Aortic valve replacement with annular enlargement via a right anterior minithoracotomy

A minimally invasive approach to aortic valve replacement offers many advantages compared to the conventional median sternotomy. However, minimally invasive approaches are technically challenging. In this video tutorial, we describe an aortic valve replacement performed via a right anterior minithoracotomy, facilitated by the use of videoscopic and automated suturing technologies.  Briefly, a right anterior minithoracotomy incision is made in the 2nd intercostal space and the 3rd rib is disarticulated. A retractor is placed, pericardiotomy performed, and stay sutures placed. Central aortic and peripheral venous cannulation is performed under transesophageal echocardiographic guidance. Cardiopulmonary bypass is initiated, and a left ventricular sump is placed. An antegrade cardioplegia line is placed, an aortic cross-clamp, inserted via a separate 5-mm incision, is applied, cardioplegia administered, and a videoscope is placed to aid visualization.  An aortotomy is made, commissural sutures are placed, and the native valve is excised. In this case, an annular enlargement is performed to accommodate a #21 Trifecta bioprosthetic valve. Annular sutures are placed manually and via automated suturing. The valve is secured using titanium fasteners.  The aortotomy is then closed with simultaneous de-airing maneuvers. Cardiopulmonary bypass is discontinued, cannulas removed, drains placed, and the 3rd rib reapproximated. The wound is then closed.