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• W1724072547 abstract "Since the emergence of limited skin incisions for aortic valve surgery in the late 1990s, several modifications have been described (1). These include upper hemisternotomy in a T- or J-shape manner, lower partial ministernotomy, right anterior or parasternal minithoracotomy, and full sternotomy with a small skin incision. However, while limited access offers advantages of minimized surgical trauma (less bone damage, pain and blood loss), the direct surgical field of view is also restricted and only permits visualization and manipulation on the cardiac situs. Consequently, the procedure requires more detailed preoperative planning and imaging, closer cooperation with anesthetists and pump technicians, good communication and teamwork with the assistant surgeon and the scrub nurses, and additional exposition tools. Furthermore, the surgeon must be well educated and experienced in managing intraoperative challenges. These circumstances have increased the complexity of the procedures, consequently limiting the uptake of minimally invasive aortic valve replacement (MIC-AVR) in most countries (Figure 1).Figure 1Case load of isolated aortic valve procedures (mechanical and xenograft) divided by total and partial sternotomy in Germany from 2004 to 2013 (courtesy of the German Society of Cardiothoracic Surgery).Here we describe key steps of the minimally invasive procedure, focusing on potential pitfalls, and recommending safeguards and solutions (see also Table 1).Table 1Pitfalls, safeguards and intraoperative bailoutsSafeguards and pitfallsThe following rules have to be kept in mind:Never work under pressure;Inform the whole team about your strategy, and be communicative;Never accept suboptimal surgical results as a cost of a limited approach;In a complex case, ask for assistance early on from an experienced surgeon;Use intraoperative transesophageal echocardiography (TEE) as a standard measurement.Preoperative planning and imagingDepending on organizational structures of the hospital, surgeons either know their patient from early on or just one day before surgery. Regardless, the patient must be seen by the operating surgeon as soon as possible, as patient characteristics play a more important role in a minimally invasive approach, compared to full sternotomy. Particular attention should be paid to body habitus (e.g., obesity, funnel chest), medical history (e.g., previous chest surgery, trauma) as well as aortic valve and root anatomy (e.g., degree of calcification, bicuspid valve, rheumatic disease, concomitant mitral calcifications). Thus, all available images should be evaluated as soon as possible. In case of doubt, a preoperative TEE and computed tomography can help to gain maximal information (1). In particular, the latter is a standard imaging modality for minimal-invasive aortic surgery in many surgical units for example, to identify the optimal intercostal space in case of a right lateral mini-thoracotomy.In case of unforeseen and unfavorable anatomy during surgery, it is important to remain calm and ask for help from an experienced surgeon if necessary. In particular, a more anterior/posterior than lateral position of pulmonary and aortic root and caudal position of the aortic annulus, as well as fatty right ventricular outflow tract musculature are challenging to approach, but can be more easily managed using additional stay sutures.Most minimally-invasive AVR procedures are more time-consuming than full sternotomy, prolonging the procedure by 10-30 min in experienced hands (2-5). This extension in time should be considered during patient and surgeon selection and communicated with the team members to ameliorate any time pressures." @default.
• W1724072547 created "2016-06-24" @default.
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• W1724072547 date "2015-01-01" @default.
• W1724072547 modified "2023-09-25" @default.
• W1724072547 title "Complications and conversions in minimally invasive aortic valve surgery." @default.
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• W1724072547 doi "https://doi.org/10.3978/j.issn.2225-319x.2014.11.14" @default.
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