Skip to main content

Advertisement

SpringerLink
Log in

Aortic valve approaches in the era of minimally invasive cardiac surgery

  • Review Article
  • Published:
Surgery Today Aims and scope Submit manuscript

Abstract

The concept of minimally invasive cardiac surgery has been gradually adopted world-wide since its inception more than 2 decades ago. Recently, catheter intervention has been used in the treatment of structural heart disease. Most notably, minimally invasive transcatheter aortic valve implantation is now an established treatment option for aortic valve stenosis. There are three major approaches for minimally invasive aortic valve surgery: via median sternotomy, via the parasternal approach, and via the thoracotomy approach. All these approaches allow for a small skin incision and/or avoid full sternotomy. Moreover, several advanced variations with additional aortic procedures or totally endoscopic management have been developed. When considering each approach, low invasiveness must be balanced with safety, as surgeons broaden their insight of advanced medicine. Physical invasiveness is largely related to the surgical approach in minimally invasive surgery. We review the history and evolution of the different surgical approaches for minimally invasive aortic valve replacement.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–20.

    CAS  PubMed  Google Scholar 

  2. Minakata K, Tanaka S, Okawa Y, Shimamoto M, Kaneko T, Takahara Y, et al. Long-term outcome of the carpentier-edwards pericardial valve in the aortic position in Japanese patients. Circ J. 2014;78(3):309–12. https://doi.org/10.1001/archneur.1988.00520270087025.

    PubMed  Google Scholar 

  3. Cosgrove DM III, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg. 1996;62:596–7. https://doi.org/10.1016/j.conb.2017.04.010.

    PubMed  Google Scholar 

  4. Yan TD. Mini-Bentall procedure: the “French Cuff” technique. Ann Thorac Surg. 2016;101:780–2. https://doi.org/10.1016/j.neurobiolaging.2014.12.040.

    PubMed  Google Scholar 

  5. Shrestha M, Krueger H, Umminger J, Koigeldiyev N, Beckmann E, Haverich A, et al. Minimally invasive valve sparing aortic root replacement (David procedure) is safe. Ann Cardiothorac Surg. 2015;4:148–53.

    PubMed  PubMed Central  Google Scholar 

  6. Luciani GB, Piccin C, Mazzucco A. Minimal-access median sternotomy for repair of congenital heart defects. J Thorac Cardiovasc Surg. 1998;116:357–8.

    CAS  PubMed  Google Scholar 

  7. Luciani GB, Mazzucco A. Neurocardiac dysregulation and neurogenic arrhythmias in a transgenic mouse model of Huntington's disease. Texas Heart Inst J. 2012;27:286–8.

    CAS  Google Scholar 

  8. Luciani GB, Lucchese G. Minimal-access median sternotomy for aortic valve replacement. J Thorac Dis. 2013;5(5):(5):S650–3. https://doi.org/10.1002/ana.410120504.

    PubMed  PubMed Central  Google Scholar 

  9. Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997;226:421–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. Svensson LG. Minimal-access “J” or “j” sternotomy for valvular, aortic, and coronary operations or reoperations. Ann Thorac Surg. 1997;64(5):1501–3. https://doi.org/10.1371/journal.pone.0126972.

    CAS  PubMed  Google Scholar 

  11. Svensson LG, D’Agostino RS. 66:431–5.

    CAS  PubMed  Google Scholar 

  12. Svensson LG, D’Agostino RS. “J” incision minimal-access valve operations. Ann Thorac Surg. 1998;66:1110–2. https://doi.org/10.1523/JNEUROSCI.21-13-04864.2001.

    CAS  PubMed  Google Scholar 

  13. Konertz W, Waldenberger F, Schmutzler M, Ritter J, Liu J. Minimal access valve surgery through superior partial sternotomy: a preliminary study. J Heart Valve Dis. 1996;5:638–40.

    CAS  PubMed  Google Scholar 

  14. Enrique Rodríguez J, Cortina J, Sota EP, Maroto L, Ginestal F, Rufilanchas JJ. A new approach to cardiac valve replacement through a small midline incision and inverted L shape partial sternotomy. Eur J Cardio Thorac Surg. 1998;14:S115–6.

