REVIEWS
The Minithoracotomy Approach: A Safe and
Effective Alternative for Heart Valve Surgery
Giovanni Mariscalco, MD, PhD, and Francesco Musumeci, MD
Department of Heart and Vessels, Cardiac Surgery Unit, Varese University Hospital, Varese; and Department of Cardiac Surgery and
Transplantation, S. Camillo Hospital, Rome, Italy
Despite criticisms over the last decade, heart valve surgery
through right anterior minithoracotomy (MT) proved
excellent short-term and long-term-term results, becoming
a feasible and popular alternative to the sternotomy ap-
proach. The rapid development and renements of tech-
niques have led to MT valve surgery being considered safe,
effective, and durable. Minithoracotomy has been demon-
strated to be a valid cost-effective and cost-saving strategy
W ith the advent of cardiopulmonary bypass (CPB) in
1954, complex surgical valve procedures became
available, with a progressive improvement in experience
with various prosthetic devices [1]. Although the rst
valvular approach through right thoracotomy under CPB
was reported by Lillehei and colleagues [2] in 1957, valve
surgery through full sternotomy (ST) became subse-
quently popular, because of the complete exposure of the
heart, the adequate myocardial protection, and the
REVIEW
reduced operative time. That conventional approach
proved to have outstanding outcomes and long-term
success in both aortic and mitral valve (MV) surgery
[36]. During the past 10 years, however, minimally
invasive valve surgery gained popularity minimizing
patient trauma, improving recovery, and reducing hos-
pital expenditures (Fig 1) [323]. Alternative approaches
to conventional ST include partial sternotomy and mini-
thoracotomy (MT) [35]. Mitral and aortic valve pro-
cedures through right MT have been proved to be safe
and efcient options with excellent early and late out-
comes [623]. Based on these results, the consensus
statement of the International Society of Minimally
Invasive Coronary Surgery (ISMICS) has recently dened
MV surgery through MT as an alternative to conventional
ST [24]. Therefore, MT has now reached recognition
worldwide, becoming widely adopted for both MV and
aortic valve (AV) surgery.
Material and Methods
A systematic search was performed using the PubMed
database to identify all studies reporting results and
outcomes of MT heart valve surgery. Search strategy
combined mitral valve, aortic valve, tricuspid
Address correspondence to Dr Mariscalco, Department of Heart and
Vessels, Cardiac Surgery Unit, Varese University Hospital, Via Guicciar-
dini 7, Varese 21100, Italy; e-mail: giovannimariscalco@yahoo.it.
2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
for valve surgery, being associated with reduced morbidity
and mortality. Tangible benets include less pain, faster
postoperative recovery, and better cosmetic results. As a
result, MT has been increasingly used as a routine approach
in many centers for both aortic and mitral valve surgery.
(Ann Thorac Surg 2014;97:35664)
2014 by The Society of Thoracic Surgeons
valve, minimally invasive, and minithoracotomy.
Published original articles, case series, and individual
reports were analyzed. All studies were identied from
the existing literature until April 2013. In addition, the
related articles function in PubMed was used as a
further check of rigor. When multiple studies had been
published by a single institution, the largest, most recent,
or most informative study was considered.
Historical and Technical Notes
In 1996, Carpentier and colleagues [25] performed the
rst video-assisted MV repair through a right antero-
lateral MT using peripheral extracorporeal circulation
with ventricular brillation. A video-assisted controlled
by a voice-activated camera arm and by robotic tele-
manipulation and three-dimensional endoscopy was
subsequently introduced [2630]. In the same years,
feasibility and myocardial functional preservation were
reached through right MT with the port-access technique
[28]. In 1998 Carpentiers group performed the rst
completely robotic MV repair [32].
A variety of surgical approaches and techniques for MV
surgery through right MT have been proposed. A dual-
lumen endotracheal tube or bronchial blocker are
generally required [616, 2634]. The entire procedures
are performed through a 4 cm to 7 cm port located in the
right inframammary groove, usually in the fourth inter-
costal space [616, 2634]. Arterial cannulation is accom-
plished with femoral artery or direct aortic cannulation,
whereas venous drainage requires femoral vein with
or without concomitant internal jugular cannulation,
generally under transesophageal echocardiography
guidance. Aortic occlusion is performed by either per-
cutaneous endovascular intraluminal balloon (the port-
access system) or transthoracic aortic clamp, inserted
through a separate transthoracic incision [616, 2634].
The majority of procedures utilize antegrade delivery of
cardioplegia into the aortic root, administered through
0003-4975/$36.00
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Ann Thorac Surg
2014;97:35664
Fig 1. Distribution of surgical approachsternotomy (black bars)
or right thoracotomy (gray bars)for degenerative mitral valve
repair by year of operation. (Reprinted from Galloway et al [7],
with permission from Elsevier.)
the balloon endovascular clamp or the direct aortic root
cannulation [1020, 2937].
In 1997, Benetti and coworkers [35] proposed the right
anterior MT approach also for AV. A transverse incision
of 5 cm to 7 cm is generally placed over the second or the
third intercostal space [1824]. Central cannulation
involving ascending aorta and right atrium or a femoral
cannulation is required [1824]. A direct cross clamping of
the aorta with antegrade cardioplegia delivery is usually
employed. Left ventricular venting is accomplished as in
other conventional AV operations. In 1999, Robin and
associates [36] performed the rst video-assisted tricuspid
valve surgery.
Results
Despite criticisms over the last decade, various in-
stitutions have proved excellent results for MT valve
surgery [626].
Hospital Mortality
Patients undergoing MV and AV surgery through right
MT have 0% to 10% hospital mortality, although recent
series testify to lower rates ranging from 0% to 2.2% along
with the modication and simplication of surgical
techniques [626]. None of the largest series documented
differences in hospital mortality between the MT and ST
approaches (Tables 1 and 2).
Chitwood and associates [27] rstly suggested that
video-assisted mitral operations can be performed safely
as compared with the conventional ones. Their rst
experience enrolled 31 consecutive patients undergoing
MT mitral valve surgery (repair and replacement)
compared with 100 patients having conventional ST [27].
No hospital deaths were documented in the MT group,
and 30-day mortality was comparable between groups
(3.2% versus 2.2%, p nonsignicant). Recent series
report even better results [616]. Galloway and associates
[7] enrolled 1601 patients affected by degenerative MV
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MINITHORACOTOMY IN HEART VALVE SURGERY
disease. The MV repair was performed in 1,071 patients
with right anterior MT and in 530 with the ST approach,
and hospital mortality was identical (1.3% versus 1.3%).
Iribarne and associates [16] provided similar results with
1,121 isolated MV operations. After propensity matching
analysis, 382 pairs were obtained: no differences in 30-day
mortality were observed between the two groups (1.8%
versus 1.8%, p 0.622) [16].
Consonant results are reported for AV surgery [1723].
Glower and associates [19] collected more than 300 AV
undergoing MT, documenting a hospital mortality of
1.3%. Glauber and associates [23] enrolled data from 637
consecutive patients undergoing isolated AV surgery: 138
MT patients were propensity matched to those under-
going ST, and equal inhospital mortality was registered
[9]. Excellent results are also reached in reoperative valve
surgery conducted through MT [3740].
Neurologic Events
Similarly to other minimally invasive valve surgery ap-
proaches, concerns have arisen for MT with reference to
possible postoperative cerebrovascular accidents (CVA).
The reduced surgical eld with its theoretically inade-
quate deairing was advocated as the main cause for
possible negative neurologic outcomes. Although early
series seem to suggest an increased CVA rate, the use of
transesophageal echocardiography and continuous CO2
insufation have recently allowed the achievement of
comparable outcomes [41]. Iribarne and associates [16]
registered no differences in early stroke (0.3% versus
1.3%, p 0.217) and delayed stroke (0.8% versus 1.3%, p
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0.725) after MV surgery. Dogan and associates [42]
randomly allocated 40 consecutive patients affected by
severe MV disease to undergo right anterior MT or ST.
Neuropsychological tests were performed a day before
and 5 days and 2 months after the operation, and failed to
demonstrate signicant differences between the two ap-
proaches. No CVA differences were also observed for
elderly patients and for AV surgery [1723, 4346].
Interestingly, comparison of endoaortic balloon occlusion
(EABO) and transthoracic clamping revealed controver-
sial results [7, 8, 47]. Modi and colleagues [8] observed a
trend toward an increased risk of stroke in the EABO
group (2.7% versus 1.2%, p 0.08), whereas other studies
did not, although more microembolic events were
detected in the same group [6, 47].
The atherosclerotic burden in aortic arch and
descending aorta seems to play a crucial role in post-
operative CVA, especially in elderly patients, using
retrograde perfusion [48]. Several studies analyzing MT
valve surgery identied retrograde perfusion as the only
independent risk factor for stroke (odds ratio 8.5; p
0.04), suggesting that retrograde perfusion is a viable
option for younger patients without vascular disease only
[10, 12, 48, 49].
Reexploration and Transfusions
Since the rst MT experiences, a potential reduction in
transfusions, bleeding, and reexplorations was expected.
However, both observational and randomized studies
 358 MARISCALCO AND MUSUMECI Ann Thorac Surg
MINITHORACOTOMY IN HEART VALVE SURGERY 2014;97:35664

Table 1. Major Published Clinical Series on Mitral Valve Surgery Through Minithoracotomy Involving More Than 1,000 Patients
First Author [Reference] Glower [6] Galloway [7] Modi [8] Seeburger [9] Murzi [10]

Year of study 19971999 19952008 19962011 19992007 20032007

Type of study PO/Multi CC/Sc PO/Bc RO/Sc RO/Sc
Number of patients 1,059 1,071 1,178 1,339 1,280
Preoperative data
Age, years 57  14/60  14a 60.4  14.0 61.1  13.9 60.3  12.7 59  14/63  13b
Male, % 51.5 61.7 49 61.2 45.4
Prior surgery, % 16.1 4.2 18.8 6.1
Intraoperative data
CPB time, min 146.1  51.4 121  38 132  53/136  57b
ACC time, min 104.6  40.3 70  32 79  43/95  43b
Mitral valve repair, % 46.4 66.5 79.9 100 75.6
EABO, % 91.5 74.8 40.7 0 4.4
Concomitant surgery, % 6.8 33.1 38.8 23.7
Type of vision Video assisted Direct vision Video assisted Video assisted Video assisted
Postoperative data, %
Reoperation for bleeding 4.3 5.4 5.13.7
Stroke 2.1 2.3 2.0 1.0 1.6
Atrial brillation 10.2 22.8 26.7 23.2
Transfusion 30.2 45.5
Infections 0.8 0.6 0.6
Aortic dissection 0.4 0.8 0.2 c 0.2
Hospital mortality 3.7 1.3 (2.0)d 2.6 2.4 1.1
a b
Age for the mitral valve repair and mitral replacement groups, respectively. Data available with reference to the adopted perfusion strat-
c d
egies. Data from a larger series (3,125 patients) by the same group [66]. Data from a larger series (1,282 patients) by the same group [52].
ACC aortic-cross clamp; Bc bicenter; CC case control; CPB cardiopulmonary bypass; EABO endoaortic balloon occlusion;
Multi multicenter; PO prospective observational; RO retrospective observational; Sc single center.
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have demonstrated conicting results [1027, 45, 53, 54].
El-Fiki and associates [50] randomly collected 100
consecutive MV patients to undergo right anterolateral
MT and ST, observing signicantly lower postoperative
blood loss in the MT group (481  142 mL versus 930 
357 mL, p 0.01). Conversely, Dogan and associates [42]
did not nd differences in chest tube output in their
randomized series (446  375 versus 446  312, p 0.99).
Similarly, disputed data exist for blood product trans-
fusions [1027, 45, 53, 54]. Grossi and colleagues [43]
observed that MT operations required less fresh frozen
plasma units (median, 1.0 unit versus 2.0 units; p 0.04)
in their rst experience. The same group subsequently
documented a lower transfusion rate (52.3% versus 64.8%,
p 0.05) along with a reduced number of units of red
blood cells (3.0  0.3 versus 4.8  0.7, p 0.02) in the port-
access group [11]. On the contrary, Holzhey and co-
workers [44] did not nd any differences in red blood
cells and platelet units, but MV patients undergoing ST
received fewer fresh frozen plasma units (1.4  4.2 versus
2.8  7.4, p 0.037). In AV patients, Glaubers group
described a signicantly lower rate of transfusion (18.8%
versus 34.1%, p 0.006) with a reduction in red blood
cells units in the MT population (0.7  1.1 versus 2  3,
p 0.001) [22, 23]. Again, other groups reported no dif-
ferences either in the percentage of patient transfusions
or in the amount of administered red blood cells, fresh
frozen plasma, and platelet units [16, 42, 44].
Finally, reexplorations for bleeding yielded comparable
results in AV and MV surgery using either the MT or the
ST approach [11, 14, 15, 17-23, 4346]. Reexploration
generally ranges from 1% to 7% in AV cases, and from 0%
to 11% in MV operations with the MT approach [623].
Iribarne and coworkers [16] encompassing more than
1,100 patients undergoing isolated MV operations, did not
nd any difference in reexploration for bleeding between
the two groups (3.7% versus 2.9%, p 0.685). Sharony and
colleagues [17] observed similar data for a total of 921
consecutive patients undergoing isolated AV replace-
ment, observing an identical reexploration rate between
two propensity matched cohorts of 233 patients under-
going MT and ST (3.4% versus 3.4%, p 1.00).
Atrial Fibrillation and Acute Kidney Injury
Limited heart manipulation and trauma is associated with
reduced postoperative atrial brillation (AF) [52].
Although the Port-Access International Registry (PAIR)
reported a 10% incidence of postoperative AF with the
port-access technique, no differences were documented
between MT and ST in MV surgery [6, 16, 26, 46]. Suri and
associates [14] observed an equal AF rate between
350 isolated MV repair performed with a MT approach
compared with 365 ST operations (26% versus 27%,
p 0.627). A lower AF rate is commonly registered in AV
patients undergoing MT access [20, 22, 23].
Ann Thorac Surg REVIEW MARISCALCO AND MUSUMECI 359
2014;97:35664 MINITHORACOTOMY IN HEART VALVE SURGERY

Table 2. Major Published Studies on Aortic Valve Surgery Through Minithoracotomy

First Author [Reference] Sharony [17] Plass [18] Glower [19] Brinkman [20] Ruttman [21] Glauber [23]

Year of study 19952002 20062008 19982010 19962009 20062009 20052010

Type of study PS (1:1) CS CS MS (1:4) PS (1:1) PS (1:1)
No. patients in MT (nal matched) 438 (233) 172 (165) 306 90 87 192 (138)
Preoperative data
Age, years 66  15.7 70  12 65  14 71.5  11.6 70.4  9.2 69.5  12.4
Male, % 54.9 63.4 55.6 55.6 54.0 57.9
LVEF, % 56  10 52.3  11.2 58  9.7 56.5  9
Aortic stenosis, % 61.4 81.9 85.3 83.2 44.2
Intraoperative data
CPB time, min 110  34 158  41 108  23 151.4  43.1a 121.6  45a
ACC time, min 79  25 107  26 91  20a 96.6  20.5a 86.9  31.8a
Central aortic cannulation, % 69.9 100 97.1 0 12.6 100
Conversion to ST, % 3.0 4.9 1.2 1.5
Postoperative data
Reoperation for bleeding, % 3.4 3.8 0.7 8.1 4.6 6.5
Stroke, % 3.4 3.8 1.6 1.2 1.2 0.7
