International Society For Minimally Invasive Cardiothoracic Surgery

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Single-port Aortic Valve Replacement Through Right Anterior Thoracotomy
Ahmed Mashhour, Konstantin Zhigalov, Sabreen Mkalaluh, Marcin Szczechowicz, Jerry Easo, Jürgen Ennker, Alexander Weymann.
Klinikum Oldenburg, Oldenburg, Germany.

Objective With the progress of transcatheter aortic valve replacement, the interest is growing toward less invasive approaches. We describe a single-port approach through a right intercostal access. Methods A 7-8 cm skin incision is made over the second right intercostal space. The right mammary vessels are divided. The third right rib is divided in a V-manner close to the sternum and a soft tissue retractor as well as a low-profile rib retractor are placed. The ventilation is reduced. The pericardium is opened and the stay sutures are put, so that the ascending aorta, the right atrial auricle and the right pulmonary veins can be accessed. This allows complete cannulation for the cardiopulmonary bypass (CPB), aortic cross-clamping and visualization for performing the valve replacement through a single incision, which is accomplished through careful preparation of the surgical site. The native valve is excised and replaced in a standard manner. Using a sutureless valve prothesis helps reduce CPB times and minimize the intricacy of valve implantation. Results We were always able to access all required structures. The valve prosthesis could always be implanted safely with primary success. No increased incidence of complications (bleeding, re-exploration, neurological deficits, postoperative arrhythmias, etc.) was noticed. Operative time and CPB times were also comparable to the open approach in our institution. We were also able to use a similar approach at the mid-sternal level for mitral valve surgery. Conclusions The single right intercostal incision is suitable for performing a complete aortic valve replacement, including cannulation. This omits unnecessary incisions for a camera and cannulation, as well as groin complications and the need for extra instrumentarium. Being also suitable for mitral valve procedures, the right anterior thoracotomy proves to a one-size-fits-all access.

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