    Google Scholar 

  15. Mikus E, Calvi S, Campo G, Pavasini R, Paris M, Raviola E, et al. Full sternotomy, hemisternotomy, and minithoracotomy for aortic valve surgery: is there a difference? Ann Thorac Surg. 2018;106(13):1782–8. https://doi.org/10.1093/hmg/ddu047.

    PubMed  Google Scholar 

  16. Chang C, Raza S, Altarabsheh SE, Delozier S, Sharma UM, Zia A, et al. Minimally invasive approaches to surgical aortic valve replacement: a meta-analysis. Ann Thorac Surg. 2018;106:1881–9.

    PubMed  Google Scholar 

  17. Plestis K, Orlov O, Shah VN, Wong J, Thomas M, Aharon A, et al. Facilitating technologies in minimally invasive aortic valve replacement: a propensity score analysis. Interact Cardiovasc Thorac Surg. 2018;27:202–7.

    PubMed  Google Scholar 

  18. Hirji SA, Funamoto M, Lee J, Ramirez Del Val F, Kolkailah AA, McGurk S, et al. Minimally invasive versus full sternotomy aortic valve replacement in low-risk patients: which will stand against transcatheter aortic valve replacement? Surgery. 2018;164:282–7.

    PubMed  Google Scholar 

  19. Szwerc MF, Benckart DH, Wiechmann RJ, Savage EB, Szydlowski GW, Magovern GJJ, et al. Partial versus full sternotomy for aortic valve replacement. Ann Thorac Surg. 1999;68:2209–14.

    CAS  PubMed  Google Scholar 

  20. Dogan S, Dzemali O, Wimmer-Greinecker G, Derra P, Doss M, Khan MF, et al. Minimally invasive versus conventional aortic valve replacement: a prospective randomized trial. J Heart Valve Dis. 2003;12:76–80.

    PubMed  Google Scholar 

  21. Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ribakove GH, Culliford AT, et al. Minimally invasive aortic valve surgery in the elderly: a case-control study. Circulation. 2003;108:II43–7.

    PubMed  Google Scholar 

  22. Tabata M, Umakanthan R, Cohn LH, Bolman RM, Shekar PS, Chen FY, et al. Early and late outcomes of 1000 minimally invasive aortic valve operations. Eur J Cardiothorac Surg. 2008;33(1):537–41. https://doi.org/10.1186/s13293-016-0125-3.

    PubMed  Google Scholar 

  23. Gosev I, Kaneko T, McGurk S, McClure SR, Maloney A, Cohn LH. A 16-year experience in minimally invasive aortic valve replacement: context for the changing management of aortic valve disease. Innov Technol Tech Cardiothorac Vasc Surg. 2014;9:104–10.

    Google Scholar 

  24. Welp HA, Herlemann I, Martens S, Deschka H. Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients. Interact Cardiovasc Thorac Surg. 2018;27:481–6.

    PubMed  Google Scholar 

  25. Kasegawa H, Shimokawa T, Matsushita Y, Kamata S, Ida T, Kawase M. Right-sided partial sternotomy for minimally invasive valve operation: “open door method”. Ann Thorac Surg. 1998;65(5):569–70. https://doi.org/10.1002/prp2.344.

    CAS  PubMed  Google Scholar 

  26. De Amicis V, Ascione R, Iannelli G, Di Tommaso L, Monaco M, Spampinato N. Aortic valve replacement through a minimally invasive approach. Texas Heart Inst J. 1997;24:353–5.

    Google Scholar 

  27. Bridgewater B, Steyn RS, Ray S, Hooper T. Minimally invasive aortic valve replacement through a transverse sternotomy: a word of caution. Heart. 1998;79:605–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. Doty DB, DiRusso GB, Doty JR. Full-spectrum cardiac surgery through a minimal incision: mini-sternotomy (lower half) technique. Ann Thorac Surg. 1998;65:573–7.

    CAS  PubMed  Google Scholar 

  29. Fenton JR, Doty JR. Minimally invasive aortic valve replacement surgery through lower half sternotomy. J Thorac Dis. 2013;5:S658–61.

    PubMed  PubMed Central  Google Scholar 

  30. Chang YS, Lin PJ, Chang CH, Chu JJ, Tan PP. “I” ministernotomy for aortic valve replacement. Ann Thorac Surg. 1999;68:40–5.

    CAS  PubMed  Google Scholar 

  31. Karimov JH, Santarelli F, Murzi M, Glauber M. A technique of an upper V-type ministernotomy in the second intercostal space. Interact Cardiovasc Thorac Surg. 2009;9:1021–2.

