Safety and Efficacy of the Transaxillary Access for Minimally Invasive Aortic Valve Surgery

Abstract

Background and Objectives: Transaxillary access is one of the latest innovations for minimally invasive aortic valve replacement (MICS-AVR). This study compares clinical performance in a large transaxillary MICS-AVR group to a propensity-matched sternotomy control group. Materials and Methods: This study enrolled 908 patients undergoing isolated AVR with a mean age of 69.4 ± 18.0 years, logistic EuroSCORE of 4.0 ± 3.9%, and body mass index (BMI) of 27.3 ± 6.1 kg/m2. The treatment group comprised 454 consecutive transaxillary MICS-AVR patients. The control group was 1:1 propensity-matched out of 3115 consecutive sternotomy aortic valve surgeries. Endocarditis, redo, and combined procedures were excluded. The multivariate matching model included age, left ventricular ejection fraction, logistic EuroSCORE, pulmonary hypertension, coronary artery disease, chronic lung disease, and BMI. Results: Propensity-matching was successful with subsequent comparable clinical baselines in both groups. MICS-AVR had longer skin-to-skin time (120.0 ± 31.5 min vs. 114.2 ± 28.7 min; p < 0.001) and more frequent bleeding requiring chest reopening (5.0% vs. 2.4%; p < 0.010), but significantly less packed red blood cell transfusions (0.57 ± 1.6 vs. 0.82 ± 1.6; p = 0.040). In addition, MICS-AVR patients had fewer access site wound abnormalities (1.5% vs. 3.7%; p = 0.038), shorter intensive care unit stays (p < 0.001), shorter ventilation times (p < 0.001), and shorter hospital stays (7.0 ± 5.1 days vs. 11.1 ± 6.5; p < 0.001). No significant differences were observed in stroke > Rankin 2 (0.9% vs. 1.1%; p = 0.791), renal replacement therapy (1.5% vs. 2.4%; p = 0.4762), and hospital mortality (0.9% vs. 1.5%; p = 0.546). Conclusions: Transaxillary MICS-AVR is at least as safe as AVR by sternotomy and can be performed in the same time frame. Its advantages are fewer transfusions and quicker postoperative recovery with a significantly shorter hospital stay. The cosmetic result and unrestricted physical abilities due to the untouched sternum and ribs are unique advantages of transaxillary access.

Right Anterior versus Right Transaxillary Access for Minimally Invasive Aortic Valve Replacement: A Propensity Matched Competitive Analysis

“…However, this explanation is highly likely to be insufficient to account for this phenomenon. Previously, we examined the feasibility of MICLATS-AVR compared to full conventional sternotomy, in which we also observed a comparable frequency of postoperative delirium syndrome (15.9%) in the sternotomy group, which did not significantly differ from that in the MICLATS-AVR group [10]. Therefore, the cause of the development of postoperative delirium syndrome appears to be also influenced by other circumstances that were not the primary focus of this study, as they do not align with the primary research question.…”

“…The field has witnessed a transformation, with surgical aortic valve replacement now amenable to minimally invasive techniques, such as sternum-sparing thoracotomies or partial hemisternotomies. Numerous studies comparing these techniques with conventional sternotomy have consistently demonstrated clear advantages, extending beyond anticipated results and cosmetically desirable outcomes [10,[15][16][17]. This not only underscores the efficacy of minimally invasive approaches but also emphasizes the undeniable patient preference for methods that reduce discomfort, expedite recovery, and enhance cosmetic results.…”

“…A more recent and innovative technique is the "single incision-direct vision" right lateral transaxillary access, known as Minimally Invasive Cardiac LATeral Surgery (MICLATS), which involves an incision of 4 to 5 cm in the right anterior axillary line [9]. This approach has shown promising initial outcomes compared to full median sternotomy [10]. However, the safety and efficacy of this approach require further investigation.…”

Update on minimally invasive cardiac surgery and enhanced recovery after surgery

“…The transaxillary group had longer operative times but reduced blood transfusion, ventilator time, wound complications, and intensive care and hospital LOS. This approach provided at least equivalent outcomes to full sternotomy AVR with excellent cosmesis and unrestricted postoperative physical activity due to the lack of sternotomy or rib spreading [11 ▪ ]. All three trials concluded that the MICS approach provided comparable results to full sternotomy with less trauma.…”

Minimally Invasive Trans-Axillary versus Full Sternotomy Mitral Valve Repair: A Propensity Score-Matched Analysis on Mid-Term Outcomes

“…As previously described [11,12], under general anaesthesia, right jugular vein was cannulated before surgical draping. The cardiopulmonary bypass was conducted maintaining normothermia after cannulation of the common femoral artery and the femoral vein, using the Seldinger technique and TOE guidance after surgical cut-down.…”