“What Are The Different Kinds Of Minimally Invasive Surgery For Aortic Valve Replacement?” Asks Jim

Recently, Jim sent me a great question that reads, “Adam – I’m 65 and diagnosed with moderate aortic valve stenosis. It seems there are a couple of different types of minimally invasive surgery. Can you help me understand that better?” (To learn more about aortic stenosis, click here.)

I was very fortunate to ask this exact question to Dr. Marc Gillinov, a leading heart valve surgeon from the Cleveland Clinic, at the Heart Valve Summit. The highlights of our discussion are provided in this video. (For the patients and caregivers of our community who are hearing impaired, I have provided a written transcript below.)

Thanks to Jim for his question and a special thanks to Dr. Marc Gillinov for his continued support of this website. As you may know, Dr. Gillinov has performed successful surgery on many patients in our community including Robin Williams (the actor and comedian), Don Spencer, Fran Zilko, Sandy Gilbert and Anita Devine.

Keep on tickin!

P.S. Below you will find the written transcript of this interview with Dr. Marc Gillinov.

Adam: Hi everybody, it’s Adam and we’re are at the Heart Valve Summit. I’m thrilled to be with Dr. Marc Gillinov from the Cleveland Clinic. And we’re going to be answering your questions that you put up at HeartValveBlog.com. This question comes in from Jim. He says: I’m 65 and diagnosed with moderate or aortic stenosis. It seems there are a couple of different types of minimal invasive surgery. Can you help me understand that better?

Dr. Gillinov: Sure. When the heart surgeon says we’re going to do a minimal invasive operation, Jim is completely right, we’re using a broad term and basically new invasive or less invasive means anything other than a standard sternotomy, a sternotomy means right down the the middle of the entire breast bone. For an aortic valve replacement operation the most common new invasive approach is going to be partial sternotomy, where we make an incision about 3” in the upper the upper part of the sternum, we still go through part of the bone. In some cases you can take a different approach and go through the side between the ribs, not too many surgeons do that because we’re not sure that there’s a big advantage to a small incision this way versus a small incision this way. But that’s a second option. So if he says minimal invasive various options what are we talking about, smaller incision, it’s either partial sternotomy or we call it small right thoracotomy.


Partial or Mini-Sternotomy

Adam: Do you always do a minimally invasive procedure or are there situations that warrants still having a full incision along the patient’s sternum?

Marc Gillinov, MD: I think the surgeon’s got to be able to do all of the possible approaches, so they do fit the approach to the patient. You’ve got to be as a surgeon a little more like a guy in a shoe store who comes out with 3, 4 or 5 boxes, and has to got to figure which pair of shoes is exactly the right fit for you. You don’t want to walk out with something that’s uncomfortable or doesn’t fit. In surgery it’s a lot more serious, you don’t want to leave with something that’s unsafe, or less effective. So yes there would probably be a regular sternomic incision, they do fine, turn on the TV, David Letterman, Bill Clinton, Arnold Schwarzenegger, regular incisions, they’re all medically doing okay. How you decide what’s best for a person, you look at all the preoperative tests, you figure out what is the surgical mission, and where do safety and effectiveness lie. And then you choose safety and effective and recommend that.

Adam: Great. Jim I hope that helped you learn more about minimally invasive approaches. Dr Gillinov as always I want to thank you for the support and the contribution to our website. Really I know there’s a lot of viewers out there, he has touched their lives and their hearts and I just want to thank you for what you’re doing at the Cleveland Clinic.

Dr. Gillinov: We thank you. I see patients walking around with your book and see them with their i-pads and their computers on your website and what you’re doing, is you’re making them feel better and that counts.

Adam: Thanks so much!

Doctor Gillinov: My pleasure!

Adam Pick
Written by Adam Pick

Adam Pick is a patient, author of The Patient's Guide To Heart Valve Surgery and the founder of HeartValveSurgery.com.

To learn how Adam has helped millions of people with heart valve disease, watch Adam's video, subscribe to his free newsletter, or visit his Facebook, or Twitter pages.