Atrial brillation, % 15.0 37.1 33.3 18b
Transfusion, % 60.7 57 64.4 18.8b
Wound infections, % 0 0 0 0 1.2 0
Pacemaker implantation, % 1.3 3.6 1.1 0.7
Ventilation time, hours 9.2  25.6b,c 10b,c 6 (59)b,c
ICU stay, days 2  2c 44.4  44.3b,c 20b,c
Hospital stay, days 6b,c 10  3c 5 (46)c 7.2  5.0b,c 5 (46)b,c
Hospital mortality, % 5.6 1.9 1.3 0 2.3 0.7
a
Longer cardiopulmonary bypass (CPB) or aortic-cross clamp (ACC) time compared to sternotomy (ST) operations (p < 0.05). b
Reduced complication
rate compared to ST operation (p < 0.05). c
Mean  SD or median (interquartile range).

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CS case series; CPB cardiopulmonary bypass; LVEF left ventricular ejection fraction; ICU intensive care unit; MS matched
observational study; MT minithoracotomy group; PS propensity score matched study.

For renal outcomes, a difcult comparison across
studies exists because of the wide variation of the
adopted denitions for acute kidney injury [53]. Gener-
ally, no differences are reported in both AV and MV
surgery using MT or ST approaches [15, 16, 43, 44, 57].
McCreath and associates [54] specically explored
the acute kidney injury issue, evaluating data from all
isolated MV operations over a 10-year period. They
demonstrated a highly signicant association between
surgical approach and peak postoperative fractional
change in creatinine (F value 13.33, p 0.0003)
indicating a greater risk of acute kidney injury with
standard ST access. For peak postoperative creatinine,
ST operations were associated with greater renal injury
(F value 12.72, p 0.0004) [54].
Septic Complications
Avoiding the potential risk of mediastinitis, MT is asso-
ciated with lower wound infections and septic complica-
tions than ST. Grossi and associates [43] fully investigated
this issue in a cohort of 197 patients having isolated MV
and AV surgery, reporting a lower rate of sepsis/endo-
carditis in the MT group (0.9% versus 5.7%, p 0.05).
Raanani and associates [15] observed consonant data on
supercial wound infections in a more recent series
(0% versus 7%, p 0.019). However, other groups did not
observe relevant differences [11, 14, 51].
Pain, Cosmesis, and Recovery
Minithoracotomy incisions minimize surgical trauma,
reduce discomfort, and improve cosmesis and patient
satisfaction [13, 37, 5558]. Analgesic usage is also
diminished in minimally invasive valvular surgery, with
the potential reduction of postoperative delirium [9, 27].
Consistent data support the notion that MT approaches
are associated with less postoperative pain and faster
return to normal activity [13, 37, 51, 5558]. Casselman
and colleagues [13] documented that 93.5% of their MV
patients experienced minimal to almost no procedure-
related pain after a MT access, and none of the
remainder mentioned excessive pain. Speziale and co-
workers [51] in their randomized MV series, investigated
the postoperative pain by the administration of a visual
analog scale (range, 0 no pain to 10 maximum pain).
The main pain scores were signicantly lower in the MT
group at all time points (second, fourth, and sixth
postoperative days: 2.8  0.9 versus 4.7  1.3, p 0.01;
2.3  0.8 versus 5.1  1.5, p <0.001; and 1.5  0.4 versus
3.1  0.9, p 0.002, respectively) [51]. In another series,
MT incision had lower pain levels from the third
 360 MARISCALCO AND MUSUMECI
MINITHORACOTOMY IN HEART VALVE SURGERY
postoperative day onward [55]. In addition, evidences
from patients undergoing MV reoperation with a MT
approach documented a less painful recovery compared
with previous ST operation [3740]. Moreover, 33.7% of
the patients were back at work or at routine activity
within 4 weeks postoperatively, with a 92.2% satisfaction
rate [13]. Interestingly, patient age did not inuence
postoperative recovery [13]. Approximately 99% of pa-
tients appreciated the nal MT cosmetic results [13].
