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Trans-right axillary Aortic Valve Replacement
Masayoshi Tokoro, Toshiaki Ito, Atsuo Maekawa, Sadanari Sawaki, Yasunari Hayashi, Junji Yanagisawa, Takahiro Ozeki, Maiko Tsuji, Mamoru Orii.
Japanese Red Cross Nagoya Daiich Hospital, Nagoya City, Aich Pref., Japan.

OBJECTIVE: Minimally invasive aortic valve replacement (AVR) is usually performed through partial sternotomy, or thoracotomy in the anterior chest wall. We adopted right lateral thoracotomy thorough right axillary skin incision as an alternative access for minimally invasive AVR (TAX-AVR).
The purpose of this study is to evaluate safety and less invasiveness of TAX-AVR compared with conventional AVR (C-AVR).
METHODS: Surgery: The patient was set in partial left lateral position, and cardio-pulmonary bypass was established through right femoral artery and vein. A small thoracotomy was made through right axillary skin incision. The ascending aorta was cross clamped and AVR was performed. Endoscopic assist was used, and all sutures were tied using a knot pusher.
Comparison with C-AVR: Between January 2007 and October 2015, 324 patients underwent isolated AVR at our institution. Of them, 88 patients underwent TAX-AVR, 197 C-AVR, and 39 para-sternum AVR. From C-AVR, emergency cases and patients with severely calcified ascending aorta were excluded, and 166 cases were enrolled as control group. Propensity matching between TAX-AVR and C-AVR patients generated 85 matched pairs. Early outcomes were compared in these 170 patients. Primary endpoints were major adverse cardiac events (MACE). Secondary endpoint was post-operative length of stay.
RESULTS: No patient was converted to sternotomy from TAX-AVR. In hospital death (0,1), MACE (4,6),in TAX-AVR and C-AVR group, respectively (NS). ICU stay and Postoperative hospitalization were significantly shorter in TAX-AVR group (TAX- vs C-AVR: 1.3 ± 1.0 days vs 2.4 ± 3.6 days, p<0.001 and 9.7 ± 6.2 days vs 17.6 ± 23.8 days, p<0.001, respectively). There was no significant difference in implanted aortic valve size (TAX- vs C-AVR: 21.9 ± 1.6 mm vs 22.3 ± 2.1 mm), Cardiopulmonary Bypass (CPB) time and cross-clamp time were significantly longer in TAX-AVR group (TAX- vs C-AVR: 138 ± 33 min vs 130 ± 40 min, p=0.036 and 102 ± 25 min vs 94 ± 30 min, p=0.013, respectively).
CONCLUSIONS: TAX-AVR was as safe as C-AVR. TAX-AVR was reproducible, cosmetically superior, and less invasive approach for AVR.

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