CC BY-NC-ND 4.0 · Thorac Cardiovasc Surg 2023; 71(05): 387-397
DOI: 10.1055/s-0042-1743593
Original Cardiovascular

Minimally Invasive Aortic Valve Replacement in Contemporary Practice: Clinical and Hemodynamic Performance from a Prospective Multicenter Trial

1   Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
Michiel D. Vriesendorp
1   Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
Michael J. Reardon
2   Department of Cardiothoracic Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
Vivek Rao
3   Department of Cardiovascular Surgery, Toronto General Hospital, Toronto, Canada
Rüdiger Lange
4   Department of Cardiovascular Surgery, German Heart Center Munich, Munich, Germany
Himanshu J. Patel
5   Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, United States
Elizabeth Gearhart
6   Department of Biostatistics, Medtronic, Mounds View, Minnesota, United States
Joseph F. Sabik III
7   Department of Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
Robert J.M. Klautz
1   Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
› Author Affiliations
Funding The PERIGON Pivotal trial was sponsored by Medtronic.


Background The advent of transcatheter aortic valve replacement (AVR) has led to an increased emphasis on reducing the invasiveness of surgical procedures. The aim of this study was to evaluate clinical outcomes and hemodynamic performance achieved with minimally invasive aortic valve replacement (MI-AVR) as compared with conventional AVR.

Methods Patients who underwent surgical AVR with the Avalus bioprosthesis, as part of a prospective multicenter non-randomized trial, were included in this analysis. Surgical approach was left to the discretion of the surgeons. Patient characteristics and clinical outcomes were compared between MI-AVR and conventional AVR groups in the entire cohort (n = 1077) and in an isolated AVR subcohort (n = 528). Propensity score adjustment was performed to estimate the effect of MI-AVR on adverse events.

Results Patients treated with MI-AVR were younger, had lower STS scores, and underwent concomitant procedures less often. Valve size implanted was comparable between the groups. MI-AVR was associated with longer procedural times in the isolated AVR subcohort. Postprocedural hemodynamic performance was comparable. There were no significant differences between MI-AVR and conventional AVR in early and 3-year all-cause mortality, thromboembolism, reintervention, or a composite of those endpoints within either the entire cohort or the isolated AVR subcohort. After propensity score adjustment, there remained no association between MI-AVR and the composite endpoint (hazard ratio: 0.86, 95% confidence interval: 0.47–1.55, p = 0.61).

Conclusion Three-year outcomes after MI-AVR with the Avalus bioprosthetic valve were comparable to conventional AVR. These results provide important insights into the overall ability to reduce the invasiveness of AVR without compromising outcomes.


Presented at the 34th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Barcelona, Spain, October 8–10, 2020.

Authors' Contribution

B.J.J.V. and M.D.V. were involved in writing of the original draft, methodology, and visualization. M.J.R., V.R., R.L., and H.J.P. helped in providing resources, and were involved in writing and review and editing of the manuscript. E.G. was involved in software, validation, formal analysis, data curation, visualization, and in writing, review and editing of the manuscript. J.F.S. III and R.J.M.K. were involved in supervision, conceptualization, resources, writing and review and editing of the manuscript. Identifier


Supplementary Material

Publication History

Received: 17 September 2021

Accepted: 04 January 2022

Article published online:
29 May 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Hamm CW, Arsalan M, Mack MJ. The future of transcatheter aortic valve implantation. Eur Heart J 2016; 37 (10) 803-810
  • 2 Cosgrove III DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62 (02) 596-597
  • 3 Rao PN, Kumar AS. Aortic valve replacement through right thoracotomy. Tex Heart Inst J 1993; 20 (04) 307-308
  • 4 Fujita B, Ensminger S, Bauer T. et al; GARY Executive Board. Trends in practice and outcomes from 2011 to 2015 for surgical aortic valve replacement: an update from the German Aortic Valve Registry on 42 776 patients. Eur J Cardiothorac Surg 2018; 53 (03) 552-559
  • 5 Sabik III JF, Rao V, Lange R. et al; PERIGON Investigators. One-year outcomes associated with a novel stented bovine pericardial aortic bioprosthesis. J Thorac Cardiovasc Surg 2018; 156 (04) 1368-1377 .e5
  • 6 Klautz RJM, Kappetein AP, Lange R. et al; PERIGON Investigators. Safety, effectiveness and haemodynamic performance of a new stented aortic valve bioprosthesis. Eur J Cardiothorac Surg 2017; 52 (03) 425-431
  • 7 Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008; 36 (05) 309-332
  • 8 Sundt TM. Measuring what matters. Ann Thorac Surg 2018; 106 (06) 1602
  • 9 Kirmani BH, Jones SG, Malaisrie SC, Chung DA, Williams RJ. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2017; 4: CD011793
  • 10 Chang C, Raza S, Altarabsheh SE. et al. Minimally invasive approaches to surgical aortic valve replacement: a meta-analysis. Ann Thorac Surg 2018; 106 (06) 1881-1889
  • 11 Furukawa N, Kuss O, Aboud A. et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients. Eur J Cardiothorac Surg 2014; 46 (02) 221-226 , discussion 226–227
  • 12 Lorusso R, Folliguet T, Shrestha M. et al. Sutureless versus stented bioprostheses for aortic valve replacement: the randomized PERSIST-AVR study design. Thorac Cardiovasc Surg 2020; 68 (02) 114-123
  • 13 Greason KL, Lahr BD, Stulak JM. et al. Long-term mortality effect of early pacemaker implantation after surgical aortic valve replacement. Ann Thorac Surg 2017; 104 (04) 1259-1264
  • 14 Sazzad F, Ler A, Kuzemczak M. et al. Automated fastener vs hand-tied knots in heart valve surgery: a systematic review and meta-analysis. Ann Thorac Surg 2020; S0003–4975(20)32080–4
  • 15 Masuda T, Nakamura Y, Ito Y. et al. The learning curve of minimally invasive aortic valve replacement for aortic valve stenosis. Gen Thorac Cardiovasc Surg 2020; 68 (06) 565-570
  • 16 Brinkman WT, Hoffman W, Dewey TM. et al. Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups. Ann Thorac Surg 2010; 90 (01) 131-135