Mon 10 April 2017
I have communicated the relative merits of keyhole therapies in relation to the mitral valve on many occasions, primarily because this is one of the least penetrated keyhole procedures in the world to date. I believe that the reason for this is related to the steep learning curve associated with the procedure. Although keyhole aortic valve surgery is also a highly specialist procedure, technical reproducibility has meant that it is much more widely practiced and can offer patients significant benefits over traditional breastbone division.
We have performed many keyhole aortic valve procedures over the last few years and although data from randomized trials are lacking, there is no doubt that, in experienced hands, there can be benefits that go far beyond the obvious cosmetic superiority of keyhole approaches.
The procedure is most commonly performed via a mini-cut through the breastbone, which essentially leaves a significant portion of the breastbone intact. The purported benefits of this are reduced bone healing requirements, and superior sternal stability.
Various studies have also shown benefits in terms of shorter ventilation times, reduced intensive care and hospital stay, and reduced blood loss (1-4). One study even concluded a potential mortality benefit (2) though larger trials are required to confirm this.
The operation undoubtedly takes a little longer, and the advent of sutureless valve technology will play a major role in carving a very important niche for keyhole aortic valve surgery in the future. Our experience suggests this, and we are now operating on patients who may previously have been declined surgery, or perhaps would have been referred for other less proven therapies.
A further advance is the advent of mini-thoracotomy aortic valve surgery (which avoids breastbone division all together by accessing the heart between ribs). Not everyone is suitable for this procedure, but for those in whom it is possible, there seems to be clinical benefits in experienced hands. (5)
If you are interested in any of the therapies discussed here, please speak to your General Practitioner or Hospital Doctor. Alternatively, please visit us at www.thekeyholeheartclinic.com or call us on +44 (0) 203 368 3028 and we would be delighted to assist you.
Inderpaul Birdi, Consultant Cardiac Surgeon, The Keyhole Heart Clinic
1. Brown et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg 2009; 137:670-9.e5
2. Murtuza B et al. Minimal access aortic valve replacement: is it worth it? Ann Thorac Surg 2008;85:1121-31
3. Phan K et al. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg 2014;98:1499-511
4. Khosbin E et al. Mini-sternotomy for aortic valve replacement reduces length of stay in the cardiac intensive care unit: meta-analysis of randomized controlled trial. BMJ Open 2011;1:e000266
5. Miceli A et al. Minimally invasive aortic valve replacement using right minithoracotomy is associated with better outcomes than ministernotomy. J Thorac Cardiovasc Surg 2014;148:133-7