Sternal Wound Healing Research Articles

Bioengineering Approaches and Novel Biomaterials to Enhance Sternal Wound Healing after Cardiac Surgery: A Crosstalk between Innovation and Surgical Practice.

Median sternotomy and steel wires for sternal closure are the standard approach for cardiac surgery. An incomplete repair associated with chest wall motion, especially in the presence of predisposing factors, can lead to life-threatening deep sternal wound infection, also known as mediastinitis, in 2-5% of cases. Despite current antibiotic and surgical treatments, mediastinitis is associated with a 10-40% mortality rate and a significant increase in morbidity and hospital stay. High mortality and difficult treatment appear to be due to bacterial biofilm, a self-produced extracellular polymeric product that incorporates host tissue and is responsible for the failure of immune defenses and standard antimicrobial therapies. Nanostructures are an effective strategy to enhance the healing process, as they establish a favorable environment for the neosynthesis of the extracellular matrix, supporting tissue development. Synthetic polymers have been proven to exhibit suitable biodegradable and mechanical properties, and their biofunctionalization to enhance cell attachment and interaction with the extracellular matrix is being widely investigated. The use of antibiotic treatments suspended in poly-D,L-lactide and polyethylene oxide and electrospun into nanofibers, or in sponges, has been shown to inhibit bacterial biofilm production. Additionally, growth factors can be incorporated into 3D bioresorbable scaffolds with the aim of constituting a structural and biological framework to organize and expedite the healing process. Therefore, these combined approaches may change the treatment of mediastinitis in the near future.

Effects of a telehealth program for wound healing promotion on the wound healing level in patients with diabetes undergoing coronary artery bypass graft surgery: A randomized controlled trial.

Patients with diabetes undergoing coronary artery bypass graft (CABG) are at risk of delayed wound healing. The telehealth program for wound healing promotion (TPWHP) was developed to improve wound healing in patients with diabetes undergoing CABG in a university hospital. This study aimed to examine the effects of the TPWHP on the healing of the sternal wound and saphenous vein graft (SVG) donor site in patients with diabetes undergoing CABG. In this randomized controlled trial, the participants were randomly assigned to the intervention (n = 30) and control (n = 30) groups. The control group received routine nursing care, whereas the intervention group received routine nursing care along with the TPWHP, which provides education and wound monitoring using multimedia and a surgical wound care booklet and monitors the wound through the LINE application on a smartphone after hospital discharge. Data were collected from June to November 2020 at two university hospitals in Bangkok, Thailand, using the demographic and health-related data form and the Thai wound assessment inventory (WAI). Data were analyzed using the Chi-squared, Fisher's exact, and Mann-Whitney U tests. The intervention group had significantly lower mean scores-indicating favorable wound healing-for SVG donor site wound healing level than the control group on days 14-21 after surgery (p = 0.012, mean = 0.58 ± 0.54 and 1.08 ± 0.82, respectively). No significant intergroup difference was observed in terms of the sternal wound healing level (p = 0.126); however, the intervention group showed lower mean scores-indicating good wound healing-than the control group. The TPWHP promotes effective wound healing of the SVG donor site; however, its efficacy on sternal wound healing was uncertain. Therefore, nurses should implement the TPWHP in collaboration with a multidisciplinary team to improve wound healing after hospital discharge. Thai Clinical Trials Registry (TCTR20211112002).

Platelet-rich plasma influence on the sternal wounds healing: A meta-analysis.

A meta-analysis research was executed to appraise the effect of platelet-rich plasma (PRP) on sternal wound healing (SWH). Inclusive literature research till April 2023 was done and 1098 interconnected researches were revised. The 11 picked researches, enclosed 8961 cardiac surgery (CS) persons were in the utilised researchers' starting point, 3663 of them were utilising PRP, and 5298 were control. Odds ratio (OR) and 95% confidence intervals (CIs) were utilised to appraise the effect of PRP on the SWH by the dichotomous approach and a fixed or random model. PRP had significantly lower sternal wound infection (SWI) (OR, 0.11; 95% CI, 0.03-0.34, p < 0.001), deep SWI (OR, 0.29; 95% CI, 0.16-0.51, p < 0.001), and superficial SWI (OR, 0.20; 95% CI, 0.13-0.33, p < 0.001), compared to control in CS persons. PRP had significantly lower SWI, deep SWI, and superficial SWI, compared to control in CS persons. However, caution must be taken when interacting with its values since there was a low sample size of some of the nominated research found for the comparisons in the meta-analysis.

Perioperative Safety of Bilateral Internal Thoracic Artery Coronary Bypass in Elderly.

The benefits of utilizing internal thoracic arteries (ITAs) in coronary bypass surgery are well-known. However, the safety of this practice in elderly patients needs to be proven. We studied all patients who are 75 years of age and older, who received at least one ITA graft while undergoing isolated, conventional (median sternotomy) coronary artery bypass graft surgery (CABG) between Jan 1st 2002 and Dec 31st 2020 (19 years). Emergent surgeries were excluded. Propensity score matching was used to reduce the patient selection effect. Study outcomes were 30-days mortality, and two sets of dependent intraoperative parameters and postoperative parameters. A total of 1855 patients undergoing CABG was included, of which 1114 received a single left (s)ITA and 741 received combined left and right (d)ITA grafts. 519 pairs were matched. The decision for sITA or dITA was made individually. Thirty-days mortality was low and similar in both groups (sITA 3.3%; dITA 2.9%, p = 0.859). The incidence of sternal wound healing disorder was higher after dITA (3.3 vs 6.9%; p 0.011), which had also a longer skin-to-skin operative time (181 vs 205 min; p 0.0001). Re-thoracotomy rates were similar (4.6 vs 6.2%; p = 0.340). There were no significant differences in other secondary parameters. harvesting both ITAs in elderly patients is safe and feasible. However, it increases the risk of sternal wound healing disorders. Long term benefit still needs to be proven.

