Singe-Center Experience: Minimally Invasive Aortic Valve Replacement

Objectives: Further development of minimally invasive techniques for isolated aortic valve replacement (MIS-AVR) is mandatory in cardiac surgery, especially under the aspect of the current successful development of interventional methods. To maintain MIS-AVR case numbers and to establish it more widely, the feasibility and safety of alternative access strategies must be continuously demonstrated.

Methods: Between 2015 and 2019, isolated AVR was performed in 215 patients in our department using a rapid deployment prosthesis, involving right anterolateral thoracotomy (RALT) or J-shaped partial upper sternotomy (JS). In RALT group cardiopulmonary bypass (CPB) was established via femoral approach, mainly using percutaneous closure systems, while in the JS group central cannulation was used. Thus calcification of femoral vessels was a contraindication for RALT, those patients where threated via JS. All patients received preoperative CT-scans for surgical planning. Perioperative data and 30-day mortality were retroperspectively analyzed.

Result: There were 99 (46%) patients in RALT and 116 (54%) patients in JS group. Patients in RALT compared with JS were mostly women (63 vs. 48%, p < 0.05), but did not show any difference regarding EuroSCORE II or age. Analysis of intraoperative data revealed a by trend prolonged duration pf operation, CPB and cross clamp time in group RALT versus JS (p = n.s.) while postoperative data such as ICU and hospital stay were comparable between the 2 groups. We observed an incidence of pacemaker implantation with 10 and 12%, however without significance. No patient suffered from wound infection, and patients in group JS were expectably free of any vessel complication whereas one patient in group RALT suffered from bleeding due to a technical failure of the femoral closing system. Conversion to full sternotomy was observed in 2 patients (2%) in RALT and no patient in JS group. Paravalvular leakage could be detected in 4% (RALT) and 6% (JS) patients (p = n.s.). Two patients died during hospital stay in group RALT (2 vs. 0%, p = n.s.)

Conclusion: Aortic valve replacement via right anterolateral thoracotomy or partial upper sternotomy seems to be a valid and reproducible technique for AVR patients. The definitive evidence should be obtained in controlled clinical trials. The optimal selection for successful access strategy is extremely important and should be performed individually for each patient. A CT scan is essential for careful preoperative planning.

Publication History

Article published online:
19 February 2021