Minimally Invasive Surgical Aortic Valve Replacement Through a Right Anterior Thoracotomy: How I Teach It

Closing the care gap: combining enhanced recovery with minimally invasive valve surgery

PURPOSE OF REVIEW

Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures.

RECENT FINDINGS

Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay.

SUMMARY

Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.

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

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.

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.

Anatomical circumstances and aortic cross-clamp time in minimally invasive aortic valve replacement

OBJECTIVES

Prolonged operative times, potentially leading to increased morbidity, are a possible drawback of minimally invasive aortic valve replacement. The aim of this study was to assess the impact of anatomical circumstances in the chest on aortic cross-clamp time.

METHODS

This retrospective study included 68 patients who underwent minimally invasive aortic valve replacement with the Perceval sutureless valve via right-anterior thoracotomy or with ministernotomy. Anatomical variables were measured during preoperative computer tomography scans.

RESULTS

Aortic cross-clamp time was shorter in those having ministernotomy than in the right-anterior thoracotomy group (41.1 vs 52.3 min; P < 0.001). Cardiopulmonary bypass (CPB) time was not significantly different between groups (P = 0.09). A multivariable linear-regression model (P = 0.018) showed the aortic dextroposition variable to be a significant predictor of the aortic cross-clamp method and CPB times (P = 0.005 and P = 0.003) independent of other anatomical variables in the right thoracotomy group (10 mm deviation from optimal position prolonged the times for 240 and 600 s). For the whole cohort, a correlation between aortic valve dimensions and operative times was found (P = 0.046, P = 0.009). A linear-regression model (P = 0.046) predicted 90 s longer aortic cross-clamp time and 231 s longer CPB time for every 1 mm smaller aortic valve diameter.

CONCLUSIONS

The anatomical variables are associated with the operative times in minimally invasive aortic valve replacement with sutureless valves. Considering this association, preplanning the procedure is recommended.

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.

A Novel Computed Tomography Scan Tool for Patient Selection in Minithoracotomy Aortic Replacement

Right anterior minithoracotomy is gaining larger acceptance for isolated aortic valve replacement. In some patients, however, surgical exposure during the intervention may be challenging even for experienced surgeons or centers. In our opinion, proper preoperative selection of the patients by computed tomography scan seems mandatory. We routinely perform right anterior minithoracotomy, and over time, we have found that the angle between the right border of the sternum and the left side of the aorta, at the level of the pulmonary artery, helps with patient selection.

Aortic Valve Replacement by a Transaxillary Anterior Minithoracotomy Approach

A modified transaxillary approach for aortic valve disease to obtain the same exposure as the anterior minithoracotomy approach and to preserve the pectoralis major muscle is presented. When the patient's right shoulder is adducted horizontally, or the right arm is flexed anteriorly 90 degrees and adducted to the left, the right axilla comes close to the chest midline. That means that a right anterior thoracotomy can be made through the right axilla when the arm position is adjusted appropriately. The modified new approach is safe and faster than the conventional transaxillary approach, and it provides cosmetic advantages to the patient.