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Updated: May 21, 2026
Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Mini-sternotomy aortic valve replacement: is it safe and effective? Comparison with standard techniques
Balakrishnan Mahesh1, Manoraj Navaratnarajah, Kwabena Mensah
1Center for Cardiothoracic Surgery and Transplantation, Harefield Hospital, Harefield, UK. drbmahesh@yahoo.co.uk
Background And Aim Of The Study:
Mini-sternotomy aortic valve replacement (MSAVR) has been increasingly performed at the authors' institution since October 2003. The study aim was to compare results obtained with MSAVR to those following AVR with conventional sternotomy (SAVR).
Methods:
Between 1998 and 2008, a total of 143 consecutive patients (mean age: 67 +/- 12.5 years) underwent AVR at the authors' institution. Of these patients, 82 underwent SAVR, and 61 underwent MSAVR performed through a reversed-L-shaped median sternotomy with a transverse limb at the right fourth intercostal space. Ascending aortic and right atrial cannulation through the mini-sternotomy were employed for cardiopulmonary bypass (CPB).
Results:
Typically, the MSAVR patients were slightly younger than SAVR patients (mean age: 67 +/- 16 years and 70 +/- 15 years, respectively; p = 0.037), had a lower incidence of diabetes (3% versus 18%, p = 0.008), and a slightly higher left ventricular ejection fraction (74.5 +/- 12% versus 71 +/- 12%, p = 0.019). There were no other inter-group preoperative differences. As expected, MSAVR required a slightly longer aortic cross-clamp time (49 +/- 19 min) compared to SAVR (44.5 +/- 16 min; p = 0.019), and longer CPB times (77 +/- 31 min versus 60 +/- 26 min; p <0.0001), though the overall operating times were similar (p = 0.38). Postoperatively, MSAVR patients were extubated at 3 +/- 5 h, similar to SAVR patients (4 +/- 5 h) (p = 0.13). The median intensive therapy unit stay was 1 +/- 1 days in both groups. The median hospital stay was comparable between groups (MSAVR, 7 +/- 5 days; SAVR, 8 +/- 4 days; p = 0.48). The MSAVR patients had a higher incidence of delayed pericardial effusions requiring pericardiocentesis (n = 4; p = 0.031), but this did not affect survival. The 30-day mortality was similar in both groups (MSAVR group, n = 1 (1.6%); SAVR group, n = 3 (3.7%); p = 0.64). At five years after surgery, freedom from cardiac-related death was 96 +/- 2.6% in MSAVR patients, and 89 +/- 4.9% in SAVR patients (p = 0.32).
Conclusion:
Mini-sternotomy AVR is technically challenging with longer CPB and aortic cross-clamp times. However, with increasing surgical experience, it offers results comparable to those achieved with conventional AVR, and with acceptable cosmetic results.
Insights
Mini-sternotomy aortic valve replacement (MSAVR) offers comparable outcomes to conventional sternotomy aortic valve replacement (SAVR). While MSAVR involves longer cardiopulmonary bypass and cross-clamp times, it provides similar recovery and long-term survival rates with better cosmetic results.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
Background:
- Mini-sternotomy aortic valve replacement (MSAVR) adoption has increased since 2003.
- Conventional sternotomy aortic valve replacement (SAVR) is the traditional approach.
Purpose of the Study:
- To compare the clinical outcomes of MSAVR versus SAVR.
- To evaluate the safety and efficacy of MSAVR.
Main Methods:
- A retrospective analysis of 143 patients undergoing aortic valve replacement (AVR) between 1998 and 2008.
- Comparison of 61 MSAVR patients with 82 SAVR patients.
- Utilized reversed-L-shaped median sternotomy for MSAVR with standard cardiopulmonary bypass (CPB) techniques.
Main Results:
- MSAVR patients were younger with higher ejection fraction and lower diabetes incidence.
- MSAVR had longer aortic cross-clamp (49 vs. 44.5 min) and CPB times (77 vs. 60 min).
- Postoperative recovery, hospital stay, 30-day mortality, and 5-year cardiac-related death rates were similar between groups.
Conclusions:
- MSAVR is technically demanding, requiring longer CPB and cross-clamp times.
- With experience, MSAVR yields results comparable to SAVR.
- MSAVR offers acceptable cosmetic results alongside comparable clinical outcomes.