    PubMed  Google Scholar 

  32. Burdett CL, Lage IB, Goodwin AT, White RW, Khan KJ, Owens WA, et al. Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery. Interact Cardiovasc Thorac Surg. 2014;19:605–10.

    PubMed  Google Scholar 

  33. Lazzara RR, Kidwell FE. Right parasternal incision: a uniform minimally invasive approach for valve operations. Ann Thorac Surg. 1998;65:271–2.

    CAS  PubMed  Google Scholar 

  34. Weinschelbaum E, Stutzbach P, Machain A, Favaloro R, Caramutti V, Bertolotti A, et al. Valve operations through a minimally invasive approach. Ann Thorac Surg. 1998;66:1106–9.

    CAS  PubMed  Google Scholar 

  35. Cosgrove DM, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg. 1998;65:1535–9.

    PubMed  Google Scholar 

  36. von Segesser LK, Westaby S, Pomar J, Loisance D, Groscurth P, Turina M. Less invasive aortic valve surgery: rationale and technique. Eur J Cardiothorac Surg. 1999;15:781–5.

    Google Scholar 

  37. Plass A, Scheffel H, Alkadhi H, Kaufmann P, Genoni M, Falk V, et al. Aortic valve replacement through a minimally invasive approach: preoperative planning, surgical technique, and outcome. Ann Thorac Surg. 2009;88:1851–6.

    PubMed  Google Scholar 

  38. Glauber M, Miceli A, Bevilacqua S, Farneti PA. Minimally invasive aortic valve replacement via right anterior minithoracotomy: early outcomes and midterm follow-up. J Thorac Cardiovasc Surg. 2011;142:1577–9.

    PubMed  Google Scholar 

  39. Glauber M, Miceli A, Gilmanov D, Ferrarini M, Bevilacqua S, Farneti PA, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg. 2013;145:1222–6.

    PubMed  Google Scholar 

  40. Gilmanov D, Bevilacqua S, Murzi M, Cerillo AG, Gasbarri T, Kallushi E, et al. Minimally invasive and conventional aortic valve replacement: a propensity score analysis. Ann Thorac Surg. 2013;96:837–43.

    PubMed  Google Scholar 

  41. Mikus E, Turci S, Calvi S, Ricci M, Dozza L, Del Giglio M. Aortic valve replacement through right minithoracotomy: is it really biologically minimally invasive? Ann Thorac Surg. 2015;99:826–30.

    PubMed  Google Scholar 

  42. Bowdish ME, Hui DS, Cleveland JD, Mack WJ, Sinha R, Ranjan R, et al. A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients. Eur J Cardiothorac Surg. 2016;49:456–63.

    PubMed  Google Scholar 

  43. Stolinski J, Plicner D, Grudzien G, Wasowicz M, Musial R, Andres J, et al. A comparison of minimally invasive and standard aortic valve replacement. J Thorac Cardiovasc Surg. 2016;152:1030–9.

    PubMed  Google Scholar 

  44. Hiraoka A, Kuinose M, Chikazawa G, Totsugawa T, Katayama K, Yoshitaka H. Minimally invasive aortic valve replacement surgery: comparison of port-access and conventional standard approach. Circ J. 2011;75:1656–60.

    PubMed  Google Scholar 

  45. Hiraoka A, Totsugawa T, Kuinose M, Nakajima K, Chikazawa G, Tamura K, et al. Propensity score-matched analysis of minimally invasive aortic valve replacement. Circ J. 2014;78:2876–81.

    PubMed  Google Scholar 

  46. Totsugawa T, Kuinose M, Ozawa M, Eto K, Yoshitaka H, Tsushima Y. Port-access aortic valve replacement. Circ J. 2008;72:674–5.

    PubMed  Google Scholar 

  47. Totsugawa T, Kuinose M, Hiraoka A, Yoshitaka H, Tamura K, Sakaguchi T. Anterolateral approach for minimally invasive aortic valve replacement. Gen Thorac Cardiovasc Surg. 2014;62:290–5.

    PubMed  Google Scholar 

  48. Totsugawa T, Hiraoka A, Tamura K, Yoshitaka H, Sakaguchi T. Minimally invasive aortic valve replacement through a right anterolateral mini-thoracotomy for the treatment of octogenarians with aortic valve stenosis. Heart Vessels. 2018. https://doi.org/10.1007/s00380-018-1262-x.

