Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Reza Tavakoli; Pascal Leprince; Max Gassmann; Peiman Jamshidi; Nassrin Yamani; Julien Amour; Guillaume Lebreton

doi:10.3791/57323

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Method Article

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

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DOI:

10.3791/57323

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March 26th, 2018

Reza Tavakoli¹^,² , Pascal Leprince¹ , Max Gassmann² , Peiman Jamshidi³ , Nassrin Yamani⁴ , Julien Amour⁵ , Guillaume Lebreton¹

¹Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie, ²Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich, ³Herzzentrum Hirslanden, Klinik St Anna, ⁴Department of Radiology, Canton Hospital Lucerne, ⁵Department of Anesthesiology and Intensive Care Unit, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie

Summary

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients' comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Abstract

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

Introduction

Among heart valve lesions diagnosed as hemodynamically relevant and clinically receiving particular attention, aortic valve stenosis is the most common valvular pathology in the United States and developed countries¹^,². In the Cardiovascular Health Study, 2% of patients had frank aortic stenosis, with a clear increase in prevalence with growing age: 1.3% in patients aged 65-75 years, 2.4% in those aged 75-85 years, and 4% in patients older than 85 years¹. For symptomatic patients presenting with severe aortic valve stenosis, aortic valve replacement is a Class I recommendation in the gu....