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The Journal of Cardiovascular Surgery 2022 February;63(1):85-90

DOI: 10.23736/S0021-9509.21.11981-0


language: English

Aortic valve replacement via right anterolateral minithoracotomy: preventing adverse events during the initial learning curve

Antonia VAN KAMPEN 1, 2, 3 , Markus KOFLER 1, Alexander MEYER 1, 2, 4, Maria GERBER 1, Simon H. SÜNDERMANN 1, 2, 5, Karel M. VAN PRAET 1, 2, Serdar AKANSEL 1, Matthias HOMMEL 6, Volkmar FALK 1, 2, 5, 7, Jörg KEMPFERT 1, 2, 5

1 Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; 2 German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; 3 University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany; 4 Berlin Institute of Health (BIH), Berlin, Germany; 5 Department of Cardiovascular Surgery, Charité University Hospital, Berlin, Germany; 6 Department of Anesthesiology, German Heart Center Berlin, Berlin, Germany; 7 Department of Health Sciences and Technology, Translational Cardiovascular Technologies, Institute of Translational Medicine, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland

BACKGROUND: Despite excellent outcomes and reduced invasiveness, the right anterolateral thoracotomy approach for aortic valve replacement (RALT-AVR) has not been broadly adopted. This study provides results regarding the initial experience and learning curve of a single surgeon performing this procedure.
METHODS: Periprocedural details and postoperative outcomes of the first 100 consecutive patients who underwent RALT-AVR at our institution were retrospectively analyzed. We conducted a cumulative sum analysis of surgical failure, defined as occurrence of 30-day-mortality, surgical revision for bleeding, conversion to sternotomy, 3rd degree heart block, paravalvular leakage, postoperative stroke or mean transvalvular gradient >20 mmHg.
RESULTS: The cohort was of low surgical risk (mean EuroSCORE II 1.31%±0.85, mean STS PROM 1.45%±0.97), 58% were males. Median cross-clamp time was 67.5 (57.8-76) min, median CPB time 105 (91.8-119) min, and median operation time 164.5 (144.5-183.2) min. There were no conversions to full sternotomy, 4 cases of revision for bleeding and 2 pacemaker implantations for 3rd degree heart block. Prosthesis function was good (median ΔPmean 10.9 [7.4-13.6] mmHg). Thirty-day-mortality was 0%. The log-likelihood graph never crossed the upper boundary, and after a steady decrease, crossed the lower boundary at 93 patients.
CONCLUSIONS: RALT-AVR can be performed with acceptable procedural times and satisfactory outcomes. For a well-trained surgeon, adapting to this new procedure does not expose patients to an increased risk, when patient selection and procedural planning are applied appropriately. Cumulative sum failure analysis is an appropriate tool to monitor the transition from standard AVR to the technically more demanding RALT-AVR.

KEY WORDS: Transcatheter aortic valve replacement; Thoracotomy; Minimally invasive surgical procedures; Aortic valve diseases, Learning curve

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