Implementing a New Minimally Invasive Transaxillary Aortic Valve Replacement Program: Lessons from the First 36 Patients

All articles of this category (opens in new window) Background: Current developments in the field of aortic valve (AV) treatment, with evolving guidelines for interventional therapy and the growing demand for sternotomy-free treatment options, urge the need to further develop and implement minimally invasive techniques for surgical AV replacement (AVR) into a clinical routine setting. Here, we report our experiences of implementing a new minimally invasive AVR program via transaxillary access (MICLAT). Methods: Retrospective study including 36 consecutive patients who underwent MICLAT-AVR in our center after starting the program in January 2025 until September 2025. All patients required AVR as determined by local Heart Team decision and were deemed suitable for a MICLAT approach by standardized preoperative evaluation. All patients were operated on by a dedicated team of five different surgeons, with varying experiences in minimally invasive cardiac surgery. Procedural and perioperative patient data, as well as 30-day mortality, were analyzed in order to evaluate the safety and feasibility of the new approach. Results: Mean patient age was 65 ± 6 years, with 20 (55.6%) patients being male. The leading pathology was AV stenosis in 29 (80.6%), followed by AV regurgitation in 7 (19.4%) patients. 24 (66.7%) patients had a functional bicuspid AV. Thirty-three (91.6%) patients received a biological prosthesis, out of which 12 (33.3%) were rapid deployment valves, and 3 (8.33%) patients received a mechanical prosthesis, with 86.1% of the prosthesis being 23 mm or larger. Five (12.9%) patients received a combined procedure via the same transaxillary access (two MVR, one TVR, one ascending aorta, one PFO closure, two LAAO). Arterial cannulation was performed via femoral (91.7%), subclavian (8.33%), or direct aortic (2.78%) access. Median CPB and cross-clamp time were 167 ± 62 and 92 ± 38 minutes. Conversion rate to sternotomy was 0%, although one patient needed to be re-operated via sternotomy due to occlusion of the RCA ostium. The same patient (2.7%) had a postoperative stroke. Rates of re-exploration due to bleeding, relevant paravalvular leakage, or pacemaker implantation were 0.0%. Median hospital stay was 11 ± 2 days, and 30-day mortality was 0.0%. Procedural and outcome data were not inferior to historical AVR cohorts of our center operated either via sternotomy, partial sternotomy, or right anterolateral thoracotomy. Conclusion: Minimally invasive AVR via transaxillary access seems to be a safe and reproducible procedure that can be implemented into standard clinical routine. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany