J Yeungnam Med Sci.  2024 Jul;41(3):213-219. 10.12701/jyms.2024.00290.

Aortic valve replacement through right anterior mini-thoracotomy in patients with chronic severe aortic regurgitation: a retrospective single-center study

• Jung EY
• Im JE
• Min HK
• Lee SS

• KMID: 2558146
• DOI: http://doi.org/10.12701/jyms.2024.00290

Abstract

Background
Aortic valve replacement (AVR) has recently been performed at many centers using a minimally invasive approach to reduce postoperative mortality, morbidity, and pain. Most previous reports on minimally invasive AVR (MiAVR) have mainly focused on aortic stenosis, and those exclusively dealing with aortic regurgitation (AR) are few. The purpose of this study was to investigate early surgical results and review our experience with patients with chronic severe AR who underwent AVR via right anterior mini-thoracotomy (RAT).
Methods
Data were retrospectively collected in this single-center study. Eight patients who underwent RAT AVR between January 2020 and January 2024 were enrolled. Short-term outcomes, including the length of hospital stay, in-hospital mortality, postoperative complications, and echocardiographic data, were analyzed.
Results
No in-hospital mortalities were observed. Postoperative atrial fibrillation occurred temporarily in three patients (37.5%). However, none required permanent pacemaker implantation or renal replacement therapy. The median values of ventilator time, length of intensive care unit stay, and hospital stay were 17 hours, 34.5 hours, and 9 days, respectively. Preoperative and postoperative measurements of left ventricular ejection fraction were similar. However, the left ventricular end systolic and diastolic diameters significantly decreased postoperatively from 42 mm to 35.5 mm (p=0.018) and 63 mm to 51 mm (p=0.012), respectively.
Conclusion
MiAVR via RAT is a safe and reproducible procedure with acceptable morbidity and complication rates in patients with chronic severe AR. Despite some limitations such as a narrow surgical field and demanding learning curve, MiAVR is a competent method for AR.

Keyword

Aortic regurgitation; Aortic valve replacement; Minimally invasive surgical procedures

Reference

References

1. Markham R, Ghodsian M, Sharma R. TAVR in patients with pure aortic regurgitation: ready to use? Curr Cardiol Rep. 2020; 22:98.

2. Wang Y, Shi J, Li F, Wang Y, Dong N. Aortic valve replacement for severe aortic regurgitation in asymptomatic patients with normal ejection fraction and severe left ventricular dilatation. Interact Cardiovasc Thorac Surg. 2016; 22:425–30.

3. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2021; 143:e72–227.

4. Murtuza B, Pepper JR, Stanbridge RD, Jones C, Rao C, Darzi A, et al. Minimal access aortic valve replacement: is it worth it? Ann Thorac Surg. 2008; 85:1121–31.

5. Bonow RO, Lakatos E, Maron BJ, Epstein SE. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation. 1991; 84:1625–35.

6. Jawarkar M, Manek P, Wadhawa V, Doshi C. Mini-bentall surgery: the right thoracotomy approach. J Chest Surg. 2021; 54:554–7.

7. Wong CH, Chan JS, Sanli D, Rahimli R, Harky A. Aortic valve repair or replacement in patients with aortic regurgitation: a systematic review and meta-analysis. J Card Surg. 2019; 34:377–84.

8. Duran CM. Aortic valve repair and reconstruction. Oper Tech Card Thorac Surg. 1996; 1:1515–29.

9. Boodhwani M, de Kerchove L, Glineur D, Poncelet A, Rubay J, Astarci P, et al. Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg. 2009; 137:286–94.

10. Im JE, Jung EY, Lee SS, Min HK. Right anterior mini-thoracotomy aortic valve replacement versus transcatheter aortic valve implantation in octogenarians: a single-center retrospective study. J Yeungnam Med Sci. 2024; 41:96–102.

11. Zubarevich A, Rad AA, Amanov L, Szczechowicz M, Osswald A, Torabi S, et al. Sutureless aortic valve replacement in pure aortic regurgitation: expanding the indications. J Cardiothorac Surg. 2022; 17:198.

12. Glauber M, Miceli A, Gilmanov D, Ferrarini M, Bevilacqua S, Farneti PA, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg. 2013; 145:1222–6.

13. Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ribakove GH, Baumann FG, et al. Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement. J Heart Valve Dis. 2004; 13:887–93.

14. Aris A, Cámara ML, Montiel J, Delgado LJ, Galán J, Litvan H. Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study. Ann Thorac Surg. 1999; 67:1583–7.

15. Dogan S, Dzemali O, Wimmer-Greinecker G, Derra P, Doss M, Khan MF, et al. Minimally invasive versus conventional aortic valve replacement: a prospective randomized trial. J Heart Valve Dis. 2003; 12:76–80.

16. Yousuf Salmasi M, Hamilton H, Rahman I, Chien L, Rival P, Benedetto U, et al. Mini-sternotomy vs right anterior thoracotomy for aortic valve replacement. J Card Surg. 2020; 35:1570–82.

17. Kawazoe K, Izumoto H, Satoh Y, Eishi K, Ishibashi K. Annuloaortic repair in the treatment of aortic regurgitation and aortic root pathology. Surg Today. 2001; 31:27–31.

18. Ito J, Nakanaga H, Fujii H, Tabata M. Endoscopically assisted selective antegrade cardioplegia in minimally invasive aortic valve replacement for patients with aortic insufficiency. JTCVS Tech. 2023; 18:28–36.

19. Allen BS, Winkelmann JW, Hanafy H, Hartz RS, Bolling KS, Ham J, et al. Retrograde cardioplegia does not adequately perfuse the right ventricle. J Thorac Cardiovasc Surg. 1995; 109:1116–26.

20. Langenberg CJ, Pietersen HG, Geskes G, Wagenmakers AJ, Soeters PB, Durieux M. Coronary sinus catheter placement: assessment of placement criteria and cardiac complications. Chest. 2003; 124:1259–65.

21. Di Eusanio M, Berretta P. The sutureless and rapid-deployment aortic valve replacement international registry: lessons learned from more than 4,500 patients. Ann Cardiothorac Surg. 2020; 9:289–97.

22. Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol. 2010; 56:455–62.