Minimally invasive valve surgery in high-risk patients

Since its inception in 1996, the performance of minimally invasive valve surgery (MIVS) has grown significantly (1-3). Many different approaches for MIVS have been described, however, the most commonly utilized include a right anterior or lateral thoracotomy, an upper hemisternotomy, and the use of robotic technology (Figure 1) (4). When compared with a standard median sternotomy (ST), the reported benefits of MIVS include: reduced surgical trauma, post-operative pain, blood loss and need for re-operation for bleeding, shorter ventilation time, intensive care unit (ICU) and hospital length of stay (LOS), decreased incidence of post-operative atrial fibrillation, reduced cost, less use of rehabilitation resources, improved cosmesis, and a more rapid return to functional activity (2,5-7). Because of these advantages, high-risk patients may especially benefit from this approach, as opposed to ST (8,9). However, these potential benefits may come with an increased risk of stroke, aortic dissection or aortic injury, phrenic nerve palsy, groin infections/complications, and increased cross-clamp, cardiopulmonary bypass, and procedure time (5).