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Minimally Invasive Aortic Valve Replacement via Right Anterior Minithoracotomy and Central Aortic Cannulation: A 13-Year Experience

Bethencourt, Daniel M. MD; Le, Jennifer PharmD; Rodriguez, Gabriela BS; Kalayjian, Robert W. MD; Thomas, Gregory S. MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2017 - Volume 12 - Issue 2 - p 87–94
doi: 10.1097/IMI.0000000000000358
Original Articles

Objective This study reports the evolution of a minimally invasive aortic valve replacement (mini-AVR) technique that uses a right anterior minithoracotomy approach with central cannulation, for a 13-year period. This technique has become our standard approach for isolated primary AVR in nearly all patients.

Methods This observational study evaluated perioperative clinical outcomes of patients 18 years or older who underwent mini-AVR from November 2003 to June 2015.

Results The mini-AVR technique was used in 202 patients during two periods of 2003 to 2009 (n = 65, “early”) and 2010 to 2015 (n = 137, “late”). The mean ± SD age was 72.5 ± 12.9 years and 60% were male. Demographic parameters were statistically similar between the study periods, except for increased body weight in the later period (75.3 ± 14.7 vs 80.9 ± 20.8 kg, P = 0.03). The mean cardiopulmonary bypass and aortic cross-clamp times were significantly different by each year and Bonferroni adjustment, with significant decreases in cardiopulmonary bypass and aortic cross-clamp times beginning 2006. Compared with the early study period, late study period patients were more often extubated intraoperatively (52% vs 12%, P < 0.001), had less frequent prolonged ventilator use postoperatively (6% vs 16%, P = 0.018), required fewer blood transfusions (mean, 2.0 ± 2.3 U vs 3.6 ± 3.0 U; P = 0.011), and had shorter postoperative stay (6.3 ± 4.5 days vs 8.0 ± 5.9 days, P = 0.026). Numerically, fewer postoperative strokes (1% vs 6%, P = 0.09) and fewer reoperations for bleeding (3% vs 6%, P = 0.3) occurred in the late period. In-hospital mortality did not differ (1/65 early vs 3/137 late).

Conclusions Overall mini-AVR intraoperative and postoperative clinical outcomes improved for this 13-year experience.

From the *MemorialCare Heart & Vascular Institute at Long Beach Memorial, Long Beach, CA USA; †Orange Coast Memorial, Fountain Valley, CA USA; ‡University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA USA; and §Division of Cardiology, University of California Irvine, CA USA.

Accepted for publication February 13, 2017.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 15–18, 2016, Montreal, Quebec, Canada.

Supported by the Memorial Medical Center Foundation. The funding body had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Disclosures: Daniel M. Bethencourt, MD, serves on the speaker's bureau for St. Jude Medical, Inc, St. Paul, MN USA, Biomet, Warsaw, IN USA, and Medtronic, Inc, Minneapolis, MN USA. Jennifer Le, PharmD, Gabriela Rodriguez, BS, Robert W. Kalayjian, MD, and Gregory S. Thomas, MD, declare no conflicts of interest.

Address correspondence and reprint requests to Daniel M. Bethencourt, MD, Cardiac Surgery, MemorialCare Heart & Vascular Institute, Long Beach and Orange Coast Memorial Medical Centers, 2865 Atlantic Ave, Suite 205, Long Beach, CA 90806 USA. E-mail:

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery