• Alberto AlbertiniEmail author


Minimally-invasive cardiac surgery (MICS) approaches are becoming increasingly popular worldwide, with more and more minimally-invasive operations for valvular disease performed every year. MICS has steadily gained popularity among cardiac surgeons, cardiologists and patients due to the excellent clinical results, faster recovery time and more appealing cosmetic result. The main advantages reported with respect to conventional cardiac surgery are cosmesis, reduction of postoperative pain, blood loss and blood product transfusion, reduced ventilation time and pulmonary complications, shorter intensive care unit (ICU) and hospital stay, lower rehabilitation and hospital costs, and possibly better long-term outcomes [1, 2]. Techniques for MICS have continued to evolve rapidly in the last two decades with the scope of reducing wound size and chest trauma and potentiating the postoperative benefits. The rationale is that, in contrast to the traditional approach which requires the surgeon to saw open the sternum and spread the edges apart to gain direct access to the heart, a smaller incision in the upper part of the chest, dividing only the upper portion of the breastbone, will maintain the overall integrity of the rib cage and at the same time reduce the postoperative respiratory distress. Smaller incisions will bleed less and necessitate less tissue dissection, reducing the risk of wound infection. Moreover, by maintaining the integrity of the lower part of the sternum, particularly subjected to traction during coughing by the abdominal muscles that are involved, there is a reduced risk of sternal instability especially in elderly, obese, diabetic and chronic obstructive pulmonary disease (COPD) patients.

Supplementary material

Video 17.1

Ministernotomy implant of Sorin Perceval S Sutureless Bioprosthesis, by courtesy of Livanova, London. (1) From min. 0.00 to min. 2.00: ministernotomy and cannulation for CPB. (2) From min. 2.20 to min. 5.00: valve excision and decalcification. (3) From min. 5.00 to min. 5.40: valve sizing and guiding sutures placing. (4) From min. 5.40 to min. 6.40: Sorin Perceval S sutureless bioprosthesis collapsing procedure. (5) From min. 6.40 to min. 8.40: Sorin Perceval S sutureless bioprosthesis implant and intraoperative TEE control (MP4 364777 kb)


  1. 1.
    Merk DR, Lehmann S, Holzhey DM, Dohmen P, Candolfi P, Misfeld M, Mohr FW, Borger MA. Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison. Eur J Cardiothorac Surg. 2015;47(1):11–17.; discussion 17. Scholar
  2. 2.
    Khoshbin E, Prayaga S, Kinsella J, Sutherland FW. Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials. BMJ Open. 2011;1(2):e000266. Scholar
  3. 3.
    Cosgrove DM 3rd, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg. 1996;62(2):596–7.CrossRefGoogle Scholar
  4. 4.
    Karimov JH, Santarelli F, Murzi M, Glauber M. A technique of an upper V-type mini sternotomy in the second intercostal space. Interact Cardiovasc Thorac Surg. 2009;9(6):1021–2. Scholar
  5. 5.
    Aris A. Reversed “C” ministernotomy for aortice valve replacement. Ann Thorac Surg. 1999;67(6):1806–7.CrossRefGoogle Scholar
  6. 6.
    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(6):781–5.CrossRefGoogle Scholar
  7. 7.
    Concistrè G, Miceli A, Chiaramonti F, Farneti P, Bevilacqua S, Varone E, Solinas M, Glauber M. Sutureless aortic valve implantation through an upper V-type ministernotomy: an innovative approach in high-risk patients. Innovations (Phila). 2013;8(1):23–8. Scholar
  8. 8.
    Granov N, Kacila M, Mujicic E, Hadzimehmedagic A, Custovic F, Kulic M. V-type mini sternotomy in aortic valve replacement. Med Arch. 2012;66(3):213–4.CrossRefGoogle Scholar
  9. 9.
    Svensson LG. Minimal-access “J” or “j” sternotomy for valvular, aortic, and coronary operations or reoperations. Ann Thorac Surg. 1997;64(5):1501–3.CrossRefGoogle Scholar
  10. 10.
