy groups (p < 0.001). Blood loss was significantly less and hospital stay significantly shorter in the hemisternotomy group compared to median sternotomy group but not the anterior right thoracotomy group. Mortality, stroke, renal, gastrointestinal and respiratory complications showed no statistical differences.

CONCLUSION

Surgical aortic valve replacement had a very low mortality and morbidity in our experience, and it is safe to start a minimal access program for aortic valve replacement.

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.

Improved operative and recovery times with mini-thoracotomy aortic valve replacement

Background

The small incisions of minimally invasive surgery have the proposed benefit of less surgical trauma, less pain, and faster recovery. This study was done to compare minimally invasive techniques for aortic valve replacement, including right anterior mini-thoracotomy and mini-sternotomy, to conventional sternotomy.

Methods

We retrospectively reviewed 503 patients who underwent isolated aortic valve replacement at our institution from 2012 to 2015 using one of three techniques: 1) Mini-thoracotomy, 2) Mini-sternotomy, 3) Conventional sternotomy. Demographics, operative morbidity, mortality, and postoperative complications were compared.

Results

Of the 503 cases, 267 (53.1%) were mini-thoracotomy, 120 (23.8%) were mini-sternotomy, and 116 (23.1%) were conventional sternotomy. Mini-thoracotomy patients, compared to mini-sternotomy and conventional sternotomy, had significantly shorter bypass times [82 (IQ 67–113) minutes; vs. 117 (93.5–139.5); vs. 102.5 (85.5–132.5), respectively (p < 0.0001)], a lower incidence of prolonged ventilator support [3.75% vs. 9.17 and 12.9%, respectively (p = 0.0034)], and required significantly shorter ICU and postoperative stays, resulting in an overall shorter hospitalization [6 (IQ 5–9) days; vs. 7 (5–14.5); vs 9 (6–15.5), respectively (p < 0.05)]. Incidence of other postoperative complications were lower in the mini-thoracotomy group compared to mini-sternotomy and conventional sternotomy, without significance. Minimally invasive techniques trended towards better survival [mini-thoracotomy 1.5%, mini-sternotomy 1.67%, and conventional sternotomy 5.17% (p = 0.13)].

Conclusions

Minimally invasive aortic valve replacement approaches are safe, effective alternatives to conventional sternotomy. The mini-thoracotomy approach showed decreased operative times, decreased lengths of stay, decreased incidence of prolonged ventilator time, and a trend towards lower mortality when compared to mini-sternotomy and conventional sternotomy.

A running suture line for aortic valve replacement does not increase the rate of postoperative complete heart block

BACKGROUND

Surgical implantation of a prosthetic aortic valve is typically done with multiple interrupted sutures. We adapted a running suture line technique for prostheses implantation to decrease the rate of complete heart block necessitating permanent pacemaker.

METHODS

374 patients undergoing isolated aortic valve replacements were identified between 2015 and 2017. Patients with preoperative heart block, patients undergoing concomitant MAZE procedure and those undergoing multivalve procedures were excluded. Interrupted technique was performed with multiple non-pledgeted sutures. Running technique was performed with three 2-0 polypropylene sutures. Propensity-score matching (caliper distance = 0.10) was used to match based on patient age, gender, BMI, diabetes mellitus, renal failure, heart failure, arrythmias, use of anti-arrhythmics, and STS PROM.

RESULTS

Propensity score matching yielded 103 pairs of running technique and interrupted technique patients for analysis. Within the propensity score-matched cohort, there were no differences in sustained complete heart block and need for pacemaker, 4 (3.8%) for running technique vs 3 (2.9%) for interrupted technique (p = 0.307). At 4 weeks, there was no difference in mean prosthetic aortic valve gradients calculated on transthoracic echocardiogram (6.39 ± 2.47 mmHg vs 6.46 ± 2.86, p = 0.850). There was no difference in paravalvular leak (0 (0%) vs 2 (1.9%), p = 0.070).

CONCLUSIONS

Surgical implantation of a prosthetic aortic valve may be performed with a running suture technique without any significant increase in risk of heart block, need for permanent pacemaker or paravalvular leak. Long-term data will be critical to evaluate any development of paravalvular leaks in the future.

Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference?

BACKGROUND

This study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others.

METHODS

All patients who underwent AVR were enrolled. The choice of the approach was left to surgeon's preference. Data were retrospectively collected, and the major baseline characteristics (including age, sex, body mass index, creatinine clearance, preoperative condition, cardiovascular risk factors, functional status, and left ventricular ejection fraction, etc.) and intraoperative variables were recorded. To adjust for differences in baseline characteristics between the study groups, a propensity score matching was performed. Linear and logistic regression analyses were performed.

RESULTS

Partial upper hemisternotomy was performed in 820 patients (43%), right anterior minithoracotomy in 488 (26%), and median sternotomy in 599 (31%). After propensity score matching, three groups of 377 patients were obtained. Cardiopulmonary bypass and cross-clamp times were shorter in the right anterior minithoracotomy group than in the median sternotomy and partial upper hemisternotomy groups (p < 0.001). No significant differences in in-hospital mortality were observed (p = 0.9). Renal failure (odds ratio, 5.4; 95% confidence interval, 2.3 to 11.4; p < 0.0001), extracardiac arteriopathy (odds ratio, 2.9; 95% confidence interval, 1.1 to 6.7; p = 0.017), and left ventricular ejection fraction (odds ratio, 0.96; 95% confidence interval, 0.93 to 0.99; p = 0.009) emerged as independent predictors of in-hospital mortality.

CONCLUSIONS

Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.

Right anterior mini-thoracotomy vs. conventional sternotomy for aortic valve replacement: a propensity-matched comparison

Background

Right anterior mini-thoracotomy (MIAVR) is a promising technique for aortic valve replacement. We aimed at comparing its outcomes with those obtained in a propensity-matched group of patients undergoing sternotomy at our two high-volume centers.

Methods

Main clinical and operative data of patients undergoing aortic valve replacement between January 2010 and May 2016 were retrospectively collected. A total of 678 patients were treated with a standard full sternotomy approach, while MIAVR was performed in 502. Propensity score matching identified 363 patients per each group.

Results

In-hospital mortality was not significantly different between the propensity-matched groups (1.7% in MIAVR patients vs. 2.2% in conventional sternotomy patients; P=0.79). No significant difference in the incidence of major post-operative complications was observed. Post-operative ventilation times (median 7, range 5-12 hours in MIAVR patients vs. median 7, range 5-12 in conventional sternotomy patients; P=0.72) were not significantly different between the two groups. Cardiopulmonary bypass time (61.0±21.0 vs. 65.9±24.7 min in conventional sternotomy group; P<0.01) and aortic cross-clamping time (48.3±16.7 vs. 53.2±19.6 min in full sternotomy group; P<0.01) were shorter in MIAVR group. EuroSCORE (OR 1.52, 95% CI, 1.12-2.06; P<0.01) was found to be the only independent predictor of intra-hospital mortality in the whole propensity-matched population.

Conclusions

Our experience shows that mini-access isolated aortic valve surgery is a reproducible, safe and effective procedure with similar outcomes and no longer operative times compared to conventional sternotomy.

Rapid deployment valve system shortens operative times for aortic valve replacement through right anterior minithoracotomy

BACKGROUND

There is growing evidence from the literature that right anterior minithoracotomy aortic valve replacement (RAT-AVR) improves clinical outcome. However, increased cross clamp time is the strongest argument for surgeons not performing RAT-AVR. Rapid deployment aortic valve systems have the potential to decrease cross-clamp time and ease this procedure. We assessed clinical outcome of rapid deployment and conventional valves through RAT.

METHODS

Sixty-eight patients (mean age 76 ± 6 years, 32% females) underwent RAT-AVR between 9/2013 and 7/2015. According to the valve type implanted the patients were divided into two groups. In 43 patients (R-group; mean age 74.1 ± 6.6 years) a rapid deployment valve system (Edwards Intuity, Edwards Lifesciences Corp; Irvine, Calif) and in 25 patients (C-group; mean age 74.2 ± 6.6 years) a conventional stented biological aortic valve was implanted.

