**2. Why cardiac surgeons should adopt minimally invasive aortic valve surgery?**

Minimally invasive cardiac surgery is a thought process that aims to minimize the extent of surgical invasiveness [12]. The American Heart Association (2008) defined it as "a small chest wall incision that does not include the conventional full sternotomy" [13]. The STS database defines minimally invasive cardiac surgery as "any procedure not performed with full sternotomy and cardiopulmonary bypass (CPB) support" [14]. The AHA definition is more realistic in the sense that an open heart surgery procedure is more likely to be conducted with cardiopulmonary bypass support. Based on the current STS definition, only TAVI can be included.

Potential advantages of MIAVR are:


**55**

full sternotomy.

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement*

f. Mortality: Joseph Lamelas [23] reported a 30-day mortality of 1.63% in 857 isolated MIAVR. Glauber et al. [11] reported in-hospital mortality of 1.5% in 593 patients. At 31.5 months mean follow up time, 94.8% survival was observed.

Optimum patient selection is essential for MIAVR. The factors to be taken into consideration include individual surgeon preference and skill sets, the patient's anatomical factors and comorbidities. The commitment and experience of the entire surgical team including anesthetists and perfusionists plays a critical role in

Patients presenting with severe and/or symptomatic aortic valve stenosis or insufficiency requiring an isolated AVR are potential candidates for MIAVR.

1.Unfavorable chest anatomy: Exposure and operative access to the ascending aorta and aortic valve are compromised in severe chest wall deformities and

2.Previous thoracic surgery: Patients with previous thoracic surgery—pleurodesis, lobectomy, and pneumonectomy have compromised anatomical exposure and access to the operative field. Such a situation also increases the risks [24] of perioperative complications—bleeding, air leak, conversation to full sternotomy.

3.Calcified ascending aorta: Assessment of a safe area for arterial cannulation and applying the aortic cross clamp requires optimum exposure. Control of bleeding from a calcified aorta—cannulation site, aortotomy—is potentially

4.Re-operation: Previous cardiac surgery is not an absolute contraindication to MIAVR. It may be a suitable option after previous valvular surgery. However, previous CABG is a contraindication due to risk of damaging patient's bypass grafts and also of inadequate myocardial protection. With full sternotomy, myocardial protection through retrograde cardioplegia, topical cooling and temporary occlusion of patent LIMA during cardioplegic arrest is possible.

5.Small aortic root (<19 mm) or aneurysmal dilation of aorta/sinuses: It may necessitate a concomitant aortic root enlargement and/or aortic root replace-

6.Severe left ventricular dysfunction: Patients with an ejection fraction <30%, dilated left ventricles are more prone to intra-operative hemodynamic instability and arrhythmias. These situations can be better managed through

7.Previous radiotherapy or pericarditis: These lead to intra thoracic and pericardial adhesions making dissection difficult. Temporary epicardial pacing wires

ment procedure which is better achieved through full sternotomy.

may not be placed effectively requiring trans-venous pacing.

dislocation of heart and great vessels (e.g., pectus excavatum).

*DOI: http://dx.doi.org/10.5772/intechopen.85242*

**3. Patient selection**

the successful outcome.

**3.2 Contraindications**

challenging with limited exposure.

**3.1 Indications**

*Minimally Invasive Right Anterior Mini-Thoracotomy Aortic Valve Replacement DOI: http://dx.doi.org/10.5772/intechopen.85242*

f. Mortality: Joseph Lamelas [23] reported a 30-day mortality of 1.63% in 857 isolated MIAVR. Glauber et al. [11] reported in-hospital mortality of 1.5% in 593 patients. At 31.5 months mean follow up time, 94.8% survival was observed.