    Malaisrie SC, Barnhart GR, Farivar RS, Mehall J, Hummel B, Rodriguez E, Anderson M, Lewis C, Hargrove C, Ailawadi G, Goldman S, Khan J, Moront M, Grossi E, Roselli EE, Agnihotri A, Mack MJ, Smith JM, Thourani VH, Duhay FG, Kocis MT, Ryan WH. Current era minimally invasive aortic valve replacement: techniques and practice. J Thorac Cardiovasc Surg. 2014;147(1):6–14. Scholar
  11. 11.
    Plass A, Scheffel H, Alkadhi H, et al. Aortic valve replacement through a minimally invasive approach: preoperative planning, surgical technique and outome. Ann Thorac Surg. 2009;88:1851–6.CrossRefGoogle Scholar
  12. 12.
    Heuts S, Maessen JG, Sardari NP. Preoperative planning of left-sided valve surgery with 3D computed tomography reconstruction models: sternotomy or aminimally invasive approach? Interact Cardiovasc Thorac Surg. 2016;22(5):587–93. Scholar
  13. 13.
    Loor G, Roselli EE. Imaging and minimally invasive aortic valve replacement. Ann Cardiothorac Surg. 2015;4(1):62–6. Scholar
  14. 14.
    Stoliński J, Plicner D, Grudzień G, Kruszec P, Fijorek K, Musiał R, Andres J. Computed tomography helps to plan minimally invasive aortic valve replacement operations. Ann Thorac Surg. 2016;101(5):1745–52. Scholar
  15. 15.
    Roselli EE. Interventions on the aortic valve and proximal thoracic aorta through a minimally invasive approach. Ann Cardiothorac Surg. 2015;4(1):81–4. Scholar
  16. 16.
    Margaryan R, Kallushi E, Gilmanov D, Micelli A, Murzi M, Solinas M, Cerillo AG, Glauber M. Sutureless Aortic Valve Prosthesis Sizing: Estimation and Prediction Using Multidetector-Row Computed Tomography. Innovations (Phila). 2015;10(4):230–235.; discussion 235. Scholar
  17. 17.
    Ammar R, Porat E, Eisemberg DS, et al. Utility of spiral CT in minimally invasive approach for aortic valve replacement. Eur J Cardiothorac Surg. 1998;14(Suppl1):S130–3.CrossRefGoogle Scholar
  18. 18.
    Kraidin JL, Pantin EJ, Anderson MB, Zhou BL, Solina AR. Edwards EndoVent as a pacing catheter for minimally invasive aortic valve surgery: a novel approach. Innovations (Phila). 2011;6(4):253–6. Scholar
  19. 19.
    Lentini S, Specchia L, Nicolardi S, Mangia F, Rasovic O, Di Eusanio G, Gregorini R. Surgery of the ascending aorta with or without combined procedures through an upper ministernotomy: outcomes of a series of more than 100 patients. Ann Thorac Cardiovasc Surg. 2016;22(1):44–8. Scholar
  20. 20.
    Russo MJ, Gnezda J, Merlo A, Johnson EM, Hashmi M, Raman J. The arrowhead ministernotomy with rigid sternal plate fixation: a minimally invasive approach for surgery of the ascending aorta and aortic root. Minim Invasive Surg. 2014;2014:681371. Scholar
  21. 21.
    Tam RK, Garlick RB, Almeida AA. Minimally invasive redo aortic valve replacement. J Thorac Cardiovasc Surg. 1997;114(4):682–3.CrossRefGoogle Scholar
  22. 22.
    Mikus E, Calvi S, Tripodi A, Dozza L, Lamarra M, Del Giglio M. Minimally invasive reoperative aortic valve replacement. Ann Cardiothorac Surg. 2015;4(1):67–70. Scholar
  23. 23.
    Gosev I, Neely RC, Leacche M, McGurk S, Kaneko T, Zeljko D, Loberman D, Javed Q, Cohn LH, Aranki SF. The impact of a minimally invasive approach on reoperativeaortic valve replacement. J Heart Valve Dis. 2015;24(2):181–6.PubMedGoogle Scholar
  24. 24.
    Gaeta R, Lentini S, Raffa G, Pellegrini C, Zattera G, Viganò M. Aortic valve replacement by ministernotomy in redo patients with previous left internalmammary artery patent grafts. Ann Thorac Cardiovasc Surg. 2010 Jun;16(3):181–6.PubMedGoogle Scholar
  25. 25.
    Zeitani J, Pugliese M, Mvondo CM, Chiariello G, Bellos K, Simonetti G, Chiariello L. Surgical approach to aortic valve replacement after previous bilateral internal thoracic artery grafting. Tex Heart Inst J. 2013;40(2):170–2.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Kaneko T, Loberman D, Gosev I, Rassam F, McGurk S, Leacche M, Cohn L. Reoperative aortic valve replacement in the octogenarians-minimally invasive technique in the era of transcatheter valve replacement. J Thorac Cardiovasc Surg. 2014;147(1):155–62. Scholar
  27. 27.
    Fischlein T, Meuris B, Hakim-Meibodi K, Misfeld M, Carrel T, Zembala M, Gaggianesi S, Madonna F, Laborde F, Asch F, Haverich A, CAVALIER Trial Investigators. The sutureless aortic valve at 1 year: a large multicenter cohort study. J Thorac Cardiovasc Surg. 2016;151(6):1617–1626.e4. Scholar
  28. 28.
    Dalén M, Biancari F, Rubino AS, Santarpino G, Glaser N, De Praetere H, Kasama K, Juvonen T, Deste W, Pollari F, Meuris B, Fischlein T, Mignosa C, Gatti G, Pappalardo A, Svenarud P, Sartipy U. Aortic valve replacement through fullsternotomy with a stented bioprosthesis versus minimally invasive sternotomy witha sutureless bioprosthesis. Eur J Cardiothorac Surg. 2016;49(1):220–7. Scholar
  29. 29.
    Fischlein T, Pfeiffer S, Pollari F, Sirch J, Vogt F, Santarpino G. Sutureless valve implantation via mini J-sternotomy: a single center experience with 2 years mean follow-up. Thorac Cardiovasc Surg. 2015;63(6):467–71. Scholar
  30. 30.
    Santarpino G, Pfeiffer S, Jessl J, Dell'Aquila AM, Pollari F, Pauschinger M, Fischlein T. Sutureless replacement versus transcatheter valve implantation in aortic valve stenosis: a propensity-matched analysis of 2 strategies in high-riskpatients. J Thorac Cardiovasc Surg. 2014;147(2):561–7. Scholar
  31. 31.
    Zannis K, Folliguet T, Laborde F. New sutureless aortic valve prosthesis:another tool in less invasive aortic valve replacement. Curr Opin Cardiol. 2012;27(2):125–9. Scholar
  32. 32.
    Misfeld M. Minimally invasive aortic valve replacement using the Perceval S Sutureless valve. Ann Cardiothorac Surg. 2015;4(2):203–5. Scholar
  33. 33.
    Borger MA, Moustafine V, Conradi L, Knosalla C, Richter M, Merk DR, Doenst T, Hammerschmidt R, Treede H, Dohmen P, Strauch JT. A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement. Ann Thorac Surg. 2015;99(1):17–25. Scholar
  34. 34.
    Perrotta S, Lentini S, Rinaldi M, D'armini AM, Tancredi F, Raffa G, Gaeta R, Viganó M. Treatment of ascending aorta disease with Bentall-de bono operation using a mini-invasive approach. J Cardiovasc Med (Hagerstown). 2008;9(10):1016–22. Scholar
  35. 35.
    Benedik J, Mourad F, Eißmann M, Jakob H, Perrey. Minimally invasive David reimplantation of bicuspid aortic valve. Ann Cardiothorac Surg. 2015;4(2):206–7. Scholar
  36. 36.
    Totaro P, Carlini S, Pozzi M, Pagani F, Zattera G, D'Armini AM, Vigano M. Minimally invasive approach for complex cardiac surgery procedures. Ann ThoracSurg. 2009;88(2):462–466.; discussion 467. Scholar
  37. 37.
    Franke UF, Albert M, Rustenbach C, Baumbach H. Minimally invasive Ross procedure through partial upper sternotomy. Interact Cardiovasc Thorac Surg. 2009;9(3):545–6. Scholar
  38. 38.