  • Paul Klaassen

    Having had the full sternotomy, I often wonder what the big deal is with people insisting on, or agitating for ‘less invasive techniques. When my surgeon was mentioning that it was sometimes possible to do the work with a partial sternotomy, my first thought was ‘No thanks, I wouldn’t try to change the car parts with the hood just open a crack, even if I could do it by feel.’ I said that I was perfectly fine with being opened as far as was necessary. If that means adding a few weeks onto the surgical recovery than so be it. The cardiac recovery is the longer and more painstaking part of the process anyway.
    Each to his own I suppose, but if I ever go through this again, I’ll be more comfortable knowing that there is room to go elbows deep, if the job requires it, than thinking that the doc will be fishing around in there blind.

  • Ken Czerwiski

    Hi Adamn,
    I had the full sternotomy based on the recommendation of my Surgeon back in April 2010.
    At that time I asked about the risk and results of full vs partial sternotomy/minimally invasive and he indicated that although minimally invasive patients recovered faster there was actually a higher risk of stoke for that type of surgery at least locally in my Hospital system (ranked #8 overall in the USA).
    That was more than enough reason for me to go with normal procedure.

  • Kerrigan

    My operation was full sternotomy. The cardio surgeon had done over 2,000 of these operations and said it was best, in my case, for the team to “have the room” they needed to do it right without increasing chances for complications. I’m very happy the way it all turned out now three years down the road.

  • Anne Shannon

    I had the partial sternotomy (for AVR- shown first in the video) at Cleveland Clinic and I would recommend it most highly if it suits your case. I had surgery on Friday afternoon and was released from the clinic on Monday morning – flew home on Tuesday morning. My pain level was almost nonexistent and I was back on my feet immediately. It was as close to a “non-operation” as can be imagined.

    I was 69 at the time and not any sort of amazing physical specimen! My doctors here were all astounded by my recovery. The cardiologist has told me that the surgeons in his group are in touch with CC to learn the technique they used on me.

    If you have time to devote to recovery, then go for the full sternotomy. I didn’t have the time so I called CC, made an appointment with one of the best heart surgeons in the world and couldn’t have been more pleased. Feel free to contact me for any more info you may need.

    Anne Shannon (exqueen@aol.com)

  • Mike Rehmus

    I had a partial sternotomy 10 days ago in the fastest AVR surgery Dr. Guadiani had ever performed, 66 minutes cut to close. After 10,000 of these operations, he knows what he is doing.

    I left the hospital 5 days after surgery and have no post-operative problems whatsoever. In fact, they keep telling me to slow down, that just because I feel great doesn’t mean I should overdo the recovery.

    Sequoia Hospital, Redwood City, CA, a great cardio hospital.

  • Lynda Knopf BS/RN

    Thank You again Adam for another interesting surgical topic presentation, via Dr Mark Gillinov of the Cleveland Clinic, who stressed the importance of “the right procedure fit for each UNIQUE patient”–Initially I asked my surgeon which procedure he would recommend for my aortic valve replacement and mitral valve viewing–he immediately answered” a full sternotomy for full visibility”–As Paul Klaassen, I was TOTALLY confident to accept the more extensive procedure re:”the full visibility SAFETY element”–one always has to be cognisant of surgical RISKS–my constant rememberance of two past cardiac surgical friend losses from “accidental aortic nicking”,one having a full sternotomy for bypass surgery and the other having minimally invasive aortic valve replacement, is my one sad unfortunate reference ..Even though I had full sternotomy surgery ,my 3 day hospitalization and subsequent recovery time was absolutely PAINLESS!!Cardiac patients are SO FORTUNATE having AMAZING surgical offerings for restored health!

  • robin fairchild

    I had minimally invasive and when later I saw the scar I wondered how on earth the surgeon was able to get inside my chest to do all that was necessary. And I guess I still wonder.

    I chose minimally invasive – turns out I was a candidate for it which is critical – not because of the scar but because the recovery was going to be quicker. I now understand the reasoning of some who choose the full sternotomy – it may be somewhat safer – but fortunately in my case things have, so far, worked out well. I suppose it will take years (and so far I’m only 3.8 months post-op) to determine if my decision will turn out to be problematical.

