Clinical Outcomes Of Right Anterior Mini-thoracotomy Aortic Valve Replacement Using Central Arterial Cannulation
Carl A. Johnson, Jr., Amber L. Melvin, Hossein Amirjamshidi, Davida A. Robinson, Peter A. Knight.
University of Rochester Medical Center, Rochester, NY, USA.
Objective: Surgical aortic valve replacement (AVR) is increasingly done through minimally invasive access: typically a hemi-sternotomy or right anterior mini-thoracotomy. The right mini-thoracotomy approach has been associated with reduced blood loss and shorter intensive care unit (ICU) stay when compared to sternotomy. Despite these potential advantages, the mini-thoracotomy approach for AVR has not been widely adopted. This may be due to concerns regarding difficulty with exposure and complications associated with femoral arterial cannulation. The use of a thoracoscope enhances visualization. Automated suturing technology is available to aid in placing difficult annular sutures. The objective of this study is to demonstrate the feasibility of a right anterior mini-thoracotomy AVR using a central arterial cannulation strategy. Methods: This is a single-center, retrospective review of 135 patients who underwent an isolated AVR performed using a right anterior mini-thoracotomy from 2015-2017. Indications for surgery were aortic stenosis and/or aortic insufficiency. Exclusion criteria were reoperation or concomitant procedures. Primary outcome was mortality. Secondary outcomes included aortic cross-clamp and cardiopulmonary bypass times, ventilator hours, and ICU and hospitalization duration. A 5 cm incision was made in the right 2nd interspace (Figure 1). A camera port was inserted lateral to this incision to aid in visualization. Central arterial and percutaneous venous cannulation was employed for cardiopulmonary bypass. Annular sutures were placed using shafted instruments or with automated suturing technology. Results: Median patient age was 71. There were no intraoperative mortalities. In-hospital mortality and 30-day mortality were 0.74% and 2.22% respectively. Aortic cross-clamp and cardiopulmonary bypass times were 88 and 114 minutes respectively. Conversion to sternotomy was 3.6% (n=5). Bleeding requiring re-operation was 5.2% (n=7). There were no surgical site infections. Median time to extubation was 5 hours. Median ICU stay was 25 hours, and median postoperative hospital length of stay was 5 days. Conclusions: Right mini-thoracotomy AVR using central arterial cannulation can be performed safely with minimal morbidity and mortality. Video assistance and automated suturing technology may facilitate this procedure. 
Figure 1: Video Assisted Right Anterior Mini-Thoracotomy Approach for Aortic Valve Replacement
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