    Moscoso Ludueña M, Rastan AJ. Complications and conversions in minimallyinvasive aortic valve surgery. Ann Cardiothorac Surg. 2015;4(1):94–8. Scholar
  39. 39.
    Tabata M, Umakanthan R, Khalpey Z, et al. Conversion to full sternotomy during minimal-access cardiac surgery: reasons and results during a 9.5 years experience. J Thorac Cardiovasc Surg. 2007;134:165–9.CrossRefGoogle Scholar
  40. 40.
    Johnston DR, Atik FA, Rajeswaran J, Blackstone EH, Nowicki ER, Sabik JF 3rd, Mihaljevic T, Gillinov AM, Lytle BW, Svensson LG. Outcomes of less invasive J-incision approach to aortic valve surgery. J Thorac Cardiovasc Surg. 2012;144(4):852–858.e3. Scholar
  41. 41.
    Murzi M, Glauber M. Central versus femoral cannulation during minimallyinvasive aortic valve replacement. Ann Cardiothorac Surg. 2015;4(1):59–61. Scholar
  42. 42.
    Brinkman WT, Hoffmann W, Dewey TM, Culica D, Prince SL, Herbert MA, Mack M, Ryan WH. Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups. Ann Thorac Surg. 2010;90(1):131–5. Scholar
  43. 43.
    Vohra HA, Vaja R, Iakovakis I, Bapat V, Szostek J, Young C. Starting out in minimally invasive aortic valve replacement in the UK. Interact Cardiovasc Thorac Surg. 2016;22(1):1–4. Scholar
  44. 44.
    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. Innovations (Phila). 2014;9(2):104–110.; discussion 110. Scholar
  45. 45.
    Phan K, Tsai YC, Niranjan N, Bouchard D, Carrel TP, Dapunt OE, Eichstaedt HC, Fischlein T, Gersak B, Glauber M, Haverich A, Misfeld M, Oberwalder PJ, Santarpino G, Shrestha ML, Solinas M, Vola M, Yan TD, Di Eusanio M. Suturelessaortic valve replacement: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2015;4(2):100–11. Scholar
  46. 46.
    Borger MA, Moustafine V, Conradi L, Knosalla C, Richter M, Merk DR, Doenst T, Hammerschmidt R, Treede H, Dohmen P, Strauch JT. A randomized multicenter trial valve replacement. Ann Thorac Surg. 2015;99(1):17–25. Scholar
  47. 47.
    Mihaljevic T, Gillinov MA, Cosgrove DM. Minimally invasive aortic valve replacement. Multimed Man Cardiothorac Surg 2006;2006(315).
  48. 48.
    Attia RQ, Hickey GL, Grant SW, Bridgewater B, Roxburgh JC, Kumar P, Ridley P, Bhabra M, Millner RW, Athanasiou T, Casula R, Chukwuemka A, Pillay T, Young CP. Minimally invasive versus conventional aortic valve replacement: a propensity-matched study from the UK national data. Innovations (Phila). 11(1):15–23. Scholar
  49. 49.
    Hiraoka A, Totsugawa T, Kuinose M, Nakajima K, Chikazawa G, Tamura K, Yoshitaka H, Sakaguchi T. Propensity score-matched analysis of minimally invasiveaortic valve replacement. Circ J. 2014;78(12):2876–81.CrossRefGoogle Scholar
  50. 50.
    Lim JY, Deo SV, Altarabsheh SE, Jung SH, Erwin PJ, Markowitz AH, Park SJ. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg. 2015;30(2):125–34. Scholar
  51. 51.
    Furukawa N, Kuss O, Aboud A, Schönbrodt M, Renner A, Hakim Meibodi K, Becker T, Zittermann A, Gummert JF, Börgermann J. Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808patients. Eur J Cardiothorac Surg. 2014;46(2):221–226.; discussion 226-7. Scholar
  52. 52.
    Burdett CL, Lage IB, Goodwin AT, White RW, Khan KJ, Owens WA, Kendall SW, Ferguson JI, Dunning J, Akowuah EF. Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery. Interact Cardiovasc Thorac Surg. 2014;19(4):605–10. Scholar
  53. 53.
