Aortic valve replacement (AVR) has undergone transformative advancements over the past decade, driven by innovations in minimally invasive techniques.

Traditional sternotomy, once the gold standard, is increasingly complemented or replaced by less invasive approaches that reduce surgical trauma while maintaining efficacy.

The clinical imperative to minimize perioperative morbidity has spurred the development of transcatheter and minimally invasive surgical modalities, reshaping treatment algorithms for aortic valve disease.

Surgical Approaches: From Mini-Sternotomy to Transcatheter Solutions

Mini-Sternotomy and Right Anterior Thoracotomy

Minimally invasive surgical AVR commonly employs a mini-sternotomy or right anterior thoracotomy approach. The mini-sternotomy involves a partial incision of the sternum, usually spanning the upper third, providing adequate exposure for valve excision and prosthesis implantation. The right anterior thoracotomy accesses the valve via a smaller incision on the right chest wall, avoiding sternotomy altogether.

These techniques reduce operative blood loss, postoperative pain, and hospital length of stay compared to full sternotomy. Furthermore, they enhance cosmesis, which is particularly significant in younger or cosmetically conscious patients.

Transcatheter Aortic Valve Replacement (TAVR)

The most revolutionary advance in minimally invasive AVR is undoubtedly transcatheter aortic valve replacement (TAVR). Initially reserved for patients with prohibitive surgical risk, TAVR indications have broadened to include intermediate and even low-risk cohorts based on robust randomized controlled trials such as PARTNER 3 and Evolut Low Risk.

TAVR entails percutaneous insertion of a collapsible bioprosthetic valve via transfemoral, transapical, or alternative access routes. The valve is deployed within the diseased native valve, eliminating the need for cardiopulmonary bypass and open chest surgery. This modality markedly reduces procedural invasiveness and accelerates patient recovery.

Valve Technologies: Innovations in Prosthetic Design and Materials

Advancements in prosthetic valve technology complement surgical approaches. Modern TAVR valves, such as the Sapien 3 Ultra (Edwards Lifesciences) and the Evolut Pro+ (Medtronic), integrate features to enhance sealing, reduce paravalvular leak, and improve durability. Novel leaflet materials and frame designs aim to minimize thrombogenicity and structural valve degeneration.

Surgical bioprostheses continue evolving with thinner leaflets and anti-calcification treatments to extend valve longevity. The advent of sutureless and rapid-deployment valves merges benefits of surgical and transcatheter techniques, allowing faster implantation and less cross-clamp time.

Patient Selection and Risk Stratification: Personalizing Minimally Invasive AVR

Precision in patient selection is critical to optimizing outcomes in minimally invasive AVR. Comprehensive evaluation incorporating anatomical, physiological, and frailty assessments guides modality choice. Multidisciplinary heart teams integrate imaging modalities such as 3D echocardiography, cardiac CT, and MRI to assess valve morphology, annulus size, vascular access, and comorbidities.

The STS (Society of Thoracic Surgeons) risk score and EuroSCORE II remain instrumental in predicting surgical mortality, yet evolving risk calculators now incorporate frailty indices and biomarkers to refine decision-making. For example, patients with extensive calcification of the aorta or hostile chest anatomy may benefit more from TAVR, while those with bicuspid valves or younger age might be better served by minimally invasive surgical AVR.

Procedural Outcomes and Complications: Contemporary Evidence

Accumulating data affirm that minimally invasive AVR techniques yield comparable or superior outcomes relative to traditional surgery. Studies report reduced ICU stays, lower transfusion rates, and faster return to baseline function. Nevertheless, specific complications merit attention. TAVR carries risks of paravalvular leak, conduction disturbances requiring permanent pacemaker implantation, and vascular access complications. Mini-sternotomy may prolong operative time but reduces sternal wound infections and respiratory complications.

The horizon of minimally invasive AVR includes integration of robotic assistance and hybrid operating rooms combining surgical and catheter-based expertise. Robotic platforms enhance precision in valve excision and implantation via small incisions, potentially reducing human error and improving ergonomics.

Hybrid suites allow seamless transition between surgical and transcatheter techniques during a single procedure, facilitating tailored treatment in complex cases. Artificial intelligence-driven imaging analytics promise to refine preoperative planning and intraoperative guidance.

Minimally invasive aortic valve replacement embodies a dynamic interplay of surgical innovation, advanced prosthetic technology, and personalized patient care. As these techniques mature, the focus shifts toward expanding access, enhancing durability, and minimizing complications.