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OBJECTIVE: Minimally invasive aortic valve replacement via right anterior thoracotomy (RAT-AVR) is an established technique. It is technically demanding due to restrictive operative field. Suturing technique commonly used for RAT-AVR is multiple interrupted sutures. The aim of this study was to establish the feasibility and safety of alternative suturing technique using semi-continuous 2/0 polypropylene that can possibly simplify the procedure and reduce crossclamp time.
METHODS: From December 2013 to December 2014, the first 41 consecutive patients who underwent RAT-AVR were analysed. Cannulation techniques used are summarised in Table 1. Aortic valve was excised and annulus debrided of calcium in usual manner. Suturing technique used was either non everting intermittent mattress technique with pledgeted 2-0 Polyester or everting semi-continuous suture technique with 2/0 polypropylene. Intraoperative transesophageal echocardiogram (TEE) and pre-discharge transthoracic echocardiogram (TTE) were used to assess paravalvular leak. Data were prospectively recorded. Continuous variable were expressed as mean±standard deviation, categorical outcome in number and percentage.
RESULTS: Semi-continuous technique was used in 33 patients. Of these, 3 patients were operated for aortic regurgitation (1 degenerative and 2 acute endocarditis) and 30 patients for calcififed aortic stenosis (7 with bicuspid morphology). Depending on the valve size, number of polypropelene sutures varied from 3 to 5. Sutures were either hand tied (27) or tied using a auto-knotting clip (6). The auto-knotting clips were used when the aortic valvular plane was deep within the chest. Paravalvular leak was observed in only one patient (TEE and TTE). There were no conversions to full sternotomy. Permanent pace-maker was required in one patient. Patient’s demographics and operative parameters are summarised in table 1.
CONCLUSIONS: RAT-AVR with continues suture is a safe and simple alternative to intermittent mattress suture technique and may help shorten the procedure time. It also simplifies the suture placement in the right coronary annulus due to the everting technique used, which can be challenging with the interrupted technique. Moreover it does not preclude the use of auto-knotting devices.

Table1

Age	68 ± 9 years
Male	22 (67%)
Logistic Euroscore	5.7 ± 3.4 %
BMI	27.6 ± 3.9
Biological Valve	31 (94%)
SVC cannula	9 (27%)
Retrograde Cardioplegia	21 (64%)
Pulmonary artery vent	23 (69%)
CrossClamp Time	80 ± 13 min
Cardiopulmonary Bypass time	105 ± 14 min