Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting

Abstract

The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.

Keywords: Aortic Valve Stenosis; Heart Valve Prosthesis Implantation; Outcome Assessment, Health Care.

Figure 1

Incision for anterior right thoracotomy in the third intercostal space.

Figure 2

Implanting the valve prosthesis during ART access aortic valve replacement. The incision in the third intercostal space is demonstrated as well as the soft-tissue retractor. Surgical exposure during ART access. ART, anterior right thoracotomy.

Figure 3

CT images with reconstruction of preoperative assessment for patient undergoing ART AVR (from top left to right): (A) Three-dimensional (3D) reconstruction showing location of ascending aorta to the right of the sternum. (B) 3D reconstruction of the great vessels and myocardium within the thorax, having removed the sternum and ribs anteriorly. (C) Axial image at the level of the mid-ascending aorta providing cross-sectional dimensions: area, diameter and perimeter. (D) Reconstructed surface anatomy of the patients thorax highlighting the third and fourth rib spaces and location of the ascending aorta. (E) Coronal CT image of the ascending aorta and root. (F) Sagittal image of the ascending aorta highlighting its distance from the planned ART incision. ART, anterior right thoracotomy; AVR, aortic valve replacement.