MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT ANTONIO MICELI DEPARTMENT OF CARDIOTHORACIC SURGERY

1. MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT ANTONIO MICELI DEPARTMENT OF CARDIOTHORACIC SURGERY FONDAZIONE TOSCANA G. MONASTERIO MASSA, ITALY

2. MIAVR is increasingly performed • and has become an alternative to standard sternotomy.

4. RIGHT PARASTERNAL APPROACH: • Technical issues: • The 2nd, 3rd, and 4th costal cartilages were removed • The right internal mammary vessels were usually ligated and divided. • High incidence of Lung Herniation, which was not only physiologically disturbing, but also was cosmetically disfiguring, and often required a second operation and mesh closure of the defect. • Lung Herniation led to MINISTERNOTOMY APPROACH

5. RATIONALE • Improve postoperative respiratory function • Reduce postoperative pain and recovery • Provide a cosmetically superior incision • Reduce dissection of other areas (low blood loss) • Facilitate a reoperation at a later date, as the lower part of the pericardium remains closed • More rapid return to functional activity, less rehabilitation resources • Beneficial effects in elderly • Reduce Costs

6. Murtuza B. et al.; Ann Thorac Surg 2008;85:1121-1131

7. 4 RANDOMIZED CONTROLLED TRIALS (1999-2003) • Some studies showed potential advantage in blood transfusion, early estubation and hospital disharge. Others failed to prove the theoretical advantages of MIAVS • Metanalysis of RCTs: no difference • Most of studies on MIAVR focus on ministernotomy Ministernotomy vs conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis Brown ML et al. JThorac CArdiovasc Surg 200;137:670-679

9. CT SCAN RIGHT ANTERIOR MINITHORACOTOMY α • Patients are suitable for RT if at the level of main PA • Aorta is rightward (>50% of ascending aorta) • The distance from ascending aorta to sternum < 10 cm • Angle α ≥45°

12. RIGHT ANTERIOR MINITHORACOTOMY VERSUS CONVENTIONAL AORTIC VALVE SURGERY: A PROPENSITY SCORE ANALYSIS Glauber M, Miceli A,Gilmanov D, Bevilacqua S, Concistrè G, Murzi M, Ferrarini M, Varone E, Chiaramonti F, Farneti PA, Solinas M.

13. OUR EXPERIENCE January 2005 Retrospective, observational, cohort study of prospectively collected data from consecutive patients undergoing AVR at Fondazione G. Monasterio CNR-Regione Toscana (Massa) 637 Patients underwent AVR Mini-sternotomy, active endocarditis, critical state Right anterior minithoracotomy (RT) 192 patients Full sternotomy (MS) 336 patients June 2010

14. RESULTS

15. RESULTS

16. RESULTS

17. RESULTS

19. CT SCAN MINISTERNOTOMY RIGHT MINITHORACOTOMY • Patients are suitable for RT if at the level of main PA • Aorta is rightward (>50% of ascending aorta) • The distance from ascending aorta to sternum < 10 cm • Angle α ≥45°

20. Upper V shaped Ministernotomy

21. MINIMAL INVASIVE FOR AORTIC VALVE: MINISTERNOTOMY OR MINITHORACOTOMY?

22. OUR EXPERIENCE January 2005 Retrospective, observational, cohort study of prospectively collected data from consecutive patients undergoing AVR at Fondazione G. Monasterio CNR-Regione Toscana (Massa) 724 Patients underwent AVR Full sternotomy Right anterior minithoracotomy (RT) 211 patients Ministernotomy (MS) 127 patients Exclusion criteria for RT: previous cardiac surgery, Right pleuritis, ascending aorta aneurysm March 2011

23. RESULTS

24. RESULTS

25. RESULTS

26. RESULTS

27. FOLLOW-UP Median follow up of 26 months (interquartile range 9- 46)

29. Intuity Perceval S Enable Reduce operative times Standardize the procedure

30. CONCLUSIONS • 1. MIAVS via is associated with • Low operative mortality and morbidity • Fast recovery and estetically pleasent scar • Excellent midterm follow-up • 2. Right anterior minithoracotomy better outcomes in terms of: • Postoperative AF • Ventilation time, ICU and hospital stay • Minimally aortic valve surgery can be performed safely with excellent results and high patient satisfaction.

31. CONCLUSIONS Can one achive the same quality of operation that one can do through the complete exposure of the heart? Yes, We can !

32. THANK YOU!