Can Complex Aortic Surgery Be Minimally Invasive?
Summary
- A new study from the University of Miami Miller School of Medicine compares outcomes of a minimally invasive procedure that replaces only the aortic valve with another that also includes ascending aortic or hemiarch replacement.
- The goal of the study was to see whether adding ascending aorta replacement increased the risk of complications, longer hospital stays or mortality.
- The research team discovered a number of differences in results but the five-year survival rates of both groups of study participants were an excellent 98.8%.
Minimally invasive heart surgery has evolved to offer patients faster recovery times, less pain and fewer complications. But what happens when the surgery is more complex than replacing a valve?
A new study from the University of Miami Miller School of Medicine tackles this question head-on, comparing outcomes of two types of minimally invasive procedures: one that replaces only the aortic valve and another that also includes ascending aortic or hemiarch replacement.
Studying Two Types of Aortic Valve Replacement
The study, led by Joseph Lamelas, M.D., professor in the DeWitt Daughtry Family Department of Surgery at the Miller School, and colleague Ahmed Alnajar, M.D., MSPH, looked at 796 patients who underwent minimally invasive aortic valve replacement (AVR) between 2019 and 2024. Of these, 624 had isolated AVR while 172 had AVR combined with ascending aortic and/or hemiarch replacement (AVR+Asc).
The goal was to see whether adding ascending aorta replacement increased the risk of complications, longer hospital stays or mortality.
This retrospective cohort study analyzed all surgeries performed by a single, experienced surgeon, Dr. Lamelas. He used a right mini-thoracotomy approach—a small incision between the ribs that avoids cutting through the sternum. The study compared outcomes including:
• Operative time
• ICU and hospital stay
• In-hospital mortality
• Stroke rates
• 30-day readmission
• Five-year mortality
What Did the Aortic Valve Surgeries Involve?
For isolated AVR, the procedure was performed through a four- to five-centimeter incision in the second or third intercostal space. For AVR+Asc, the incision was made slightly lower to allow better access to the ascending aorta. Cardiopulmonary bypass was initiated through femoral artery and vein cannulation.
In cases involving hemiarch replacement, circulatory arrest was used along with retrograde cerebral perfusion to protect the brain. The aorta was carefully reconstructed using prosthetic grafts and long-shafted instruments, with meticulous, two-layer suturing to ensure hemostasis.
Study Results
The research team discovered a number of differences in results between the two types of aortic surgeries. But the five-year survival rates of both groups of study participants were an excellent 98.8%.
“Our findings suggest that even these high-complexity cases—such as those involving root or hemiarch pathology—can be approached successfully through a sternotomy-sparing mini-thoracotomy approach via experienced hands, preserving surgical durability without compromising recovery,” said Dr. Lamelas. “This work builds on prior studies by expanding the minimally invasive approach to a broader, higher-risk population, although should be performed by surgeons extremely experienced with this approach”
Other notable study results include:
• Longer surgery times: As expected, AVR+Asc took longer. The time the heart was stopped (cross-clamp time) was 124 minutes versus 69 minutes for AVR alone. The time on the heart-lung machine (CPB time) was also significantly longer.
• Low rates of conversion to sternotomy: Conversion from minimally invasive thoracotomy to sternotomy occurred in only one patient from each group.
• Minimal infectious complications: Rates of pneumonia and sepsis and surgical site infections were low and similar across groups, highlighting the safety of the minimally invasive approach.
• Less surgical trauma, less bleeding: Although transfusion needs were higher in AVR+Asc patients, the majority still avoided major blood loss. Nearly 80% requiring no RBC transfusion. This reflects the reduced tissue injury and smaller operative field associated with the mini-thoracotomy approach.
• Low readmission rates: While 30-day readmission was higher in AVR+Asc (5.8% vs. 2.1%; P = .018), the absolute rate remained low for both groups. Importantly, readmissions were not driven by major complications, supporting the overall safety and effectiveness of complex surgery in a minimally invasive fashion.
• Low mortality and stroke rates: Despite the increased complexity, in-hospital mortality was 1.2% for AVR+Asc and 0% for AVR. Stroke occurred in only one AVR+Asc patient.
Perhaps just as importantly, Dr. Alnajar received bountiful, grateful feedback from study participants.
“During follow-up calls, patients undergoing the ascending aortic surgery shared with me how thankful they were,” he said. “Not just for the smooth recovery, but for returning to full, active lives and maintaining it for years after this surgery. That kind of outcome is a clear result of the meticulous planning and technique we bring to each case.”
Why Does This Matter?
This study shows that even complex aortic surgeries can be done safely through a minimally invasive approach, without significantly increasing the risk of death or major complications. That’s a big deal for patients who might otherwise face a full sternotomy and a longer recovery.
It also opens the door for broader use of minimally invasive techniques in patients with combined aortic valve and ascending aortic disease.
Minimally invasive AVR with ascending aortic or hemiarch replacement is not only feasible. It’s safe and effective when done with skilled hands.
“While TAVR has transformed treatment for isolated aortic valve disease, open, minimally invasive surgery remains a vital option, especially when combined aortic surgeries are needed,” said Dr. Alnajar. “This approach ensures patients receive the least-invasive option without compromising outcomes or durability.”
Tags: aortic valve replacement, DeWitt Daughtry Family Department of Surgery, Dr. Ahmed Alnajar, Dr. Joseph Lamelas, heart disease