RESULTS

Aortic cross-clamp (42.1 ± 12 min vs. 68.3 ± 20.3 min; p < 0.001) and bypass time (80.4 ± 39.3 min vs. 106.6 ± 23.2 min; p = 0.001) were shorter in the rapid deployment group (R-group). We observed no differences in clinical outcome. Postoperative gradients (R-group: max gradient, 14.3 ± 8 mmHg vs. 15.5 ± 5 mmHg (C-group), mean gradient, 9.2 ± 1.7 mmHg (R-group) vs. 9.1 ± 2.3 mmHg (C-group) revealed no differences. However, larger prostheses were implanted in C-group (25 mm; IQR 23-27 mm vs. 23 mm; IQR 21-25; p = 0.009).

CONCLUSIONS

Our data suggest that the rapid deployment aortic valve system reduced cross clamp and bypass time in patients undergoing RAT-AVR with similar hemodynamics as with larger size stented prosthesis. However, larger studies and long-term follow-up are mandatory to confirm our findings.

Automated CTA based measurements for planning support of minimally invasive aortic valve replacement surgery

Minimally invasive aortic valve replacement (mini-AVR) procedures are a valuable alternative to conventional open heart surgery. Currently, planning of mini-AVR consists of selection of the intercostal space closest to the sinotubular junction on preoperative computer tomography images. We developed an automated algorithm detecting the sinotubular junction (STJ) and intercostal spaces for finding the optimal incision location. The accuracy of the STJ detection was assessed by comparison with manual delineation by measuring the Euclidean distance between the manually and automatically detected points. In all 20 patients, the intercostal spaces were accurately detected. The median distance between automated and manually detected STJ locations was 1.4 [IQR= 0.91-4.7] mm compared to the interobserver variation of 1.0 [IQR= 0.54-1.3] mm. For 60% of patients, the fourth intercostal space was the closest to the STJ. The proposed algorithm is the first automated approach for detecting optimal incision location and has the potential to be implemented in clinical practice for planning of various mini-AVR procedures.

Non-sutureless minimally invasive aortic valve replacement: mini-sternotomy versus mini-thoracotomy: a series of 1130 patients

OBJECTIVES

Aortic valve replacement through conventional sternotomy still represents the gold-standard surgical approach for aortic valve disease. However, given the increasing number of patients with comorbidities, strategies that can improve operative results are always sought. Minimally invasive aortic valve surgery, although related to a steep learning curve, might be associated with improved postoperative outcomes. The main aim of this study was to assess whether significant differences exist in terms of operative and early results between a mini-sternotomy and a right mini-thoracotomy approach for isolated aortic valve replacement without sutureless technologies.

METHODS

This is an observational retrospective multicentre study from nine Italian cardiac centres that analyses prospectively collected data of patients who underwent isolated minimally invasive aortic valve replacement between January 2010 and December 2014. Two approaches are considered (mini-sternotomy and mini-thoracotomy) and compared in terms of operative and early outcomes.

RESULTS

After interrogation of the centralized database, a total of 1130 patients were retrieved (854 mini-sternotomy and 276 mini-thoracotomy). Patients in the mini-sternotomy group had a higher risk profile. There was no difference in terms of early mortality; cardiopulmonary bypass and cross-clamp time did not differ significantly between the groups; and a significantly higher number of reoperations for bleeding was observed in the right mini-thoracotomy group.

CONCLUSIONS

Both mini-sternotomy and mini-thoracotomy could be performed safely, with low mortality and postoperative morbidity. The mini-thoracotomy approach was associated with a significantly higher rate of reoperation for bleeding. Uptake among cardiac centres was low. Sutureless technologies could potentially increase surgical volume by simplifying the mini-thoracotomy procedure.

Minimally Invasive Aortic Valve Replacement

With the advent of transcatheter aortic valve replacement and the emergence of rapid deployment aortic valves, there is a resurgent interest in minimizing the trauma of surgical aortic valve replacement (AVR). The present review summarizes the history of minimal access AVR and attempts to collate the existing evidence regarding minimal access AVR.