Transaxillary aortic valve replacement with sutured prostheses

Clinical vignetteA 52-year-old male patient attended the local emergency department due to a 3-week history of progressive dyspnea, intermittent chest tightness and cough, initially treated with an antibiotic course but with no improvement.During initial assessment, there was evidence of heart failure due to severe aortic stenosis.Past medical history was significant for hypertension and type 2 diabetes, and he was a smoker.Transthoracic echocardiography demonstrated evidence of impaired left ventricular (LV) systolic function (ejection fraction ~39%) and a mildly dilated LV.Coronary angiogram demonstrated no coronary artery disease.Following surgical assessment and computed tomography (CT) review, anatomical features were favorable for a minimally invasive transaxillary surgical approach to address the aortic valve pathology. Surgical techniques PreparationThe patient is positioned supine.The right arm is flexed posteriorly to allow access to the right side of the chest to facilitate the transaxillary incision, placement of the aortic cross-clamp, and positioning of the cardiopulmonary bypass sump sucker (this port is then used for chest drainage).The mid and anterior axillary lines are fully visible and accessible.A transvenous ventricular pacing wire is sited during the anesthetic preparation, as well as an intercostal nerve block, to facilitate perioperative management and allow for enhanced recovery of the patient.Surgery can be performed with lung isolation or with a single lumen endotracheal tube with short, limited periods of intermittent apnoea until cardiopulmonary bypass is established. ExposureA 4-to 5-cm longitudinal skin incision in the right anterior axillary line is made, followed by a pectoralis muscle-sparing anterolateral mini thoracotomy following the rib to approach the 3 rd or in certain cases, the 4 th intercostal space.