Right Anterior Minithoracotomy for Aortic Valve Replacement: A Widely Applicable, Simple, and Stepwise Approach

Abstract

Objective A stepwise approach for right anterior minithoracotomy aortic valve replacement (RAT-AVR), without sutureless valves, special instruments, or preoperative imaging, was developed. We report our experience with this widely applicable, simplified approach. Methods Patients with a history of previous chest surgery, documented PVD, severe COPD, LVOT size <2.0 cm, and root size <2.8 cm were excluded. Chest CT was not mandatory. The stepwise surgical approach consists of 1) tolerability of single-lung ventilation; 2) 5-cm long incision on third right anterior ICS; 3) small pericardial opening to localize the aortic valve annular plane by digital palpation; 4) shingling of the correct rib to create a box field; 5) optimizing exposure with stay sutures; 6) femoral or central cannulation with right superior pulmonary vein venting and usual antegrade cardioplegia; 7) performing a standard AVR without adjunct instruments; and 8) reconstructing 1 costochondral cartilage. Results Fifty-five patients were operated. The mean age was 68.5 years (SD 10.4); 29.1% were female. Median STS PROM was 1.18 (0.4 to 6.6). Pump and cross-clamp times were 104.8 minutes (SD 27.9) and 73.2 minutes (SD 22.8), respectively. There was no need for a knot pusher. There was 1 conversion, 1 reopening for bleeding, and 1 pacemaker insertion. No patient had a stroke, MI, or death at 30 days. The median LOS was 6 days (3 to 19). Conclusion RAT-AVR can be applicable and performed safely in a wide range of patients by adopting a simple, stepwise approach with intraoperative assessment, without the need for special imaging, instrumentation, or advanced training.