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Updated: Nov 4, 2025
Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Cerebral microemboli in mini-sternotomy compared to mini- thoracotomy for aortic valve replacement: a cross sectional
Marija Bozhinovska1, Matej Jenko1, Gordana Taleska Stupica1
1Clinical Department of Anaesthesiology and Perioperative Intensive Therapy, University Medical Centre Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia.
Background:
Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.
Methods:
Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke's Cognitive Examination Revised Test before and 30 days after surgical procedure.
Results:
A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677-10.60, p = 0.027). Addenbrooke's Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001).
Conclusion:
There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline. TRIAL REGISTRY NUMBER: clinicaltrials.gov , NCT02697786 14.
Insights
Mini-thoracotomy and mini-sternotomy approaches for aortic valve replacement showed no difference in cerebral microembolic load. Postoperative cognitive decline was associated with patient age, not microembolic signals.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Minimally Invasive Procedures
Background:
- Minimally invasive aortic valve replacement (AVR) via mini-thoracotomy offers benefits over mini-sternotomy.
- Concerns exist regarding potential increased cerebral embolization and neurologic decline with mini-thoracotomy due to limited surgical exposure.
Purpose of the Study:
- To compare neurological complications between mini-thoracotomy and mini-sternotomy AVR.
- To assess intraoperative cerebral microembolic signals and postoperative cognitive function.
Main Methods:
- Trans-cranial Doppler monitored microembolic signals during AVR in 52 patients (25 mini-sternotomy, 27 mini-thoracotomy).
- Cognitive function was evaluated using the Addenbrooke's Cognitive Examination Revised Test preoperatively and 30 days postoperatively.
Main Results:
- No significant differences in microembolic load or cognitive decline between the two surgical groups.
- Total microembolic signals correlated with cardiopulmonary bypass duration.
- Postoperative cognitive decline was associated with patient age, not microembolic load.
Conclusions:
- Both mini-thoracotomy and mini-sternotomy AVR demonstrate comparable intraoperative microembolic loads.
- Age is a significant factor in postoperative cognitive decline following AVR, independent of microembolic signal burden.
