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Early Results of Minimally Invasive Aortic and Mitral Valve Surgery through a Minithoracotomy.
Antonio Lio, Antonio Miceli, Matteo Ferrarini, Mattia Glauber.
Cardiac Surgery and Great Vessel Department, Istituto Clinico Sant'Ambrogio, Milan, Italy.

Early Results of Minimally Invasive Aortic and Mitral Valve Surgery through a Minithoracotomy.
Objective. Benefits of minimally invasive cardiac surgery have been recognized when compared with a median sternotomy approach. However, few experience exist in minimally invasive mitral and aortic valve surgery (MIMAVS). We describe our experience with 69 patients who underwent aortic and mitral valve surgery through a right minithoracotomy.
Methods. A retrospective study was undertaken on 69 patients scheduled for MIMAVS through a right minithoracotomy from October 2012 to December 2014. A 5 cm incision was performed in the 3rd intercostal space. Cardiopulmonary bypass (CPB) was estabilished with central cannulation of the ascending aorta and a double-stage venous return cannula placed percutaneously into the right femoral vein.
Results. The most frequent type of MIMAVS was the replacement of aortic valve with mitral valve repair (35 patients, 50%). A sutureless aortic prosthesis was implanted in 48 patients (70%). Concomitant procedures were performed in 22 patients (32%): 12 tricuspid valve annuloplasty, 8 atrial fibrillation ablation and 2 septal myectomy. Mean CPB and cross-clamp times were 135 ± 41 and 95 ± 32 minutes, respectively. Introduction of sutureless aortic prostheses has increased the number of patients treated with a minimally invasive approach, with a significant reduction of CPB (120 ± 23 min vs 160 ± 67 min in stented prosthesis, P<0.05) and cross-clamp times (85 ± 19 min vs 110 ± 40 min in stented prosthesis, P<0.05).
Postoperatively, no patient died in-hospital. A stroke occurred in two patients. 3 patients required permanent pacemaker (PMK) for heart block. Conversion to full sternotomy was required in 1 patient. Median ICU and in-hospital stay were 1 and 6 days. No paravalvular leakage or prosthesis displacement was reported.
Conclusion. MIMAVS is a feasible approach that could be implemented with the use of sutureless devices. Need for concomitant mitral valve surgery is not contraindication for
sutureless valve implantation.
Table 1. Results
Mean age (years ± SD)66 ± 12
Female, N (%)47 (68.2)
Ejection fraction % (mean ± SD)57.1 ± 8.8
NYHA III-IV class N (%)18 (27.3)
Pulmonary Hypertension, N (%)25 (36.4)
Log. Euroscore % (median ± IQR)8 (4-15)
AVR and MVR, N (%)27 (40)
AVR and MV repair, N (%)35 (50)
MV and Aortic valve repair, N (%)7 (10)
AVR with sutureless valve, N (%)48 (70)
Combined procedures
TV annuloplasty , N (%)12 (17.4)
AF surgery, N (%)8 (11.6)
Myectomy , N (%)2 (2.9)
Convertion to sternotomy , N (%)1 (1.5)
CEC min135 ± 41 min
X-clamp min95 ± 32 min
Stroke, N (%)2 (2.9)
Transient AF, N (%)16 (24)
Blood transfusion, N (%)10 (15)
Permanent PMK implantation, N (%)3 (4.3)
Ventilation (median, IQR)6 (5-15)
ICU stay (median, IQR)1 (1-1)
Ward stay (median, IQR)6 (5-8)


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