Surgical Transaxillary Aortic Valve Replacement: Improving Computed Tomography-Based Preoperative Patient Selection

All articles of this category (opens in new window) Background: The transaxillary thoracotomy for SAVR has gained increasing popularity as a safe alternative to right anterior thoracotomy, upper hemisternotomy, and median sternotomy. Patient selection relies on preoperative CTA and is crucial for procedural safety. The aim of this retrospective study is to identify parameters in CTA that allow complexity prediction of the transaxillary approach for SAVR. Methods: Between June 2024 and March 2025, 43 patients underwent SAVR via transaxillary thoracotomy. Preoperative CTA were analyzed according to a standardized protocol. Surgeries were performed by four surgeons with experience in minimally invasive cardiac surgery. Postoperatively, the complexity of each case was determined by the operating surgeon on a subjective basis. We investigated the correlation of aortic valve morphology, annulus and arch anatomy, as well as chest-wall to aortic valve distance, with procedural complexity. Results: The mean age of patients was 59.5 ± 12.0 years. The mean EuroScore II was 1.5% (range: 0.6–12.8%). Sixty-two point eight percent ( n = 27) of patients had a bicuspid aortic valve. The majority of cases were low complexity (62.8%, n = 27), with 25.6% ( n = 11) medium and 11.6% ( n = 5) high complexity. The mean distance of the third intercostal space (ICS) to the ascending aorta (AscAo) and to the aortic annular plane was 85.8 ± 11.3 and 150.7 ± 15.0 mm, respectively. The distance of the aortic annular plane showed low correlation ( r = 0.158, p = 0.311), while the distance of the AscAo showed moderate correlation to the complexity of the procedure ( r = 0.328, p = 0.032). The horizontal position of the AscAo correlated moderately with case complexity ( r = −0.285, p = 0.064). The tortuosity index of the AscAo correlated significantly with procedural complexity ( r = −0.455, p = 0.002). The tortuosity angle and the length of the ascending aorta both correlated moderately ( r = −0.306, p = 0.049; r = −0.330, p = 0.033, respectively). The calcium score of the aortic valve did not correlate with case complexity. Aortic cross-clamp time showed significant correlation with the complexity of the operation ( r = 0.414, p = 0.006). Conclusion: The distance from the third ICS to the annular plane might indicate the feasibility of transaxillary SAVR, but offers limited insight into case complexity. However, preprocedural evaluation of the AscAo tortuosity, the distance from the third ICS to the AscAo, and the horizontal position of the aorta might be helpful in procedural planning, foreseeing procedural complexity. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany