Right Anterior Minithoracotomy Can Be Established as a Standard Approach for Isolated Aortic Valve Surgery

Objectives: In the era of TAVI, conventional aortic valve replacement continuously is getting outperformed in high- and intermediate-risk patients. However, in low-risk patients, open surgery is still the gold standard. In addition to median sternotomy, the less invasive approaches via partial upper sternotomy and right anterior minithoracotomy (RAM) are well established alternatives. Those minimally invasive approaches aim to reduce surgical trauma and quicken recovery. Furthermore, patients increasingly demand minimally invasive approaches for cosmetic issues. Compared to partial sternotomy, RAM leaves the osseous thorax untouched. We report our experience with the RAM access.

Methods: Between October 2013 and July 2018, we performed 316 minimally invasive procedures via RAM with an increasing number during the past years. The mean age of the patients was 68.1 ± 10.3 years. The average EuroSCORE II and STS-PROM were 1.63 ± 1.05, respectively, 1.48 ± 0.90.

Results: Isolated aortic valve replacement was performed in 310 patients (98.1%). In six (1.9%) patients, a concomitant procedure (four Bentall procedures, one aortic annular enlargement, and one CABG) was performed. Conversion rate to median sternotomy was 2.2% (four due to inappropriate exposure and three due to bleeding complication). The mean operating time was 127.9 ± 34.1 minutes with mean aortic clamp time of 41.5 ± 13.9 minutes. A total of 158 (50.0%) patients received a conventional biological valve, 25 (7.9%) a mechanical valve, and 133 (42.1%) a rapid deployment valve. The postoperative pacemaker rate was 3.5% (11 patients), with a slightly increased rate of 5.3% (7 out of 133) in the rapid deployment valve group. Thoracic wound complications occurred in five patients (1.6%). The 30-day overall mortality was 1.3% (four patients), with two patients dying from a procedure-related complication.

Conclusion: In our experience, RAM is a safe and reproducible approach for isolated aortic valve replacement, especially in low-risk patients. Both conventional and rapid deployment valves are feasible to implant. In selected cases, concomitant procedures on the ascending aorta are also possible. RAM is associated with excellent clinical outcomes. The complication rates are comparable low. In our point of view, the main advantage is the untouched integrity of the osseous thorax which translates in negligible low rates of wound complications.