title: Current era minimally invasive aortic valve replacement: techniques and practice.
abstract: BACKGROUND
  Since the first aortic valve replacement through a right thoracotomy was reported in 1993, upper hemisternotomy and right anterior thoracotomy have become the predominant approaches for minimally invasive aortic valve replacement. Clinical studies have documented equivalent operative mortality, less bleeding, and reduced intensive care/hospital stay compared with conventional sternotomy despite longer procedure times. However, comparative trials face challenges due to patient preference, surgeon bias, and the lack of a standardized minimally invasive surgical approach.
  
  
  METHODS
  Twenty cardiothoracic surgeons from 19 institutions across the United States, with a combined experience of nearly 5000 minimally invasive aortic valve replacement operations, formed a working group to develop a basis for a standardized approach to patient evaluation, operative technique, and postoperative care. In addition, a stepwise learning program for surgeons was outlined.
  
  
  RESULTS
  Improved cosmesis, less pain and narcotic use, and faster recovery have been reported and generally accepted by patients and by surgeons performing minimally invasive aortic valve replacement. These benefits are more likely to be verified with standardization of the procedure itself, which will greatly facilitate the design and implementation of future clinical studies.
  
  
  CONCLUSIONS
  Surgeons interested in learning and performing minimally invasive aortic valve replacement must have expertise in conventional aortic valve replacement at centers with adequate case volumes. A team approach that coordinates efforts of the surgeon, anesthesiologist, perfusionist, and nurses is required to achieve the best clinical outcomes. By first developing fundamental minimally invasive skills using specialized cannulation techniques, neck lines, and long-shafted instruments in the setting of conventional full sternotomy, the safest operative environment is afforded to patients.
authors.affiliation: Northwestern University, Chicago, Ill.
authors.forename: S Chris
authors.initials: SC
authors.lastname: Malaisrie
authors.affiliation: Swedish Medical Center, Seattle, Wash.
authors.forename: Glenn R
authors.initials: GR
authors.lastname: Barnhart
authors.affiliation: University of Pennsylvania, Philadelphia, Pa.
authors.forename: R Saeid
authors.initials: RS
authors.lastname: Farivar
authors.affiliation: Penrose St Francis Health Systems, Colorado Springs, Colo.
authors.forename: John
authors.initials: J
authors.lastname: Mehall
authors.affiliation: Gulf Coast Cardiothoracic, Ft Myers, Fla.
authors.forename: Brian
authors.initials: B
authors.lastname: Hummel
authors.affiliation: St Thomas Heart Hospital, Nashville, Tenn.
authors.forename: Evelio
authors.initials: E
authors.lastname: Rodriguez
authors.affiliation: Albert Einstein Medical Center, Philadelphia, Pa.
authors.forename: Mark
authors.initials: M
authors.lastname: Anderson
authors.affiliation: Cardio-Thoracic Surgeons, PC, Birmingham, Ala.
authors.forename: Clifton
authors.initials: C
authors.lastname: Lewis
authors.affiliation: Penn Presbyterian Medical Center, Philadelphia, Pa.
authors.forename: Clark
authors.initials: C
authors.lastname: Hargrove
authors.affiliation: University of Virginia Health System, Charlottesville, Va.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: Lankenau Hospital, Wynnewood, Pa.
authors.forename: Scott
authors.initials: S
authors.lastname: Goldman
authors.affiliation: Alta Bates Summit Medical Center, Oakland, Calif.
authors.forename: Junaid
authors.initials: J
authors.lastname: Khan
authors.affiliation: The Toledo Hospital, Toledo, Ohio.
authors.forename: Michael
authors.initials: M
authors.lastname: Moront
authors.affiliation: New York University School of Medicine, New York, NY.
authors.forename: Eugene
authors.initials: E
authors.lastname: Grossi
authors.affiliation: Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Massachusetts General Hospital, Boston, Mass.
authors.forename: Arvind
authors.initials: A
authors.lastname: Agnihotri
authors.affiliation: Baylor Heart Hospital, Dallas, Tex.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mack
authors.affiliation: Hatton Institute, Good Samaritan Hospital, Cincinnati, Ohio.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Smith
authors.affiliation: Emory University School of Medicine, Atlanta, Ga.
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.affiliation: Edwards Lifesciences, Irvine, Calif.
authors.forename: Francis G
authors.initials: FG
authors.lastname: Duhay
authors.affiliation: Edwards Lifesciences, Irvine, Calif.
authors.forename: Mark T
authors.initials: MT
authors.lastname: Kocis
authors.affiliation: Baylor Heart Hospital, Dallas, Tex. Electronic address: whryanmd@yahoo.com.
authors.forename: William H
authors.initials: WH
authors.lastname: Ryan
mesh_terms: D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D002983:Clinical Competence; D004503:Education, Medical, Graduate; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000193:education / Q000379:methods*; D006801:Humans; D059032:Learning Curve; D011859:Radiography; D056346:Sternotomy / Q000009:adverse effects / Q000193:education; D013908:Thoracotomy / Q000009:adverse effects / Q000193:education; D016896:Treatment Outcome; D014463:Ultrasonography
keywords: 2; 28; 35; 35.2; CPB; CT; MIAVR; RAT; TEE; UHS; cardiopulmonary bypass; computed tomography; minimally invasive aortic valve replacment; right anterior thoracotomy; transesophageal echocardiography; upper hemisternotomy