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This video shows a step-by-step demonstration of minimally invasive aortic valve replacement through a right anterior minithoracotomy. It focuses on the key technical steps, highlighting practical nuances and explaining the advantages of this approach.
The case presented involved a 79-year-old man who developed progressive dyspnea while hiking in the Alps. Echocardiography showed severe aortic valve stenosis with preserved left ventricular function. Coronary angiography demonstrated no significant coronary artery disease.
The patient also had stage IV chronic kidney disease. Following a heart team discussion, surgical aortic valve replacement was selected.
For isolated aortic valve procedures, the right anterior minithoracotomy is the authors’ standard approach.
Computed Tomography Angiography
Careful preoperative planning was essential. In every patient, contrast-enhanced computed tomography angiography (CTA) is obtained to assess the position of the ascending aorta relative to the sternum and rib cage. When the ascending aorta lies posterior or leftward behind the sternum, exposure through a right anterior thoracotomy becomes more demanding. In such cases, a ministernotomy may be more appropriate. Atherosclerotic burden in the ascending aorta and femoral vessels was also evaluated, as this directly determines the cannulation strategy.
Operative Steps
The procedure began with percutaneous arterial and venous cannulation of the right groin under transesophageal echocardiography (TEE) guidance. A 5 centimeter minithoracotomy was created in the second or third intercostal space, guided by the preoperative computed tomography (CT) scan. The ribs remained intact, as did the internal mammary artery and vein, which defined the medial border of the incision.
A soft-tissue retractor was inserted. Gentle rib spreading was used only during pericardial opening and suspension. Pericardial traction sutures were placed to mobilize the ascending aorta toward the right hemithorax and toward the incision. Once exposure was established, the rib spreader was removed. A small opening was made in the posterior pericardial reflection to accommodate the posterior jaw of the Chitwood clamp. The clamp was positioned around the distal ascending aorta. A root vent was placed. The left ventricular vent was inserted through the right upper pulmonary vein, which laid directly beneath the incision. Long-shafted instruments were particularly helpful in this setting. The authors routinely use graspers, needle holders, and scissors with a working length of 17 centimeters.
After aortic clamping and cardioplegia delivery, a high transverse aortotomy was performed. In this case, a bioprosthesis was implanted. To avoid interaction with the supravalvular stent, the aortotomy was positioned approximately two centimeters above the sinotubular junction. During valve excision and annular debridement, the entire annulus is rarely visible in a single view. This was expected. The key was a structured workflow—progressing systematically from cusp to cusp around the annulus.
A small malleable retractor assisted with exposure. Sizing was performed using the white end of the Perceval sizer. It should pass with mild friction while avoiding oversizing. An extra-large valve was then selected. Three guiding sutures were placed at the nadir of each cusp. These were passed through the green guiding loops, allowing the prosthesis to be parachuted into position.
Following deployment, commissural alignment, implantation depth, and coronary ostial clearance were confirmed. Post-dilation was then performed. The guiding sutures were removed, and the aortotomy was closed in standard fashion. An epicardial pacing wire was placed on the anterior right ventricle. The aorta was then declamped. After weaning from cardiopulmonary bypass, the cannulae were removed using the Perclose system, with additional Angio-Seal closure for arterial access when required. Once hemostasis was confirmed, the ribs were reapproximated, and the incision was closed in the usual manner.
Advantages
This approach offers several practical advantages over other minimally invasive techniques. Rib spreading is limited, and once pericardial traction is established, the rib spreader is removed. Neither the ribs nor the internal mammary artery are transected. The setup remains straightforward—no endoscopes, monitors, or 3D visualization are required. The procedure is performed through a single incision under direct vision, preserving natural eye–hand coordination. If femoral access is unsuitable, central cannulation—arterial, venous, or both—can be performed without difficulty. The anterior incision provides a direct line of sight toward the aortic root, allowing excellent exposure of the valve. This exposure is maintained despite a high transverse aortotomy, making the technique particularly well suited for sutureless rapid-deployment prostheses.
Disclosure
Dr. Jules François is a proctor for Corcym.
This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.
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