Surgery that looks like transcatheter aortic valve implantation: the transaxillary concept for minimally invasive aortic valve replacement in 1,848 consecutive patients

Background: The transaxillary (TxA) approach for minimally invasive aortic valve replacement (MICS-AVR) is a sternum-sparing technique that combines surgical valve replacement with virtually no visible scarring. We report institutional outcomes of the first 1,848 consecutive TxA MICS-AVR procedures. Methods: This retrospective single-center cohort included all consecutive patients undergoing isolated TxA MICS-AVR between January 2019 and June 2026. Patients with active endocarditis, redo surgery, or concomitant procedures were excluded. Primary endpoints were 30-day mortality and major adverse cardiac and cerebrovascular events (MACCEs). Univariable and multivariable logistic regression explored associations with adverse outcomes. Results: Mean age was 67.7±8.1 years, Society of Thoracic Surgeons Predicted Risk of Operative Mortality (STS-PROM) 1.39%±2.90%, and European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) 1.65%±1.12%. TxA use among surgical treatments for isolated aortic valve disease rose from 18.8% in 2019 to 99.2% in 2025. Mean operative, cardiopulmonary bypass, and cross-clamp times were 132±34, 69±23, and 43±16 minutes. No intraoperative death occurred; 1.6% required conversion to sternotomy. Thirty-day mortality was 0.5%, and MACCE occurred in 1.6%, including stroke in 0.9% and myocardial infarction in 0.5%. In multivariable analysis, mortality associations were strongest for insulin-treated diabetes [odds ratio (OR) 8.56], left ventricular ejection fraction (LVEF) <40% (OR 8.45), and intraoperative transfusion (OR 17.86); corresponding MACCE associations included insulin-treated diabetes (OR 3.06), coronary artery disease (OR 2.46), peripheral arterial disease (OR 3.23), sternotomy conversion (OR 5.33), and transfusion (OR 5.49). These outcomes accompanied rapid institutional adoption of the technique, while operative efficiency remained favorable and the need for sternotomy conversion stayed low throughout the cohort. Given only 10 deaths and 30 MACCEs, multivariable findings should be considered exploratory and hypothesis-generating. Conclusions: Across 1,848 consecutive procedures, TxA MICS-AVR showed excellent reproducibility and safety. As long-term evidence increasingly supports surgical valve replacement in patients with extended life expectancy, TxA uniquely combines durable surgery with a cosmetic result comparable to transcatheter therapy, offering a scalable and strategically relevant platform for contemporary aortic valve care.