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Review
. 2015 Jan;4(1):26-32.
doi: 10.3978/j.issn.2225-319X.2015.01.01.

Minimally invasive aortic valve surgery: state of the art and future directions

Mattia Glauber  1 , Matteo Ferrarini  1 , Antonio Miceli  1
Affiliations
Review

Minimally invasive aortic valve surgery: state of the art and future directions

Mattia Glauber et al. Ann Cardiothorac Surg. 2015 Jan.

Abstract

Minimally invasive aortic valve replacement (MIAVR) is defined as an aortic valve replacement (AVR) procedure that involves a small chest wall incision as opposed to conventional full sternotomy (FS). The MIAVR approach is increasingly being used with the aim of reducing the "invasiveness" of the surgical procedure, while maintaining the same efficacy, quality and safety of a conventional approach. The most common MIAVR techniques are ministernotomy (MS) and right anterior minithoracotomy (RT) approaches. Compared with conventional surgery, MIAVR has been shown to reduce postoperative mortality and morbidity, providing faster recovery, shorter hospital stay and better cosmetics results, requires less rehabilitations resources and consequently cost reduction. Despite these advantages, MIAVR is limited by the longer cross-clamp and cardiopulmonary bypass (CPB) times, which have raised some concerns in fragile and high risk patients. However, with the introduction of sutureless and fast deployment valves, operative times have dramatically reduced by 35-40%, standardizing this procedure. According to these results, the MIAVR approach using sutureless valves may be the "real alternative" to the transcatheter aortic valve implantation (TAVI) procedures in high risk patients "operable" patients. Prospective randomized trials are required to confirm this hypothesis.

Keywords: Minimally invasive; aortic valve replacement (AVR); sutureless valve.

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Figures

Figure 1
Figure 1
Minimally invasive approaches. (A) Ministernotomy; (B) right anterior minithoracotomy; (C) right parasternal approach; (D) transverse sternotomy. The minimally invasive incision is marked by the dotted line.
Figure 2
Figure 2
Right thoracotomy criteria. (A) At the level of main pulmonary artery, the ascending aorta is rightward (more than one half located on the right in respect to the right sternal border); (B) the distance from the ascending aorta to the sternum does not exceed 10 cm; the α angle (angle between the midline and the inclination of ascending aorta) should be >45°.
Figure 3
Figure 3
Sutureless and fast deployment valves. (A) EnableTM; (B) Perceval STM; (C) IntuityTM.
Figure 4
Figure 4
The combination of minimally invasive aortic valve replacement using sutureless/fast deployment valves has improved postoperative mortality. Black line: in-hospital mortality reduction from 3.4% in 1997 to 2.6% in 2006 for isolated AVR according to STS data (2). Red line: the introduction of sutureless valves associated with MIAVR has decreased the inhospital mortality from 1.6% in 2005 to 0.7% in 2013 (13,26). AVR, aortic valve replacement; MIAVR, minimally invasive aortic valve replacement; STS, Society of Thoracic Surgeon.
Video
Video
Minimally invasive aortic valve surgery: state of the art and future directions.
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References

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