    Article  PubMed  Google Scholar 

  49. Nakamura Y, Nakajima H, Niinami H. Single-operator knot-tying by knot-pusher for minimally invasive cardiac surgery. Asian Cardiovasc Thorac Ann. 2015;23:617–9.

    PubMed  Google Scholar 

  50. Ito T, Maekawa A, Hoshino S, Hayashi Y. Right infraaxillary thoracotomy for minimally invasive aortic valve replacement. Ann Thorac Surg. 2013;96:715–7.

    PubMed  Google Scholar 

  51. Ito T, Maekawa A, Hoshino S, Hayashi Y. Right infra-axillary mini-thoracotomy for aortic valve replacement. Ann Cardiothorac Surg. 2015;4:57–8.

    PubMed  PubMed Central  Google Scholar 

  52. Wang D, Wang Q, Yang X, Wu Q, Li Q. Mitral valve replacement through a minimal right vertical infra-axillary thoracotomy versus standard median sternotomy. Ann Thorac Surg. 2009;87:704–8.

    PubMed  Google Scholar 

  53. Yamazaki M, Kin H, Kitamoto S, Yamanaka S, Nishida H, Nishigawa K, et al. Efficacy of the stonehenge technique for minimally invasive aortic valve replacement via right infraaxillary thoracotomy. Ann Thorac Cardiovasc Surg. 2017;23:45–8.

    PubMed  PubMed Central  Google Scholar 

  54. Yamazaki M, Yoshitake A, Takahashi T, Ito T, Kimura N, Hirano A, et al. Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy. Gen Thorac Cardiovasc Surg. 2018;66:700–6.

    PubMed  Google Scholar 

  55. Vola M, Fuzellier J-F, Chavent B, Duprey A. First human totally endoscopic aortic valve replacement: an early report. J Thorac Cardiovasc Surg. 2014;147:1091–3.

    PubMed  Google Scholar 

  56. Vola M, Fuzellier J-F, Campisi S, Grinberg D, Albertini J-N, Morel J, et al. Total endoscopic sutureless aortic valve replacement: rationale, development, perspectives. Ann Cardiothorac Surg. 2015;4:170–4.

    PubMed  PubMed Central  Google Scholar 

  57. Borger MA, Moustafine V, Conradi L, Knosalla C, Richter M, Merk DR, et al. A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement. Ann Thorac Surg. 2015;99:17–24.

    PubMed  Google Scholar 

  58. LaPietra A, Santana O, Pineda AM, Mihos CG, Lamelas J. Outcomes of aortic valve and concomitant ascending aorta replacement performed via a minimally invasive right thoracotomy approach. Innovations (Phila). 2014;9:339–42.

    PubMed  Google Scholar 

  59. Lamelas J, LaPietra A. Right minithoracotomy approach for replacement of the ascending aorta, hemiarch, and aortic valve. Innovations (Phila). 2016;11:301–4.

    PubMed  Google Scholar 

  60. Lamelas J, Mawad M, Williams R, Weiss UK, Zhang Q, LaPietra A. Isolated and concomitant minimally invasive minithoracotomy aortic valve surgery. J Thorac Cardiovasc Surg. 2018;155:926–36.

    PubMed  Google Scholar 

  61. Yan TD. Mini-Bentall procedure. Ann Cardiothorac Surg. 2015;4:182–90.

    PubMed  PubMed Central  Google Scholar 

  62. Shrestha ML, Beckmann E, Abd Alhadi F, Krueger H, Meyer-Bockenkamp F, Bertele S, et al. Elective David I procedure has excellent long-term results: 20-year single-center experience. Ann Thorac Surg. 2018;105:731–8.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwa-cho, Amagasaki, Hyogo, 660-8550, Japan

    Go Ueno & Nobuhisa Ohno

Authors
  1. Go Ueno
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nobuhisa Ohno
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nobuhisa Ohno.

Ethics declarations

Conflict of interest

We have no conflicts of interest to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ueno, G., Ohno, N. Aortic valve approaches in the era of minimally invasive cardiac surgery. Surg Today 50, 815–820 (2020). https://doi.org/10.1007/s00595-019-01848-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00595-019-01848-z

Keywords

Search

Navigation