Aortic Valve Replacement with Edwards INTUITY Sutureless Bioprosthesis Through Right Anterior Minithoracotomy

Median sternotomy remains the gold standard approach for aortic valve replacement. Recently, there has been growing evidence of interest in performing aortic valve replacement via right anterior minithoracotomy. This minimally invasive sternum-sparing procedure has been shown to be a reliable and safe technique, with better postoperative outcomes than full sternotomy (1). On the other hand, aortic valve replacement via right minithoracotomy may be challenging. Exposure of the surgical field may be limited, thus increasing cross-clamp time. In this setting, sutureless aortic bioprostheses are very interesting, as they facilitate implantation.

In the following video, the authors show their technique for Edwards INTUITY bioprosthesis implantation, through a right anterior minithoracotomy. The patient was a 69-year-old man suffering from terminal renal failure (dialysis three times a week), and presenting with NYHA stage III dyspnea. He was diagnosed with a calcified severe aortic stenosis. Before surgery, he underwent a body contrast-enhanced CT scan. The authors consider patients suitable for right anterior minithoracotomy if, at the level of the main pulmonary artery: (i) less than 50% of the ascending aorta lies out of the right sternal border, and (ii) the distance between the ascending aorta and the thoracic wall is less than 10 cm (1). The authors believe that right minithoracotomy is not feasible in all patients. Anatomical landmarks in the CT scan, as indicated above, should be a surgeon’s guide as he/she decides if a patient is suitable for this procedure.

The patient was positioned supine and intubated with a single-lumen endotracheal tube. Defibrillator pads were placed on the chest wall. CPB was established between the right atrium, cannulated with a 29 French double-stage cannula passed through the thoracotomy, and associated with active venous blood drainage. The right axillary artery was dissected at the level of the delto-pectoral groove. In the authors’ experience, this arterial surgical site presents four major advantages: (i) antegrade perfusion; (ii) eliminating issues with peripheral vascular disease, as the axillary artery is usually free from atherosclerosis; (iii) easy hemostasis at removal; and (iiii) better wound healing compared to the groin (2). The patient had an uneventful postoperative outcome and was discharged to a rehabilitation center on postoperative day six.

References

1. Gilmanov D, Bevilacqua S, Murzi M et al. Minimally invasive and conventional aortic valve replacement: a propensity score analysis. Ann Thorac Surg 2013;96:837–43.
2. Hysi I, Guesnier L, Gautier L, Fabre O. Axillary artery cannulation for aortic valve replacement through right anterior minithoracotomy. Int J Cardiol 2014;177:664–5.