Hospitalization and Costs
Minithoracotomy operations result in a decreased inten-
sive care unit stay and hospitalization, being associated
with faster recovery and earlier discharge [13, 27, 42,
4651]. A recent review of nine studies encompassing
more than 500 MV patients reported a shorter mean
intensive care unit stay and total hospital stay for patients
who underwent MT, ranging from 10 hours to 2.1 days,
compared with ST patients, ranging from 1.6 to 3.9 days
[56]. The total hospital stay was shorter, ranging from 5.6
to 13 days compared with ST patients (6.25 to 15 days)
[56]. Similar results were achieved for AV procedures
[1720, 22, 23]. In the study by Glauber and colleagues
[23], MT patients had a shorter mechanical ventilation
time (median, 6 versus 8 hours; p 0.004) and post-
operative length of stay (median, 5 versus 6 days; p
0.02). In a larger AV experience, Sharony and colleagues
[17] demonstrated that MT patients were discharged
home rather than sent to rehabilitation facilities or
nursing homes in a greater percentage (65.7% versus
52.9%; p 0.05). Iribarne and coworkers [57] provided a
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detailed analysis of effectiveness of MT versus ST mitral
valve surgery for 847 patients. The minimally invasive
approach was associated with a $3,595 lower median cost
of hospitalization ($33,418 versus $37,013, p 0.003), and
the mean difference in direct costs between groups was
$5,993  $2,008 (p 0.003) [57]. Lower costs were also
observed for cardiac imaging (p 0.004), laboratory tests
(p 0.005), and radiology expenditures (p 0.002) [57]. In
this setting, a higher rate of patients were discharged
home or with a home health aid (78% versus 58%),
requiring a lower need for rehabilitation facility (22%
versus 42%) [46].
Midterm and Long-Term Outcomes
Patients operated on for MV surgery using a MT
approach exhibit excellent survival rates, ranging from
100% to 99%, 98% to 97%, and 96% to 80% at 30 days, 1
year, and 5 years postoperatively, respectively [7, 9, 13, 34].
Freedom from reoperation ranges from 99% at 1 year to
93% at 5 years [7, 9, 13, 33, 58, 59]. After a follow-up of 4.2
 2.4 years, Iribarne and coworkers [20] registered no
signicant differences in mortality at 30 days (p 0.622)
or at 1 year (p 0.599) between the two approaches.
Quality of MV repair in the Raanani series [15] was also
comparable. In their patient population, follow-up
extended for as long as 100 months (34  24): NYHA
class similarly improved in both groups (p 0.394). Late
echocardiographic analysis revealed that 82% in the port-
access group and 91% in the ST group were free from
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moderate or severe mitral regurgitation (p 0.11), and
freedom from reoperation was 97% and 95% (p 0.6),
respectively [15].
In AV patients, Glauber and colleagues [23] presented a
median follow-up of 30 months (range, 17 to 54), with a
survival of 96%  2% versus 88%  4% (p 0.3) for MT
and ST, respectively. Sharony and colleagues [17]
observed a 36-month cumulative survival of 85% for the
MT group and 84.4% for the ST group (p 0.55).
