Minimally Invasive AVR Surgery

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Mike From Michigan

Active member
Mar 15, 2004
Shelby Twp. Michigan
I was wondering how many of you had the minimally invasive (MI) AVR procedure?

My surgeon said that he does it on about 15% of his patients and that it reduces pain, recovery time and blood loss (as can be expected). Also, instead of a 10-12 inch scar on the full sternotomy you only end up with a 3-4 scar and the chance of infection is reduced.

The surgeon said that the main patient criteria for this is that the patient cannot be overweight, should be under 50, cannot have any possibility of coranary heart disease that could require a bypass and the aorta itself needs to be in good shape (not dilated ot having atherosclerosis). In rare cases, the heart is not positioned normally (either slightly "turned away" or the aorta is in the way), so that could also preclude having the MI surgery. Is other cases, what starts out as a MI procedure end up as a full sternotomy due to unforeseen circumstances during surgery. Also of course, the surgeon must be qualified to do this procedure as it takes more skill. The only downside is that it is a longer procedure and you are on the pump a little longer (~15+ minutes). If possible I will go with this MI procedure - I meet the under 50 and not overweight criteria, hopefully the other tests will show that I qualify to have this done. I don't see why I (or anyone) would choose not to have this procedure if I/they qualified with all the advantages, or am I missing something - seems like a no-brainer to me...

Since it seems like most of the post-surgery stories involve full sternotomies, I am curious why more of you didn't elect to have the MI procedure done. Was it for one of the reasons mentioned above or something else I missed?

Was it even offered as an option to you?

Were any of you given this option and turned it down? If so, why?

For those of you who have had it, how was the recovery time and pain?

Any other thoughts on this? Thanks.
A lot of places don't offer the minimally invasive techniques, either due to lack of training, or disagreements about the benefits. I asked about a minimally invasive (MI) surgery when I went for my AVR. The Chief of Cardiothoracic and Minimally Invasive Surgery said they don't offer it for valve replacements.

Since then, I have considered it, and I'm not sure that MI is necessarily at the maturity level it needs to be for me to be comfortable with it for AVR purposes. Note that I know some people here have had it quite successfully, and the following is not meant to bash MI surgery. It's just some of my impressions, twisted logic, and suppositions:

I suspect that, with the MI techniques, your pump time may be longer, as it is just more difficult and time-consuming to do in a more confined space.

I also think the traditional sternum splitting provides a full view and access to the heart, whereas some parts may be difficult to view from a window surgery. It certainly is more difficult to access the heart as easily and fully.

I'm not sure that there is a reasonable difference in recovery time. I've read several places that flat-out state that the recovery time is the same. However, they may be referring to just the heart's recovery as being the the same.

Intercostal pain complications seem to be as frequent with the MI surgeries as the standard ones. The main difference in recovery is that there are limitations on lifting for 10-12 weeks when the sternum has been sawn.

Just from casual observation, not a scientific study, I believe I've seen more infections and fluid problems on this site from MI surgeries than standard ones, so I'm not sure I agree about the lower infection risk without something more than one doctor's casual statement. It would be interesting to run a poll on that.

I had a full sternum split, and one of the items I note on the operation report is, "After copious irrigation with antibiotic saline, the chest was closed with eight, #5 wires..." You're not likely to get "copious irrigation" with antibiotic saline through a window, and I suspect therein may lie part of the difference. Then again, it's harder for the surgeon to leave his ham sandwich lunch in there by mistake, too...

I believe this is similar in ways to the tissue vs. mechanical valve debate: it is something of another Hobson's choice. Again, both methods work, but they also each have their strong and weak points.

My bottom line is that I'll pick my surgeon for his/her capabilities. Then I'll go with whatever method that surgeon is most comfortable and confident with.

Best wishes,
Check in the PreSurgery forum for "video of minimally invasive aortic valve replacement," which was posted by pgruskin.

Also, note: the statement in the B&W Hospital preview is what your surgeon said, verbatim.
I had an ascending aortic aneurysm resection and Minimally Invasive AVR. My incision line was only 4 inches long, and as far as pain- it was not bad at all- took extra strength tylenol for it. I was on bypass for 88min. Cross Clamp 54min. I was 1 month shy of my 50th birthday. There is a web cast showing avr- MI on Brigham & Womens hospital site, it is mentioned in one of the recent threads. I will PM you the site since I don't know how to enter them here. Kathy H
Just to complicate things... :D

My scar from a full sternotomy is only 5.5", I just measured (I had a pediatric surgeon so I guess he's used to working in small spaces). IMO, the chest tube scars look worse than the sternotomy scar. But to me, the main drawback to MI surgery is the surgeon's ability to gain immediate and full access to the heart if something were to go wrong. Having said all that, if I need a valve replacement in the future and they can do it by the keyhole (port) method or cath method (has been done for pulmonary valve) I would probably go for it.
Well, Bryan, my surgeon has hands like André the Giant, so my sternum scar is just over 10". But then, I wasn't any beauty to begin with.

