*6.1.2 Minimally invasive surgical (MIS) approaches*

*Aortic Stenosis - Current Perspectives*

heart disease [8] consider *two global risk categories*:

aorta, and sequelae of chest radiation).

lain aorta, and sequelae of chest radiation).

A resume of risk categories is shown in **Table 2**.

*\*ESC/EACTS guidelines consider two categories (low and increased surgical risk).*

Thus, the current **ESC/EACTS guidelines** for the management of valvular

1.Low surgical risk (STS or EuroSCORE II < 4% or logistic EuroSCORE I < 10% and no other risk factors not included in these scores, such as frailty, porcelain

2.Increased surgical risk (STS or EuroSCORE II >4% or logistic EuroSCORE I > 10% or other risk factors not included in these scores such as frailty, porce-

**Risk category STS score EuroScore II EuroScore** Low risk <4% <4% <10% Intermediate risk 4–8% >4–7%\* >10–20%\* High risk >8% >7\* >20%\*

**Risk assessment tool**

In conclusion, the decision to proceed with AVR or TAVI requires careful weighing of the potential for improved symptoms and survival and the morbidity and mortality of surgery and should be made by the heart team according to the individual patient characteristics. Checklist for choice of therapeutic intervention option (**Table A1**) could be consulted and printed from the additional material, in order to provide aspects that should be considered for the individual decision, based on the current recommendation of de ESC/EACTS

*Based on 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults with Aortic Stenosis and the 2017 ESC/EACTS Guidelines for the management of valvular* 

The conventional approach to AVR consists of a mid-line incision and full sternotomy, which provide a complete and comfortable access to the heart. Since it was first successfully carried out by Harken and Starr in 1960 [26, 27], there has been a continuous innovation in prosthetic technology and surgical techniques. All these collective efforts have resulted in improvements in both operative and long-term results [17]. Regardless of surgical approach, elected AVR is the gold standard for the treatment of severe AS. Several studies have shown short- and long-term outcomes,

**36**

guidelines.

*heart disease [8, 19, 25].*

*Risk assessment tools.*

**Table 2.**

**6.1 Surgical approach**

*6.1.1 Conventional AVR*

**6. Interventional therapeutic options**

Prohibitive risk >50%

Minimally invasive surgery aims to minimize the degree of surgical intrusiveness. Currently, there are several surgical approaches. The partial sternotomy and right anterior minithoracotomy are the most frequently used incisions for a minimally invasive approach to the aortic valve. The choice of interventional approach depends on the patient's anatomy as observed in preoperative imaging studies such as CT.

The "J" incision is the most widely used approach among the partial upper hemisternotomy approach (**Figure 2**). **Figure 3** shows the access view through right anterior minithoracotomy.

**Figure 2.** *Partial upper hemisternotomy approach. Operative field distribution from surgeon view [17].*

**Figure 3.** *Right anterior thoracotomy through 2 or 3° intercostal space [17].*
