Minimally Invasive Aortic Valve Surgery.

Aortic valve replacement is the standard treatment for patients with severe or symptomatic aortic insufficiency or aortic stenosis. In the past, the standard method of replacing the aortic valve has been via a median sternotomy approach. However, in some patients, this midline anterior chest incision may not heal properly, cause pain, and be associated with a prolonged recovery. In patients with osteoporosis or diabetes, the thinned out sternum may take a long time to heal and be associated with a significant amount of pain. Over the past two decades, surgeons have developed alternative access routes to the aortic valve. The two main approaches to the aortic valve include a mini-thoracotomy and the minimally thoracoscopic approach. A third way of implanting the aortic valve is via a percutaneous approach combined with a mini-anterior thoracotomy. All these surgical approaches to the heart require general anesthesia, use of transesophageal echocardiogram, and full cardiac monitoring. In addition, the perfusionist must have the open heart-lung machine ready in case a complication occurs and there is a need to convert to a median sternotomy. The operating room is fully prepared in the same way as when a conventional aortic valve surgery is going to be performed. The minimally invasive aortic valve surgery is performed by making a 4 cm to 6 cm incision on the anterior chest wall (to the left of the sternum) which gives direct access to the left ventricle. Another variation is to make a 4 cm to 6 cm horizontal incision in the right third intercostal space to access the root of the aorta. In both these scenarios, the femoral vessels are used to place the patient on the heart-lung machine. The most difficult part of the surgery is getting proper access to the aortic root. The rest of the procedure is then done the same as a conventional aortic valve replacement. Percutaneous aortic valve surgery is performed by making a 6 cm incision at the left costal margin and accessing the heart. A transesophageal probe is placed in the esophagus, and special instruments are used to make a hole in the left ventricle apex, and a valve-containing device is guided to the aortic annulus. The stenotic valve is dilated first. Once the device is in place, the valve is released at the aortic annulus, and the instruments are removed. The hole in the ventricle is closed with sutures. There also is a robotic-assisted valve surgery procedure where three to five small incisions are made, and the surgeon uses robotic arms to conduct the surgery. Again, the most difficult part of this technique is to perform the actual aortic valve anastomosis. Most experts believe that the robotic surgery should be combined with an open incision so that the surgeon can manually perform the aortic anastomosis. The minimally aortic valve surgeries are also more expensive than the routine method of replacing the aortic valve as they require expensive disposable equipment. Copyright © 2024, StatPearls Publishing LLC.

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