Kathy, my clamp time was 31 minutes, bypass time 46 minutes. However, I had no repairs to the aorta.

Best wishes,
Hi Mike,
My husband who is 70 had minimally invasive avr on 12/18/03 performed by Dr. Cohn at Brigham and Women's hospital in Boston. You have to have a surgeon who is "very" experienced in the procedure (he has done over 3000 or more) and you have to have clean arteries. I'm sure that if they run into trouble, they can easily open the sternum the rest of the way. The first surgeon we went to at Yale was very against minimally invasive surgery and my husband said he understood why when he took a look at the size of his hands! :) Dick was on bypass 106 min., cross clamp 64 min. He had no pain from the incision at any time after the surgery and was back to tennis and golf at 3 months. The site to see the video is:
Mike this might also shed some light on it:
Journal of Cardiac Surgery
Volume 18 Issue 2 Page 133 - March 2003

Prospective Comparison of Minimally Invasive and Standard Techniques for Aortic Valve Replacement: Initial Experience in the First Hundred Patients
Pierre Corbi, M.D., Mohammad Rahmati, M.D., Erwan Donal, M.D.*, Hervé Lanquetot, M.D., Chistophe Jayle, M.D., Paul Menu, M.D., and Joseph Allal, M.D.

Background:Aortic valve replacement (AVR) can be performed through a partial upper sternotomy. In this study we compared the early postoperative outcome in two groups of patients who underwent AVR with a minimally invasive procedure(n = 30)or with a conventional approach(n = 70). The predicted operative mortality (Parsonnet Index) was slightly higher in the conventional group(17.69 ± 0.85 versus 12.7 ± 1.02), reflecting the greater mean age of the patients(70.96 ± 1.17 versus 64.20 ± 2.57). Results: The distribution of the different etiologies of aortic valve pathology did not differ between groups. There was no postoperative death in the mini-invasive group. Cardiopulmonary bypass time was longer in the mini-invasive group, but the other operative parameters did not differ between groups. Postoperative morbidity regarding the need for blood transfusion, the duration of assisted ventilation, length of stay in the intensive care unit, and abnormalities of cardiac rhythm and conduction was slightly but not significantly reduced in the mini-invasive group. Conclusions: Our data demonstrate that a partial upper sternotomy is a safe and effective technique for AVR. Postoperative morbidity is not significantly reduced in patients undergoing AVR by this approach. Further studies in a larger patient population are necessary to assess whether postoperative morbidity is significantly reduced.(J Card Surg 2003;18:133-139)

My husband's cardiologist at Brigham said it was like "getting hit by a sixteen wheeler instead of an 18 wheeler", but my husband didn't find that to be true.
Thanks for all your replies!

Thanks for all your replies!

Thank you everyone (so far) for your 2 cents on this.

I guess when the time comes I'll grill the surgeon a little more about his expertise with the MI procedure. In our one discussion I was very impressed about how open and candid he was and that he didn't mind answereing all my questions. I'm still leaning the MI way and if I get good vibes from him about doing it then that is the way I'll go.

My MRI is this Tuesday (5/25) so the next meeting with him should give the final verdict. I am also impressed in that he wants to be there during the MRI to direct the technician to look at specific things so there is nothing left uncovered. I spoke with the tech. when we set up the appointment time and he said that this particular surgeon is very thorough when it comes to MRI testing, more than any other Dr. he deals with. That is a good sign...
Mike, those do sound like good signs from the surgeon. He is meticulous and involved, which seems like it just has to be a big plus.

You're comfortable with the surgeon, which is key. If he has the experience, and he's that comfortable with the minimally invasive approach, then there's no real reason not to go with it. After all, it's really the sugeon's comfort level that becomes your own.

Here's to a successful surgery and a quick recovery!


plz all of u decide on your own in terms of valves and procedures, but a study with n=30 is just simply NOT significant - end of conversation!!!

ar bee
Go RU...

Go RU...

Bob H:

Just to let you know - I am a RU grad, class of '82, so I am quite familiar with New Brunswick, NJ. I was hoping to get back there this fall for the Homecoming football game but until this AVR thing is settled, those plans are on hold of course...

Thanks for all your insights, opinions and advice...

Hi Mike

Hi Mike

Another Jersey resident here chimming in. I don't know how different the AVR surgery is from MVR but I had MI surgery on my mitral valve this past January. At 30 yrs. old, I am able to shamefully admit that the reason I chose the MI surgery was for vanity reasons. I still like wearing v-neck & low cut shirts at my age so it was a no brainer for me. However, my surgeon warned me that the pain is just as significant due to the separation of the ribs which also take approx. 6 weeks to heal. My incision scar is 2.5 inches long and is as thin as a fishing wire. It's located just under my bustline. My chest tube scars look worse than the incision scar, how do you like that. As many have already advised, not all surgeons are qualified to do MI surgery so make sure your surgeon is highly qualified with a few MI's under his belt. Best wishes to you! This site is the best for support & info!
By the way-was the bar The Golden Rail in NB when you were at Rutgers? That's my old stomping ground :)
Keep us posted!
Those NB bars...

Those NB bars...


You said your Dr. warned you that the pain for MI surgery was about the same for the normal procedure due to the rib spreading - how was your pain level? Also, you can be sure I won't elect to have the MI AVR (if I qualify) unless I feel completely confident that the surgeon is an expert in that procedure - so far I have been impressed with him. I have a MRI this coming Tuesday then will meet with him about a week later for hopefully the final disposition.

I guess the Golden Rail is after my time at RU - the big off-campus bars back in my days ('78-'82) were the Knight Club and Old Queens Tavern - both on Easton Ave. I was "lucky" back then as the drinking age was only 18 so the pubs in the Student Centers were also hot spots and the beer was cheap - if you had $5 on you, you were good for the night! :D Believe it or not a popular band was "Atlantic City Expressway" that did a lot of very good Springsteen and Southside Johnny covers and the lead singer was a very young guy by the name of Jon Bon Jovi - I even saw them perfom in a frat house! It was years later when I read an article on him about his beginnings in music that I realized the connection as of course back when I saw him he was a no name - but he did a good Springsteen impersonation voice-wise. Ahh, those Jersey memories... :)
When I had my heartport procedure for minimally invasive mitral valve replacement they ended up having to remove part of a rib and then wire it back in place. I don't know if it broke when they were spreading my ribs or if they did it preemptively. I had quite a bit of pain in that area mostly from very painful muscle spasms. My incision looked really large right after surgery but it ended up being two incisions and not really connected in the middle. The largest is about 6 1/2 inches long. The surgery was about 7 1/2 hours long and I don't remember the bypass time offhand but it was much longer than I would have expected. The surgeon said he really doesn't know why it ended taking so long but that that is the way it goes sometimes.
Over 7 hours. Can't remember why?

Hmmm, Betty. Maybe he did have a turkey club sandwich with him when he went into surgery, and suddenly realized it was missing as he went to leave... :eek: :D


Gotta love Bruce & Bon Jovi! I'm a closet fan of Bon Jovi so I'm a bit jealous you got to see him at a frat house before he was famous.
Anyway, I am going to explain my experience with the pain but please remember everyone is different. Everyone's body is different and pain levels and tolerance vary. In regards to my pain, your not going to like what I have to say, but I want to be honest, on a scale of 1-10, 10 big highest level of pain of course, I would rate it as the following:
Immediately after surgery in ICU Level 10, it hurt like hell to even take a breath
Day after surgery, Level 8, the chest tubes are what really bothered me, because they were rubbing against the ribs that were spread, so it was pretty painful
Day 3, they removed the chest tubes and the pain decreased to what I would consider Level 6
For the 5 weeks post surgery, I would rate it a Level 5. Less pain but very uncomfortable. I felt like I had to guard myself and protect my chest. It hurt to sneeze and cough. The incision itself is very sensitive and I temporarily lost feeling in my right arm and breast due to nerves being cut during the surgery. Don't panic---all feeling is now back, it does return after a few weeks.
On the up side I was only in the hospital for 3 nights and was released in the morning of the fourth day. That's pretty incredible for open heart surgery. My surgeon said it is usually a shorter hospital stay with MI surgery as long as everything goes well. Additionally, they will have you are morphine for the time you are in ICU and probably the step-down unit. So if you experience the pain levels I described, you get to push a button attached to your IV and self-administer pain meds. You'll doze off a few times and it won't be so bad.
I'm the biggest baby in the world & was panic stricken the day of surgery but I got through it and so did everyone else here on this site. I believe it's mind over matter. You have to stay positive & remember why you are doing this surgery in the first place--to live a long, healthy life. The whole process from surgery to recovery and back to normal life is usually 6-8 weeks. In the grand scheme of things that is a short period of time to sacrafice and suffer in order to have such a reward when it's over. Trust me, you will be thankful you did it and you will physically feel great afterwards.
Best of luck to you, please keep in touch and let us all know what's going on.
Dawn :)