Minimally Invasive Aortic Valve Surgery: Cleveland Clinic Experience

Douglas R. Johnston; Eric E. Roselli


Ann Cardiothorac Surg. 2015;4(2):140-147. 

In This Article

Abstract and Introduction


Background Minimally invasive surgery has become a routine approach for aortic valve disease over the last 18 years at the Cleveland Clinic. It is performed in isolation or in combination with other procedures. The objective of this study is to review trends and outcomes in these patients.

Methods Cleveland Clinic Cardiovascular Information Registry (CVIR) was searched for aortic valve procedures from 1996 to 2013. All patients undergoing isolated or combined aortic valve operations were included for analysis. The incision type and procedure type were reviewed and trends were evaluated over time. Cleveland Clinic outcomes with minimally invasive approaches to the aortic valve are reviewed.

Results A total of 22,766 aortic valve surgical procedures were performed in this 18-year timeframe. Of these, 3,385 (14.9%) were minimally invasive procedures (MIPs) and 2,379 (10.5%) were isolated minimally invasive aortic valves. MIPs increased from 12.4% to 29.6% of the total aortic valve volume over the period of the study. Combined procedures, including concomitant surgery on the aorta, mitral valve, tricuspid valve, and arrhythmia surgery increased over time as well. Overall mortality for primary and reoperative aortic valve operations continues to decline and has consistently been less than 1% for several years.

Conclusions A programmed approach to minimally invasive aortic valve surgery (MIAVS) with careful patient selection, appropriate use of preoperative imaging, and selective conversion to sternotomy when necessary, allows for aortic valve replacement (AVR) and a wide range of concomitant procedures to be performed safely in a large number of patients.


Since the minimally invasive approach to valve surgery was first brought to the Cleveland Clinic by Cosgrove, it has been increasingly adopted by cardiac surgeons worldwide.[1,2] Minimally invasive surgery has evolved to become the standard of care for isolated aortic or mitral valve disease at our institution, with a wide variety of approaches, techniques and cannulation strategies employed over the past two decades[3,4] (Figure 1). Techniques have been refined and iterative improvements have continued to allow for expanded indications and improved outcomes.

Figure 1.

Rising trend of less-invasive aortic valve surgery at Cleveland Clinic. Reproduced with permission (4).

While minimally invasive approaches to aortic and mitral valve surgery have evolved in parallel, there are unique considerations that inform the choice of incision for such patients. In the case of degenerative mitral valve disease, robotic and thoracotomy approaches have become the norm, while the protocol for aortic valve disease is more complex. The combination of disease state, concomitant cardiac disease, age, comorbid conditions, and procedure type define a different paradigm for decision making in aortic valve disease.

The primary disease process for which patients are referred for aortic valve surgery remains aortic stenosis. This population is older and more likely to have concomitant vascular disease compared to the mitral valve population. In addition to senile aortic stenosis, bicuspid aortic valve disease is a major etiology referred for surgery. These patients present a unique challenge in tailoring the operation to the individual, as both the treatment of associated aneurysm and prevention of future disease or need for reoperation must be considered.

The objectives of this study are to describe the trends in minimally invasive aortic valve surgery (MIAVS) at the Cleveland Clinic from the inception of this technique to the present; to review the current practice of MIAVS in terms of patient selection, known pitfalls, cannulation and protection strategies; and to review outcomes of this current strategy.