A Sternal Sparing Approach to Mitral Valve Replacement – Comparative Study

  • Mohd Azam Haseen Associate Professor & Chairperson, Department of Cardiothoracic Surgery, JNMC & AMU, Aligarh.
  • Amit Srivastava Senior Cardio Thoracic & Vascular Surgeon, Apex Super Speciality Hospital, Varanasi.
Keywords: Right anterolateral thoracotomy, Median sternotomy, mitral valve replacement


Background: A variety of techniques including Mini-sternotomy, right anterior mini-thoracotomy, Port Access approach (Heartport), indirect endoscopic techniques and robotic techniques have been described to reduce incision size in mitral valve surgery. We used a mini-thoracotomy technique (Right Antero Lateral Thoracotomy - RALT) for mitral valve patients and compared our results with the conventional technique (mid sternotomy).

Methods: We randomly allocated 100 consecutive patients presenting to our practice for mitral valve surgery between two groups. The first group (test group) consisted of 50 patients in which mitral valve surgery was performed via mini-right anterolateral thoracotomy (RALT group) approach. The control group (50 patients) underwent classical mitral valve surgery through median sternotomy (MS group). Standard aortic and bicaval cannulation with antegrade blood cardioplegia was adopted in both groups.

Results: The mean age of patients in RALT group was 31.8 ±6.2 years and in MS group was 32.2 ± 7.8 years. The two groups were comparable with respect to age, sex, mitral valve lesion, ejection fraction and NYHA class. The mean CPB time (min) and mean aortic clamp time (min) were significantly less in MS group as compared to RALT group. However, the mean total operative time in RALT and MS group was almost similar. The average blood loss (in ml) via Mediastinal drains was significantly higher in MS group, requiring more blood transfusion as compared to RALT group (p<0.001). The mean extubation time in RALT group was 5.2 ± 0.5 hours and 9.5 ± 2.2 hours in MS group, which was statistically significant in lower in RALT (P<0.001). In MS group, 11 patients (22%) suffered from postoperative complications versus 10 patients (20%) in the RALT group, with no significant difference between the groups. There was no reported mortality in both the group.

Conclusions: The cosmetic appearance in RALT group was excellent, that rivals that of robotically assisted techniques and the patients' wounds were scarcely apparent in the female patients. The study demonstrates the efficacy and safety of this technique, with excellent cosmetic results and no additional cost or risk to the patients.



Download data is not yet available.

Author Biography

Amit Srivastava, Senior Cardio Thoracic & Vascular Surgeon, Apex Super Speciality Hospital, Varanasi.




1. Bonow RO, Carabello BA, Chatterjee K, et al.ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: are port of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48: 1–148.
2. Guedes MA, Pomerantzeff PM, Brandao CM, Vieira ML, Grinberg M, Stolf NA. Mitral valve surgery using right anterolateral thoracotomy: Is the aortic cannulation a safety procedure? Rev Bras Cir Cardiovasc. 2010; 25(3): 322-5.
3. Kumar AS, Prasad S, Rai S, Saxena DK. Rightthoracotomy revisited. Tex Heart Inst J. 1993;20(1): 40-2.
4. Cohn LH. As originally publised in 1989: Right thoracotomy, femorofemoral bypass, and deep hypothermia for re-replacement of the mitral valve. Updated in 1997. Ann Thorac Surg. 1997 Aug;64(2):578-9.
5. Wang YQ, Chen RK, Ye WW, et al. Open-heart surgery in 48 patients via a small right anterolateral thoracotomy. Tex Heart Inst J.1999; 26(2): 124-8.
6. Malik A, Asghar M, Farman T, Laiq N, Shah SMA, Khan RA. Standard median sternotomy versus right anterolateral thoracotomy for mitral valve replacement. J Med Sci. 2015;23(1): 42-45.
7. McClure RS, Cohn LH, Wiegerinck E, et al. Early and late outcomes in minimally invasive mitral valve repair: an eleven-year experience in 707patients. J Thorac Cardiovasc Surg. 2009;137(1): 70-5.
8. Attallah AR, Al-Elwany SE, Ayyad MAKS, Abdelwahab AM. Early clinical outcome after right anterolateral thoracotomy as an alternative for median sternotomy for mitral valve replacement. The Egyptian Cardiothoracic Surgeon 2020; 2:47 – 54.
9. Srivastava AK, Garg SK, Ganjoo AK. Approach for primary mitral valve surgery: right anterolateral thoracotomy or median sternotomy. J Heart Valve Dis. 1998; 7(4): 370-75.
10. Mishra YK, Malhotra R, Mehta Y, Sharma KK, Kasliwal RR, Trehan N. Minimally invasive mitral valve surgery through right anterolateral minithoracotomy. The Annals of thoracic surgery. 1999; 68(4): 1520-24.
11. Badkhal A, Thakre A, Joge U, Kawlkar U. Comparison of Standard Midline Sternotomy and Minimally Invasive Thoracotomy for Mitral valve Replacement. International Journal of Contemporary Medical Research 2016;3(11):3218-3221.
12. Shah ZA, AhangarAG, Ganie FA, Wani ML et al. Comparison of Right Anterolateral Thorocotomy with Standard Median Steronotomy for Mitral Valve Replacement. IntCardivasc Res J. 2013;7(1):15-20.
13. Murphy GJ, Reeves BC, Rogers CA, Rizvi SI,Culliford L, Angelini GD. Increased mortality,postoperative morbidity, and cost after redblood cell transfusion in patients havingcardiac surgery. Circulation. 2007; 116: 2544-52.
14. Modi P, Hassan A, Chitwood WR., Jr. Minimallyinvasive mitral valve surgery: A systematicreview and meta-analysis. European Journal ofCardio-Thoracic Surgery. 2008; 34(5): 943–952.
How to Cite
Haseen MA, Srivastava A. A Sternal Sparing Approach to Mitral Valve Replacement – Comparative Study. Int Arch BioMed Clin Res [Internet]. 2020Sep.30 [cited 2021Jul.25];6(3):CS1-CS4. Available from: http://iabcr.org/index.php/iabcr/article/view/611
ORIGINAL ARTICLES ~ Cardiothoracic Surgery