    Lehmann S, Merk DR, Etz CD, Seeburger J, Schroeter T, Oberbach A, Uhlemann M, Hoellriegel R, Haensig M, Leontyev S, Garbade J, Misfeld M, Mohr FW. Minimallyinvasive aortic valve replacement: the Leipzig experience. Ann Cardiothorac Surg. 2015;4(1):49–56. Scholar
  54. 54.
    Van der Merwe J, Casselman F, Stockman B, Van Praet F, Beelen R, Maene L, Vermeulen Y, Degrieck I. Minimally invasive primary aortic valve surgery: the OLVAalst experience. Ann Cardiothorac Surg. 2015;4(2):154–9. Scholar
  55. 55.
    Foghsgaard S, Gazi D, Bach K, Hansen H, Schmidt TA, Kjaergard HK. Minimally invasive aortic valve replacement reduces atelectasis in cardiac intensive care. Acute Card Care. 2009;11(3):169–72. Scholar
  56. 56.
    Ariyaratnam P, Loubani M, Griffin SC. Minimally invasive aortic valver replacement: comparison of long-term outcomes. Asian Cardiovasc Thorac Ann. 2015;23(7):814–21. Scholar
  57. 57.
    Brown ML, McKellar SH, Sundt TM, et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009;137:670–9.e5.CrossRefGoogle Scholar
  58. 58.
    Johnston DR, Roselli EE. Minimally invasive aortic valve surgery: Cleveland clinic experience. Ann Cardiothorac Surg. 2015;4(2):140–7. Scholar
  59. 59.
    Murtuza B, Pepper JR, Stanbridge RD, et al. Minimal access aortic valve replacement: is it worth it? Ann Thorac Surg. 2008;85:1121–31.CrossRefGoogle Scholar
  60. 60.
    Neely RC, Boskovski MT, Gosev I, Kaneko T, McGurk S, Leacche M, Cohn LH. Minimally invasive aortic valve replacement versus aortic valve replacement through full sternotomy: the Brigham and Women's Hospital experience. Ann Cardiothorac Surg. 2015;4(1):38–48. Scholar
  61. 61.
    ElBardissi AW, Shekar P, Couper GS, Cohn LH. Minimally invasive aortic valve replacement in octogenarian, high-risk, transcatheter aortic valve implantation candidates. J Thorac Cardiovasc Surg. 2011;141(2):328–35. Scholar
  62. 62.
    Santana O, Reyna J, Grana R, Buendia M, Lamas GA, Lamelas J. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011;91(2):406–10. Scholar
  63. 63.
    Shrestha M, Krueger H, Umminger J, Koigeldiyev N, Beckmann E, Haverich A, Martens A. Minimally invasive valve sparing aortic root replacement (Davidprocedure) is safe. Ann Cardiothorac Surg. 2015;4(2):148–53. Scholar
  64. 64.
    Vola M, Campisi S, Gerbay A, Fuzellier JF, Ayari I, Favre JP, Faure M, Morel J, Anselmi A. Sutureless prostheses and less invasive aortic valve replacement: just an issue of clamping time? Ann Thorac Surg. 2015;99(5):1518–23. Scholar
  65. 65.
    Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improuves patient satisfaction while reducing costs of cardiac valve replacement. Ann Surg. 1997;226(4):421–6. discussion 427–428.CrossRefGoogle Scholar
  66. 66.
    Ghanta RK, Lapar DJ, Kern JA, Kron IL, Speir AM, Fonner E Jr, Quader M, Ailawadi G, et al. Minimally invasive aortic valve replacement provides equivalent outcomes and reduced cost compared with conventional aortic valve replacement: A real world multi-istitutional analysis. J Thorac Cardiovasc Surg. 2015;149(4):1060–5. Scholar
  67. 67.
    Hassan M, Miao Y, Maraey A, Lincoln J, Brown S, Windsor J, Ricci M. Minimally invasive aortic valve replacement: cost-benefit analysis of ministernotomy versus minithoracotomy approach. J Heart Valve Dis. 2015;24(5):531–9.PubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Salus Hospital GVM Care and ResearchReggio EmiliaItaly

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