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Minimally Invasive AVR is Just Cosmetic

Wednesday, March 1, 2017

John Pepper of the Royal Brompton and Harefield Hospitals, London, United Kingdom, argues that there is not yet the evidence to support the superiority of minimally invasive aortic valve replacement over a full sternotomy approach. Dr. Pepper is responding to Christopher Young’s talk "Minimally Invasive AVR is More than Just Cosmetic."

This presentation was originally given during the SCTS Ionescu University program at the 2015 Annual Meeting of the Society for Cardiothoracic Surgery in Great Britain and Ireland. This content is published with the permission of SCTS. Please click here for more information on SCTS educational programs. 


The issue is the sutureless valve and not the mini-sternotomy. The sutureless valve can be unpredictable. I advocate the use of a standard valve (I use Magna Ease) using Cor-Knot to secure the prosthesis via the smaller incision. It is more reproducible (in my hands anyway) than the somewhat unpredictable sutureless valves. The AXC time for a standard valve may be 10-15 minutes more than the published times for a sutureless valve - but the guaranteed placement of the valve with negligible paravalvular leak issues is appealing. MICS AVR via hemisternotomy is straightforward and actually quicker than via a sternotomy. Replacing the ascending aorta via the hemisternotomy using ACP is also straightforward. There is less bleeding, less back pain, it is psychologically better for the patient and there are some cosmetic benefits.
I use a Perimount Magna Ease with a upper hemisternotomy and reserve the Intuity system for the frail patients in whom a shorter CPB time is preferable and where the aorta is in reasonable shape. A conventional AVR is a great operation even in the elderly, assuming they are in reasonable shape, they recover very well. I have also replaced the root and arch through such an incision. Planning and having a great mentor (Dr Malakh Shrestha) have been keys to getting a great outcome from this surgical approach. I agree that the incision preserves the overall integrity of the thoracic skeleton and makes it easier and more comfortable for patients post operatively. In my practice, now in India, minimising the skin incision is what the patients want, particularly in the field of mitral surgery as the patients tend to be younger and especially for young women a median sternotomy can be perceived as undesirable for societal reasons.

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