الفهرس 
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Abstract
Minimally invasive aortic valve replacement (MIAVR) has been shown to achieve similar mortality rates to conventional aortic valve replacement, albeit with more technical demand. MIAVR uses a smaller incision and avoids complete division of the sternum, conferring several benefits: lower ventilation time, pain scores, intensive care unit (ICU) stay and hospital stay. There is also evidence to suggest a lower transfusion requirement during surgery and a reduced volume of blood lost from chest drainage.
However, with limited space to work, operative times are generally longer with minimally invasive approaches, although reduced aortic cross-clamping times and cardiopulmonary bypass (CPB) times were reported with minimally invasive AVR as well.
So, more efforts should be put in supporting a wider spread of these strategies. The aim of this study was to compare the pre and postoperative outcome of aortic valve replacement through minimal invasive approach (limited right anterior thoracotomy) and the conventional approach (median sternotomy).
50 consecutive adult patients with severe aortic valve disease scheduled for elective aortic valve replacement as a multicenter study in Armed Forces Hospitals from December 2018 to June 2021 were prospectively randomized to undergo either operation through conventional median sternotomy and central cannulation for standard cardiopulmonary bypass (MS group I, n = 25) or minimally invasive surgery through right anterior small thoracotomy (RAMT group, n = 25).
Preoperative clinical evaluation, intra operative (site and length of incision; type of cannulation), CBP and aortic clamp times were evaluated.
Post operative ICU support; mechanical, chemical (Inotropes) and Blood & fluids supports. ICU and hospital stays, ICU mortality, operative cost and postoperative complications were evaluated
Statistical analysis of current findings revealed the following:
• Mean age of the patients was 58.6 years in the RAMT group and 58.4 years in the conventional group.
• Mean BMI was nearly similar in RAMT (29.1) and MS (29.8) groups.
• Majority of patients were males (n=32; 64%),
• No significant differences between studied groups regards to ejection fractions, LVEDD and LVESD (p>0.05).
• Peak and mean pressure gradient were significantly higher in RAMT group compared with conventional group (p<0.01).
• The incision length was significantly shorter in RAMT group compared to conventional group (5.5±0.5 vs 14.5±0.7 cm with p<0.0001).
• Patients in the RAMT group had longer cardiopulmonary bypass time (189.1±44.5 vs 166.6±24.2, P= 0.031) and crossclamping time (141.9±32.4 vs 118.0±19.5, P=0.003) minutes with nearly equal operative time among two procedures and no cases in RAMT converted to conventional sterornotomy.
• No significant differences between studied groups regards to difficulties of weaning from CPB, need for pharmacological support, DC chock or need for pacemakers.
• Minimally invasive AVR by way of RAMT was significantly associated with lower output of chest drain (356.4 ± 98.8 ml vs 535.2 ± 212.1) and lower incidence of usage of blood components p<0.01.
• Minimally invasive AVR by way of RAMT was significantly associated with shorter mechanical ventilation time (4.8±2.2 hours in the RAMT group versus 7±1.9 hours in the Conventional Group), shorter time to mobilization (7.1±2.8 hours in the RAMT group versus 10.2±3.9 hours in the Conventional Group), shorter ICU length of stay (39.8±8.3 hours in the RAMT group versus 55.7±13.4 hours in the Conventional Group) and shorter hospital stay (5.4±0.6 days in the RAMT group versus 7.1±0.9 days in the Conventional Group) with p<0.001.
• Minimally invasive AVR by way of RAMT was insignificantly associated with lower incidence of postoperative pharmacological support, no heart block nor neurological deficit compared to conventional group even though RAMT group had higher incidence of postoperative fever with equal incidence of AF in both groups.
• Minimally invasive AVR by way of RAMT was significantly associated with low postoperative pain score (4.4 ± 1.8 vs 6.0 ± 1.9) and less analgesic consumption (2 vs to 4) compared to conventional group with p<0.01.
• As for cosmetic score, patients in RAMT group recorded excellent significant score compared to those in conventional group (p<0.01). Also for patient satisfaction, patients in RAMT group recorded insignificant higher satisfaction score compared to those in conventional group (p>0.05).
• The overall cost effectiveness plane indicates that conventional sternotomy surgery is significantly less costly than RAMT (88,639.6±9,345.4 LE vs 111,250.4±1,626.3 LE respectively) p<0.001.