BACKGROUND: Annular enlargement (AE) at the time of aortic valve replacement (AVR) is an option to prevent patient-prosthesis mismatch in patients with a small annulus. While traditionally performed via median sternotomy, we previously published a series of 12 patients who underwent AE through a minimally invasive approach1. Here we provide an update on these promising results through analysis of 30 subsequent cases with this approach. METHODS: We conducted a retrospective review of 42 patients who underwent minimally invasive AVR with AE between 2016-2023. All cases were performed by a single surgeon via right anterior thoracotomy. Outcomes, echocardiographic data, and mortality were assessed. RESULTS: Average age was 66 + 10 years. Thirty-seven (88.1%) patients were female and average BMI was 34.5 + 7.72 kg/m2. Indications for valve replacement were reoperation due to prosthetic valve dysfunction in 7.1%, congenitally bicuspid valve in 16.7%, and aortic stenosis due to degenerative disease in 73.8%. Mean cardiopulmonary bypass and cross-clamp times were 165.07 + 54.54 and 123.80 + 38.13 minutes, respectively. Pre- and post-replacement mean gradients were 41.6 + 14.2 mmHg and 10.6 + 4.8 mmHg on average, respectively. Average indexed effective orifice area based on valve manufacturer measurements was 0.974 cm2/m2, ranging from 0.77 to 1.29 cm2/m2. No patients had postoperative perivalvular leak. There was one conversion from thoracotomy to hemi-sternotomy and no conversions to full sternotomy. Blood products were administered to 19% of patients postoperatively. Mean ventilation time was 12.4 + 16.2 hours and average length of stay was 5.7 + 3 days. There was one in-hospital mortality, but no additional mortalities within 30 days. Among the 41 patients who survived to hospital discharge, 39 (95%) were discharged home, one (2.4%) was discharged to a nursing home, and one (2.4%) was discharged to a rehabilitation facility. CONCLUSIONS: While there is a growing body of evidence to support sternal-sparing techniques for AVR, specific anatomic characteristics such as a small aortic annulus can make a minimally invasive approach more challenging. Our results demonstrate that annular enlargement via right anterior thoracotomy remains feasible and effective with excellent outcomes, provided that the surgeon is experienced in minimally invasive cardiac surgery.LEGEND: Minimally Invasive Aortic Annular Enlargement Steps: A: Right anterior mini thoracotomy incision with soft tissue retractor B: Annular enlargement procedure C: Hemashield patch placement D: Valve sizer with Hemashield patch in place E: Prosthetic valve with enlarged annulus.