  • Lynda Knopf BS/RN

    Dr.Mark Gillinov(Cleveland Clinic Surgeon)gave a precise helpful presentation re: cardiac surgical procedures terminology–the broad term regarding minimal invasive surgery as” anything other than the regular standard sternotomy”.Because standard sternotomy cardio-surgery offers a wide internal viewing range, whereby the surgeon most accurately can access the immediate surgical needs–especially when the individual presents” multi-valves” conditions, I agree with Paul Klaassen’s #1 comment–My standard sternotomy for aortic valve replacement and mitral valve repair was painless from post op day and onward,even allotting me a day early discharge!

  • Ken Czerwiski

    I am truly suprised by the Full Sternotomy patients who indicate they had minimal to ‘no pain’ after their Aortic Valve replacement surgery.
    I had the Aortic valve surgery, a single by-pass using an existing artery in my chest, and the “Maze” procedure for A-fib during the same surgery.
    Although I was released from Hospital on the 5th day I suffered severe pain for for several months that was truly debilitating.
    In the end, I ended up taking controlled substanse pain relieving medication for over 12 weeks and finally weening myself off of it.
    I continued to have various discomfort in my chest which I can only describe as ‘muscular’ in nature for over 5 months.
    Apparently everyone is different, surgery results are not same, etc.
    I often wondered if perhaps a ‘nerve’ was severed during my surgery causing the discomfort.
    Those that do not suffer much should be grateful to have avoided the ordeal I went through.
    Merry Christmas to ALL!
    Ken

  • Jim Marcum

    I have had both the regular surgical procedure for Aorta Valve replacement in 2005 and just a month ago I had minimally invasive Mitral Valve replacement. I wanted the Minimally invasive surgery because I didn’t want to deal with the long healing process. As patients we seek all the answers and many good Dr’s try to educate us as best they can. I’ve learned you get the surgery and the procedure done that your particular Dr is most comfortable with and in many cases his limited abilities possibly he nor his hospital can perform minimally invasive surgery so they schedule you for what they do and that is the old type. I even had one hospital ‘Lie” to me and tell me I was not a candidate for minimally invasive surgery so they would have to do it the old way. They sell the company or ‘hospitals’ products. Ask questions and you will make people mad but ask them anyway. As best you can prepare yourself with the internet and talking to others you will still come up against things you didn’t expect or hear about. Keep a good attitude as best you can. Wake up in the ICU and put a smile on your face. Accept things as they occur and just will yourself to get through it. Try to keep other patients smiling too. It seems like helping others is the best help you can give yourself. We have to trust our doctors and do as they say. Have a good attitude with the Nurses it can only benefit you in the long run. Take it easy. Rest when you are tired. Walk when you feel like it. Try to do things on your own but don’t over do, reaching and don’t lift anything. Healing will come and it will only be a memory that hopefully will make us healthier and stronger in faith. God bless you all.

  • Jim Marcum

    To compare the different surgical approaches and healing process is difficult. There is a lot of difference in the two. My first Surgery through the Sternum for Aorta Valve replacement went extremely well. I had basically no pain except when getting up or down and it was brief, I took no pain medicine and was out of the hospital on the third day after surgery. I did have a lot of depression and worry and these were hard to get through until I went back to work and got my life back to normal. I had minimal invasive Mitral Valve replacement a month ago and there is a lot of difference in symptoms and the things you have to over come. I had a lot of fluid to get rid of in my lungs that I never had with the sternum surgery. Fluid actually squirted out of two drain holes under my arm and it was scary to see that much fluid squirting out of you when you realize pneumonia or infection could settle in your lungs. It took about three days to rid myself of this fluid. There is also pain where the slides go under your arm and across to your heart. I think there is more pain with the minimally invasive surgery actually and the incision under your arm is a tough place to heal. The bones are not broken though so I look forward to healing up sooner. I have read where some people go back to work in 2 weeks. I will have been off a month and it will be 5 weeks before I see the surgeon again. But I am 61 and being my second heart surgery I knew and was told it would be more difficult for me. The Dr has told me that my surgery could not have went any better. That everything had been normal so I guess the fluid is just a bad part of this type of surgery. My wife said I was in surgery for over 5 hours and that is not really good to be on the heart lung machine that long, if I was. So with me the verdict is not quite in yet on which procedure is really the best. I hope this most recent one is and I’m back to work in a week or so. We will see. Pray for me and I will pray for you also. If you have any questions for me fire away and I will answer you as soon as I get your question or email me at jim.marcum70!@Hotmail.com

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