Valvular heart disease epidemiology has been dramatically chanced over the past decades in developed nations, mainly due to the decreased prevalence of rheumatic heart disease.
Due to this growing number of cases and the necessity to reduce the surgical trauma, numerous alternative incisions to the median sternotomy were evaluated. Minimally invasive aortic valve surgery is now most commonly performed via a limited skin incision, with a partial upper sternotomy that extends into the third or fourth intercostal space (also known as a ‘J’-sternotomy or reversed-L-shaped sternotomy). Right anterior thoracotomy (RAMT) for aortic valve replacement (AVR) represents a further step towards reduced invasiveness and functional operations. In our Center, RAMT was adopted after a 10-year-long program of minimally invasive mitral valve surgery, from which we redeployed technical skill and technological instrumentation.
In our view, RAMT can be adopted after careful patients’ selection, integrating clinical and imaging data that we discuss in this chapter; operative details are also described since those are the critical keypoints of the procedure itself. Furthermore, the advent of rapid deployment and sutureless valves favoured the spread of this approach; in our CUSUM analysis a clear absence of the learning curve was found when surgeons are proctored, due to a “transmitted learning” effect.
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