Why Minimally Invasive Aortic Valve Replacement (MICS AVR)?

Understanding minimally invasive surgery is important. Making the right decisions could change your life.

Minimally Invasive Aortic Valve Replacement is not new!

Minimally invasive Aortic Valve Replacement or MICS AVR often referred to as mini AVR or key hole aortic valve replacement was first performed in 1996. The first few MICS aortic valve replacements were performed by groups at the Harvard Medical School’s teaching Hospital, Brigham and Women’s Hospital in Boston and the Cleveland Clinic. MICS AVR has been performed for close to two decades and has an excellent track record of safety. Several scientific publications have now been published demonstrating that outcomes as well as safety is at the least equal if not superior to the conventional open heart technique.  When performed by trained surgeons who regularly perform minimally invasive procedures the outcome is definitely superior to the conventional technique.

There are two techniques by which MICS Aortic Valve Replacement can be performed. The Right anterior thoracotomy approach (RAT) does not require any bone to be cut. The Upper hemisternotomy technique requires the upper part of the sternum or breastbone to be cut.

As a technique the ‘RAT approach’ is superior but requires a skilled and experienced surgeon to perform the operation.

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Reduction in Pain

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Reduced Use of Narcotic Analgesia

Right anterior thoracotomy or RAT Approach

In this superior technique the aortic valve is approached between the ribs on the right side. Usually the space between the second and third rib is the site of entry. Once the aorta is exposed the rest of the operation is the same as all other techniques of replacing the aortic valve. The advantage of this approach is that none of the bones are cut, significantly reducing pain. It allows for much faster healing. The cut is a mere 4cms. Skin infection is  near zero and as no bone is cut the dreaded bone infection (Osteomyelitis)  is eliminated. Not cutting the bone also decreases blood loss during the operation and this in turn translates into significantly reduced need for blood transfusion.

The Upper Hemisternotomy Approach

In this approach the upper part of the breast bone or sternum is cut. Only the upper 1/3rd of the sternum is cut leaving the lower one third intact. The skin cut is a mere 2 inches. This is a useful approach in those where a parasternal technique is considered difficult. The approach is useful in special situations where the entire aorta or the aortic root requires replacement (Bental procedure). Such an operation may be required when the aorta is enlarged above the aortic valve requiring replacement. Since the bone is cut this approach is considered inferior to the parasternal technique. It however has its role and is performed routinely the world over.

 

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Reduction in Wound Infection

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Reduced Blood Transfusion

Days In Hospital

Days to Recover

PARASTERNAL Aortic Valve Replacement

The recovery after the parasternal approach for aortic valve replacement is faster as no bones are cut. However not all patients are suitable for this approach. The decision on the right approach is made by the surgeon and depends on the anatomy.

The upper hemisternotomy technique involves cutting the upper 1/3rd of the sternum on one side. This cut in the skin is as small as the parasternal approach and heals without complications. The pain is more than the parasternal approach though. Some restrictions to physical activity apply with this approach as the bone is partially cut. It should be noted that the recovery is much faster than open surgery.

Right anterior thoracotomy or RAT approach after healing.
Upper hemisternotomy approach after healing.

Total MICS Aortic Valve Replacements

  • Success Rates 99% 99%

Our Experience

Having initiated the program in 2008 the surgical group headed by Dr Nambala at Apollo, Bangalore has performed more than 450 Minimally Invasive Aortic valve replacements (MICS). The outcomes have been exceptionally good and match the best hospitals in the world. We are one among a handful of centers in the country that can perform this operation without cutting the bone. We take great pride in our outcomes and we routinely conduct training programs, observerships and live workshops at other centers with the aim of training surgeons across the country. Till date we have performed live surgeries at almost all leading heart centers in the country and our series is the largest in the country.

Recovery after Minimally Invasive Aortic Valve Replacement

In general, recovery after a heart operation is influenced by the patients health prior to surgery. In those who have been active prior to their heart operation discharge from the hospital could be as early as 48 hours. When a parasternal approach has been used for valve replacement most patients can resume all normal activity within a week after discharge from hospital. Below are answers to a list of questions that patients frequently ask following their heart surgery. Please note that this is only a general guide and any special instructions given to you in particular, at the time of discharge, must be followed.
How soon can I resume brisk activity after my valve replacement?

Following a minimally invasive aortic valve replacement brisk activity can be resumed within a week. With the RAT approach (no bones cut) it can be resumed faster than with the upper hemisternotomy technique. Some patients are back to swimming within ten days after surgery. Brisk walking or normal daily activity is unrestricted after a week following replacement. Again it’s important to understand that the patients condition prior to the surgery will impact on their recovery after surgery. Onset of significant symptoms such as syncope or loss of weight in general mean that the disease is advanced or neglected and such patients may require longer to recover. Your surgeon should be able to tell you by his experience, on how long it would take for you recover in most instances.

Are there any additional risks attached to minimally invasive valve replacement?
No there are no additional risks to a minimally invasive procedure if performed by a formally trained surgeon. Its important to ask your surgeon where he trained in these techniques. While most surgeons may not like being asked these questions its important to know if your surgeon actually went through a formal training program in minimally invasive techniques. While most procedures can be done after attending a brief course, special situations will require formal training to save a life on the operating table. Unfortunately its not alway possible to predict when such situations arise. Its always best to consult an experienced minimally invasive surgeon with formal training for good outcomes. Minimally invasive aortic valve replacement is a well established technique and several scientific papers have already been published with equal or superior outcomes when compared to the open technique. These techniques definitely require more skill than conventional surgery and are probably unsafe to be practiced by untrained surgeons.
What is the length of hospitalisation after minimally invasive AVR?
The duration of hospitalisation does not usually exceed 3 days including the day of surgery in otherwise fit patients. Its important for patients to understand that their recovery is dependent on how fit they are prior to admission. Patients presenting with complications take longer to recover compared to patients who are active and without complications. Older patients may require a day or two longer.
Watch the technique of a minimally invasive aortic valve replacement (MICS AVR) by the parasternal approach.
Mrs VG underwent a minimally invasive aortic valve replacement for critical aortic stenosis about a year ago. This year she completed the 10km run in Hyderabad. This is a tribute to her spirit to overcome odds, the tenacity of the human mind and advantages of non bone cutting minimally invasive technique.

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