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Surgical Aortic Valve Replacement without Visible Scars: The Right Lateral Access
13 February 2020 (online)
Objectives: Increasing patients’ request of reduced trauma with improved postprocedural quality of life and faster recovery on the one hand, and expanding indications to TAVR for always-lower risk patients on the other, are challenging the solid position of surgical AVR.
Actually two well-established access routes exist—the partial upper sternotomy and the anterolateral thoracotomy through the second intercostal space—but both do have their limitations. Sternal instability, rib luxation, lung herniation, and malperfusion due to loss of right internal artery are infrequent, but undoubtable do exist. Therefore, we like to add a further access route to our surgical toolbox: the right lateral or transaxillary access.
Methods: A 5-cm skin incision in the right anterior axillary line to access the third intercostal space allows safe and reproducible surgery with (nearly) no visible scars. Aortic valve replacement can be performed using sutured as well as rapid deployment valves. After the procedure, the skin incision disappears in the right axilla. No traces of surgery are visible unless the patient lifts his arm above 90 degrees. The technique is presented in the video.
Results: The initial as-treated series of 45 patients is reported. Intention-to-treat included 46 patients, with one patient being converted to partial sternotomy due to lung adhesions. Mean patient’s age was 68.4 ± 8.6 years, being predominantly male (58.1%). STS-PROM of 1.47 ± 0.88 revealed low surgical risk. Mean skin-to-skin time was 121.1 ± 26.5 min with an average x-clamp time of 45.9 ± 14.3 min. In 74.2%, rapid deployment valves were used. The procedures themselves were uneventful. Except one patient having transient seizures, postoperative courses were uneventful.
Conclusion: The right-lateral or transaxillary access adds a further way of MICS-AVR to our surgical toolbox on the way to a tailor-made therapy. The technique is safe, reproducible, independent from expensive equipment, and provides an unbeaten cosmetic results without any visible scars on the front view of thorax.