The patient underwent surgery with right anterior thoracotomy incision. After anesthesia induction, he was intubated with a double-lumen endotracheal tube for single lung ventilation and had intraoperative transesophageal echocardiography. On supine position, the external defibrillator pads were placed, and the skin incision and peripheral cannulation was performed. By peripheral cannulation via femoral artery and vein, a right anterior thoracotomy with a 5 cm skin incision from the third intercostal space near the sternal border was performed. The right internal thoracic artery and veins were ligated. A soft tissue retractor was inserted into the incision. Pericardial fat was excised and pericardiotomy was performed 4 cm anterior to the right phrenic nerve. The pericardium was retracted by passing sutures through the chest wall away from the incision. The operative field was insufflated with carbon dioxide. A 23 mm Medtronic Hancock bioprosthetic valve (Medtronic, Minneapolis, MN, USA) was implanted (Figure 1). Cross-clamp and cardiopulmonary bypass times were 83 min and 108 min, respectively. Postoperative course was uneventful.

Figure 1: Sutured aortic bioprothesis valve replacement via right anterior thoracotomy approach.

Improved cosmesis, less pain and narcotic use, and rapid recovery have been reported, which offer more comfort to both patients and surgeons. Several studies address ministernotomy, while outcomes of minimally invasive valve replacement via RAT have not been well-defined, yet. Establishing the more comfortable way of operation for aortic valve surgery requires a coordinated effort by the surgeon, anesthesiologist, perfusionist, and nurses. Upper hemisternotomy may be applied by less experienced minimal invasive AVR surgeons. However, stability of the manubrium is the weaker chain of the operation. The sternotomy is re-approximated using steel wires. Right anterior thoracotomy avoids sternotomy, while the integrity of the sternum minimizes the postoperative discomfort with a limited skin incision.[1] Although, the surgical site is smaller and the aortic valve sits deeper within the wound. Exposure is facilitated by minimizing cannulation techniques within the incision, coupled with strategic placement of pericardial sutures.[2] Most studies show that RAT is a safe procedure associated with low mortality and postoperative complications. The in-hospital mortality of 1.5% is lower than the recent mortality rate reported in the Society of Thoracic Surgeons Database.[3] Although cross-clamp and cardiopulmonary bypass times were longer than in the standard approach, the low incidence of postoperative stroke, renal failure, atrial fibrillation, and blood transfusions, as well as the short postoperative recovery, are consistent with other minimally invasive approaches, highlighting the safety of this procedure.[4] In addition, due to the psychological and cosmetic results, it is a preferable method.[5]

In conclusion, minimally invasive aortic valve replacement via a right anterior thoracotomy is a safe and effective method.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

1) Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-7.

2) Malaisrie SC, Barnhart GR, Farivar RS, Mehall J, Hummel B, Rodriguez E, et al. Current era minimally invasive aortic valve replacement: techniques and practice. J Thorac Cardiovasc Surg 2014;147:6-14.

3) Brown JM, O'Brien SM, Wu C, Sikora JA, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg 2009;137:82-90.

4) Glauber M, Karimov JH. A completely detachable aortic clamping instrument for minimally invasive cardiac surgery. Innovations (Phila) 2010;5:309-10.

5) Sarıoglu T, Erek E, Kınoglu B, Aydemir N, Sarıoglu A, Sansoy V. Aort kapak hastalığı ve subaortik stenoz olgularında alternative ‘less invaziv' yaklaşım: Sağ anterior submammarian minitorakotomi. Turk Gogus Kalp ve Dama 2000;8:771-3.