Surgery that looks like transcatheter aortic valve implantation: the transaxillary concept for minimally invasive aortic valve replacement in 1,848 consecutive patients

Background: The transaxillary (TxA) concept for minimally invasive aortic valve replacement (MICS-AVR) is a sternum-sparing access technique combining surgical valve replacement with virtually absent visible scarring. This study reports the institutional outcomes of the first 1,848 consecutive TxA MICS-AVR procedures.
Methods: This retrospective single-center observational cohort analysis included all consecutive patients undergoing isolated TxA MICS-AVR between January 2019 and June 2026. Exclusion criteria were active endocarditis, redo surgery and concomitant procedures. Thirty-day mortality and major adverse cardiac and cerebrovascular events (MACCEs) served as primary endpoints. Univariable and multivariable logistic regression identified exploratory associations with adverse outcomes.
Results: Mean age was 67.7±8.1 years, Society of Thoracic Surgeons Predicted Risk of Operative Mortality (STS-PROM) 1.39%±2.90% and European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) 1.65%±1.12%. The proportion of TxA access among surgical treatments for isolated aortic valve disease increased from 18.8% [2019] to 99.2% [2025]. Mean operative, cardiopulmonary bypass and cross-clamp times were 132±34, 69±23 and 43±16 minutes, respectively. No intraoperative death occurred; conversion to sternotomy was required in 1.6%. Thirty-day mortality was 0.5% and the composite MACCE rate was 1.6%, including stroke in 0.9% and myocardial infarction in 0.5%. Multivariable exploratory associations of mortality were diabetes on insulin [odds ratio (OR) 8.56; 95% confidence interval (CI): 2.10–34.93; P=0.002], left ventricular ejection fraction (LVEF) <40% (OR 8.45; 95% CI: 2.28–31.25; P=0.001) and intraoperative transfusion (OR 17.86; 95% CI: 1.89–168.8; P=0.012). Variables associated with MACCE were diabetes on insulin (OR 3.06; 95% CI: 1.08–8.64; P=0.035), coronary artery disease (OR 2.46; 95% CI: 1.09–5.56; P=0.031), peripheral arterial disease (OR 3.23; 95% CI: 1.13–9.28; P=0.029), conversion to sternotomy (OR 5.33; 95% CI: 1.31–21.76; P=0.020) and intraoperative transfusion (OR 5.49; 95% CI: 0.97–31.12; P=0.054). Given the low absolute event counts inherent to this low-risk cohort (n=10 deaths; n=30 MACCE out of 1,848 patients), these multivariable models should be interpreted as exploratory and hypothesis-generating.
Conclusions: TxA MICS-AVR demonstrates excellent reproducibility and safety across 1,848 consecutive procedures. Against emerging long-term evidence favoring surgical valve replacement in patients with extended life expectancy, the TxA approach uniquely combines durable surgical therapy with a cosmetic outcome comparable to transcatheter procedures—representing a strategically relevant and scalable platform for the contemporary management of aortic valve disease.