Specic Patient Populations
ELDERLY AND OBESE PATIENTS. Among elderly patients, valve
surgery using MT compared with ST is associated with
shorter hospitalization, decreased resource use, and
improved postoperative functional status [43-46]. Grossi
and coworkers [43] rst addressed the potential benets
of minimally invasive approach in the elderly (>70
years) by enrolling 370 consecutive patients undergoing
isolated AV or MV surgery. Although hospital mortality
was comparable in the two groups, the MT approach
conferred a signicantly lower incidence of sepsis or
wound complications, less fresh frozen plasma, and
shorter length of stay. Lamelas and associates [45] also
collected data on elderly patients (75 years) with both
approaches, registering lower inhospital mortality (1.7%
versus 9.5%, p 0.01) and lower composite post-
operative morbidity and mortality (21% versus 45.2%, p
< 0.001) in the MT group. Holzhey and associates [44]
observed that long-term survival for elderly patients
(>70 years) undergoing MT and ST was 66%  5.6%
versus 56%  5.5% at 5 years and 35%  12% versus 40%
 7.9% at 8 years (p 0.43), respectively. Recent data
suggest that also obese patients and subjects affected
by chronic obstructive pulmonary disease operated
on for isolated valve surgery benet from the MT
approach [60, 61].
REOPERATIONS. Right MT has potential benet for both
reoperative MV and AV surgery, avoiding sternal reentry
and the risk of injury to cardiac structure and patent
grafts [3740]. In addition, the partial dissection of adhe-
sions implies a limited postoperative bleeding, with
reduction in the risk of blood transfusion and reexplora-
tion [3740]. The largest series, from Sharony and col-
leagues [40], accounted for 498 patients with previous
cardiac operations, of whom 337 were operated on
through ST (AV 160, MV 177) and 161 through MT
(AV 61, MV 100), documenting equal hospital mor-
tality, less hospital morbidity, decreased length of stay,
and slightly favorable midterm survival in the MT group.
Patients undergoing reoperation through MT state
they have less perioperative pain, faster recovery, and
better nal aesthetic results with respect to their prior
ST [3740].
Tricuspid and Combined Valve Surgery
Data on tricuspid valve (TV) surgery through MT are
lacking. The largest reported series by Lee and colleagues
[64] retrospectively enrolled 141 consecutive patients
undergoing TV operation through MT, although 73% of
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subjects had a concomitant MV operation [64]. Thirty-day
mortality was 2.1%, whereas stroke occurred in 2.8% of
patients and reexploration for bleeding in 5.6% [64].
Survival at 5 years was 48%  12% for patients having TV
surgery alone [64]. The same investigators also compared
the outcomes of 124 TV operations using MT, with an
equal number of subjects with ST [65]. The TV group
through MT revealed a lower 30-day mortality (2% versus
11%, p 0.007), less postoperative AF (18% versus 24%,
p 0.0025), less acute kidney injury (3% versus 11%, p
0.016), and shorter length of stay (11 versus 15 days, p
0.012). Seeburger and colleagues [66] analyzed 35 isolated
TV: valve repair was obtained in 77% of cases and hos-
pital mortality accounted for 5.7% of subjects. The mean
follow-up was 35  40 months and revealed a 5-year
survival of 90%. Similarly to MV and AV operations
through MT, excellent results are reported for isolated
reoperative TV operations [67].
Reports also describe combined valve surgery using the
MT approach, indicating the feasibility of either repair or
replacement with a good eld exposure to access the
aortic, mitral, and tricuspid valves without any particular
difculties [6870].
Robotic Valve Surgery
Relevant advances in telemanipulation, including com-
bination of three-dimensional vision, the computer-
enhanced EndoWrist (Intuitive Surgical, Sunnyvale, CA)
with an instrument tip allowing seven degrees of
freedom, a tremor ltering system, and motion scaling
enable performing MV robotic surgery through incisions
of only a few millimeters in diameter [7174]. Although
the robotic approach is restricted to a few specialized
centers, available data demonstrate that it is as safe and
effective as conventional approaches [7174]. Equivalent
early and late results, reduced patient trauma, more rapid
return to work, diminished blood loss, and limited length
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MINITHORACOTOMY IN HEART VALVE SURGERY
of stay are key elements of the increasing success of
robotic MV surgery [7174].
Study Limitations
Valve surgery through MT is undoubtedly associated
with prolonged aortic cross-clamp and CPB times
[11, 1416, 22, 23, 44, 57]. However, the longer surgery
times do not imply increased morbidity and mortality,
and high volume centers report shorter operative times,
although an important learning curve undoubtedly exists
along with consequent ethical issues [610, 17, 18, 20]. In
evaluating their initial MT experience for MV surgery,
Gammie and associates [75] documented a progressive
improvement in operative efciency over time, reaching a
plateau only after 135 cases performed by a single sur-
geon. Brinkman and coworkers [24] collected data on 90
patients who had AV surgery through MT, reporting a
learning curve that attens after approximately 45 to 50
cases (Fig 2). The majority of complications and reoper-
ations have been clearly demonstrated to occur in early
series [31, 71, 74, 76]. Mohr and coworkers [31] reported a
high mortality rate in their early MT cases with an evident
reduction after renements of surgical techniques (from
9.8% to 3%). Chitwood and colleagues [71] reported lower
rates of reoperation for MV repair failure in the latter two
thirds of a series of 300 robotic MV repairs. The same
group subsequently observed that learning mitral valve
surgery using telemanipulative technology proceeds ac-
cording to a logarithmic curve, with a learning percentage
of 95% [76].
REVIEW
The incidence of aortic dissection has been reported to
be between 0.3% and 3.5% by different groups using
different techniques of cannulation and aortic cross
clamping [22, 37, 47]. Jeanmart and colleagues [62]
described in detail their vascular complications in a
cohort of 978 MV patients undergoing MT surgery. They
encountered an overall rate of peripheral vascular
Fig 2. Decrease in surgical time with
surgeon experience using port
access. (Reprinted from Brinkman et al [20],
with permission from Elsevier.)
 362 MARISCALCO AND MUSUMECI
MINITHORACOTOMY IN HEART VALVE SURGERY
complications of 1%, with 44.4% happening at the time of
surgery and 63.6% during long-term follow-up [62]. All
aortic complications happened at the time of the surgery,
with 0.9% of aortic dissection mainly due to cannulation
problems. Mortality for aortic complications was 22.2%
[62]. Finally, phrenic nerve palsy occurs in 3% of the pa-
tients, groin infection in 3%, groin lymphocele in 6.5%,
iliac artery injury in 2.5%, and conversion to full
sternotomy in 1%, respectively [14, 15, 18, 21, 27, 63].
Conclusions
Over the past decade, the rapid development and
renement of techniques have led to consider valve sur-
gery through MT safe, effective, and durable. Despite
longer surgery times compared with the ST approach, the
MT approach has proven to be a cost-effective and cost-
saving strategy in valve surgery, being associated with
reduced morbidity and mortality rates. Patient satisfac-
tion is a testament to a variety of tangible benets of MT,
including less pain, faster postoperative recovery, and
better cosmetic results. Valve surgery through MT also
demonstrated excellent results in terms of freedom from
reoperation and long-term survival. However, these
enthusiastic reports should be tempered based on
important criticisms related to the MT approach that
cannot be ignored. The majority of the published series
are single-center retrospective experiences, comparing
noncontemporaneous patient populations with uncer-
tainty regarding consecutive recruitment. The inuence
of surgeon expertise on outcomes is also difcult to
REVIEW
ascertain. In addition, patients with concomitant surgical
procedures, diseased ascending aorta, and unfavorable
chest anatomy are generally excluded from comparisons,
leading to an incomplete assessment of the full spectrum
of patients with valve diseases treated with MT. Powered
randomized trials detecting and measuring objectively
the magnitude of benets versus risks between MT and
ST approaches are needed, to denitively conrm MT as
a complete and valid alternative approach for isolated
and combined heart valve surgery.
We thank Fondazione Cesare Bartorelli (Milan, Italy) for his
support.
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