A 16-Year Experience in Minimally Invasive Aortic Valve Replacement Context for the Changing Management of Aortic Valve Disease Igor Gosev, MD, Tsuyoshi Kaneko, MD, Siobhan McGurk, BS, Scott R. McClure, MD, Ann Maloney, BA, and Lawrence H. Cohn, MD Objective: The aim of this study was to evaluate short- and long-term morbidity and mortality in patients with aortic valve disease who had minimally invasive aortic valve replacement (AVR) through upper hemisternotomy. Methods: From July 1996 to June 2012, a total of 1639 patients underwent minimally invasive aortic valve surgery (AVR). Patient data were extracted from hospital electronic records after institutional review board approval. Outcomes of interest included postoperative compli- cation rates, perioperative mortality, and long-term survival. Results: The mean age was 67 years (SD, 14 years; range, 22Y95 years). Of the total cohort, 211 (13%) underwent reoperative AVR. Postopera- tively, 2.3% (37/1639) had reoperations to correct bleeding, 2.7% (44/1639) had strokes, 20.4% (334/1639) had new-onset atrial fibril- lation, and 1.5% (24/1639) required permanent pacemakers. Only 34% (571/1639) of the patients received packed red blood cells. The median discharge was on day 6 (5Y8), and 72.2% of the patients (1184/1639) were discharged home. Operative mortality was 2.9% (48/1639), and long-term survival at 1, 5, 10, and 15 years was 96%, 93%, 92%, and 92%, respectively. Operative mortality was 5.7% (12/208) for the reoperative patients. Conclusions: The upper hemisternotomy approach for AVR is safe and reliable, especially for patients undergoing reoperations and those older than 80 years. Key Words: Minimally invasive surgery, Mini-sternotomy, Aortic valve replacement. (Innovations 2014;9:104Y110) A ortic valve replacement (AVR) with biological or mechan- ical prosthesis is the standard of care for treating symp- tomatic aortic valve stenosis and regurgitation. 1 During the past 16 years, minimally invasive approaches to AVR have seen in- creased use and recently became one of the most common cardiac surgery procedures performed. After initial reports by Cosgrove and Sabik 2 in 1996, Cohn et al 3 in 1996, and Benetti et al 4 in 1997, minimally invasive AVR through upper hemisternotomy became the predominant approach. 5 Minimally invasive AVR promotes expeditious healing and accelerated return to baseline physical health by way of minimizing surgical trauma. 3,6 Standard AVR typically requires exposure of the heart and its vessels through a complete sternotomy. A minimally invasive approach via upper hemister- notomy allows access to the heart through a small incision 6 to 9 cm in length, with less tissue dissection and without fully separating the sternum. It provides excellent visualization of the ascending aorta and the aortic root and allows for direct can- nulation of the right atrium (RA) and/or vent and retrograde cannula placement in most of the cases. In addition, some studies suggest that minimally invasive surgery reduces blood loss, 7Y11 surgical trauma and pain, 7Y9 time on the ventilator, 9Y11 and length of hospital stay 8 and may accelerate recovery. 4Y7 Patients with a wide anterior-posterior chest diameter, scoliosis, or significant chest wall deformity or patients who have contraindications to transesophageal echocardiography (TEE) have a relative con- traindication for a hemisternotomy approach because of diffi- culty with exposure of the ascending aorta and the aortic valve or inability to control distension/deairing of the left ventricle because of a lack of imaging. 12 Multiple technological advancements have made an upper hemisternotomy approach to AVR easier, safer, and faster than in the early days. Vacuum-assisted cardiopulmonary bypass (CPB), smaller and more flexible cannulas, advancements in TEE tech- nology, and carbon dioxide application to the operative field as well as better understanding of the myocardial protection have created an environment where minimally invasive AVRs are not reserved only for high-volume academic centers but are a feasible treatment modality for all medical institutions. 13 In recent years, transcatheter aortic valve implantation (TAVR) has become an accepted option for high-risk patients. 14 Perioperative outcomes as well as 1- and 2-year survival in pa- tients without significant aortic insufficiency after TAVR are similar to those after surgical AVR. 15,16 ORIGINAL ARTICLE 104 Innovations & Volume 9, Number 2, March/April 2014 Accepted for publication December 29, 2013. From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA. Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 12 Y 15, 2013, Prague, Czech Republic. Disclosure: The authors declare no conflicts of interest. Address correspondence and reprint requests to Igor Gosev, MD, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 USA. E-mail: igorgosev@partners.org. Copyright * 2014 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/14/0902-0104 Copyright © 2014 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.