International Society For Minimally Invasive Cardiothoracic Surgery

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Right Anterior Minithoracotomy For Surgical AVR As A Standard Of Care In Intermediate Surgical Risk Patients
Gabriele Tamagnini1, Marco Paris1, Carla Beggino1, Marianna Nardozza1, Liborio Mammana2, Matteo Saccocci1, Elisa Mikus3, Josč Luis Zulueta1, Mauro Del Giglio1.
1Istituto Clinico San Rocco, Ome, Italy, 2Istituto Clinico Sant'Ambrogio, Milano, Italy, 3Maria Cecilia Hospital, Cotignola, Italy.

Background: Right Anterior Minithoracotomy for sAVR is effective and with excellent outcomes. We believe this approach might be safe and effective even in those patients with Intermediate Surgical Risk patients (4%<STS Risk Score<8%) and severe calcified aortic stenosis, ideally suitable for TAVI procedures in the PARTNER 2 Trial setting. Methods: Retrospectively, from January 2010 to June 2018, we collected 102 consecutive adult patients with intermediate surgical risk, undergoing isolated surgical aortic valve replacement (SAVR) for tricuspid severe aortic stenosis. Minimally invasive aortic valve replacement was performed by a single surgeon, through a 4 to 6 cm long RAT at the third intercostal space without rib avulsion or ligation of the RIMA. As our standard setting, we perform a complete central cannulation with normotermic systemic perfusion and blood-based cardioplegia. Results: All procedure went successfully. Complete central cannulation (arterial = distal ascending aorta, vein = atrial appendage) and RAT approach have been used in all cases. Baseline characteristics: male 36,36%; mean age of 83,4 ± 3,8 yrs; mean STS Risk Score of Mortality 4,81% ± 0,71% [range 4,02%-6,83%] and of Morbidity/Mortality 24,57% ± 4,65%. Results: median implanted prosthesis diameter was 23 mm; mean CPB duration was 49,3 ± 14.9 minutes; aortic cross-clamping time was 36,8 ± 14,7 minutes; median ventilation time was 6 hrs; median ICU stay 2,5 days. Observed mean bleeding rate in the first 12 hours was 476 ± 230 ml, 37,5 % patients needed blood transfusion (median number of bags: 2). PM implantation rate was 2,17%. The total in-hospital stay median duration was 7 days. Observed 30-day mortality rate was 1,96%, observed Morbidity/Mortality rate was 9,3%. No paravalvular aortic regurgitation more than mild at discharge was observed. Conclusion Results show that our approach is safe and effective for surgical aortic valve replacement in intermediate-risk patients. RAT approach is a valid option in this subset of patients to avoid the most common complications after TAVR procedure. Complete central cannulation is safe, avoiding the risk of peripheral CPB implantation with no impact on perioperative mortality.

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