The outcome of sternum healing among diabetic patients undergoing open heart surgery: a literature review

Background: As part of the surgery, sternotomy is a common technique to expose the underlying organs, allowing surgeons to explore the targeted organ. Despite the benefits offered, it has several considerable complications; one of them is wound healing defect. The impairment of sternal wound healing after sternotomy could be superficial and/or deep. This condition is influenced by many factors, including diabetes mellitus, obesity, and other comorbidities. These anomalies will affect the normal healing process of the bone and other connective tissue, particularly after a major invasive event, such as in sternotomy. This study aimed to review the outcome of sternum healing among diabetics that underwent heart surgery with a sternotomy approach. Methods: Works of literature reviewed in this study were obtained from Pubmed and Google Scholar databases starting from 1992 until April 2022. The keywords used were ‘sternal wound healing’, ‘cardiac surgery’, and ‘diabetes mellitus’. An advanced search based on the exact phrases was conducted on Google Scholar. Gathered kinds of literature were then selected based on relevancy. Results: The majority of articles reviewed were observational, and most of them had CABG as a part of open heart surgery, followed by valvular and aortic surgeries and others. The incidence of impaired sternal healing and other complications (superficial and/or deep) was more commonly seen among patients with diabetes. Most studies also reported a significant correlation between DM and the incidence of impaired sternal healing, suggesting that DM was a significant predictor of it. Conclusion: Diabetes mellitus is a medical condition that must be taken into account among the candidates for open heart surgery, particularly if it is poorly controlled. The Hyperglycaemic state experienced by the patients will lead to multiorgan damage and immunological dysfunction that could affect the healing process of the sternum.

Effect of nutritional status on wound healing after coronary artery bypass graft (CABG) surgery.

To assess the pre-operative nutritional status and its effect on wound healing of patients having undergone coronary artery bypass graft surgery. The hospital-based prospective study was conducted at the Armed Forces Institute of Cardiology/National Institute of Heart Disease, Rawalpindi, Pakistan, from October 2017 to March 2018, and comprised patients who underwent coronary artery bypass graft surgery. Sternal wound healing as an outcome measure was assessed with nutritional status. Investigation of dietary data focussed on various food groups and their impact on wound healing. Data was analysed using SPSS 21. Of the 330 patients, 16 (4.8%) died within hospital. The final sample, as such, comprised 314(95.2%) patients; 273 (86.9%) males and 42 (13.1%) females, with an overall mean age of 56.6±8.3 years. The mean body mass index was 26.9±4.3kg/m². There was non-significant relationship between body mass index and wound healing (p>0.05). Significant relationship was observed between albumin, blood glucose and wound healing (p<0.05). Low levels of albumin and poor blood glucose control before surgery was found to be associated with delayed wound healing. Nutritional intervention prior to coronary artery bypass graft surgery may lead to reduced risk and complications during / after surgery.

A study on origin, termination, and course characteristics of internal thoracic artery relevant to coronary surgeries and reconstructive procedures.

ABSTRACTObjectives:The internal thoracic artery is a favored vessel for coronary artery bypass grafting and is utilized for breast reconstructive surgeries. Our study focuses on the origin, termination, and course characteristics of the internal thoracic artery. A comprehension of these morphological features and possible variations will definitely aid a clinician in appropriate harvesting of the artery for clinical procedures.Materials and Methods:200 thoracic halves (from 100 embalmed adult human cadavers of either sex) were obtained from the department of anatomy. The origin, course characteristics, termination levels, and patterns for the internal thoracic artery were studied.Results:The internal thoracic artery originated from the first part of subclavian artery. The most common course pattern observed was medial concavity (88.5%). In 10% of cases, a tortuous course was observed. No artery with lateral concavity or rectilinear course pattern was documented. The artery terminated in the sixth space in 93.5% of cases. In 98% of cases, bifurcation in termination was observed. Trifurcation in termination was also observed in 2% of cases. The average length of variant artery (third terminating branch) was documented to be 5.5 cm.Conclusion:The increased utilization of the internal thoracic artery for coronary bypass arterial surgery and its role in sternal wound healing has made it imperative for clinicians to keep in mind its anatomical characteristics and local variations. This knowledge definitely will improve prognosis and decrease intraoperative/postoperative complications in patients undergoing coronary surgeries, percutaneous subclavian catheterizations, and reconstructive procedures.

Impact of skeletonized harvesting of the internal thoracic artery on intrasternal microcirculation considering preparation quality.

Previous studies have demonstrated the impact of internal thoracic artery (ITA) harvesting on microcirculation in parasternal tissues. However, the impact of skeletonized ITA harvesting on intrasternal microcirculation is unknown. Intraskeletal tissue perfusion has been proven to be crucial for deep wound healing. Furthermore, the impact of different levels of surgical preparation quality on intrasternal microcirculation has not been investigated yet. Sternal microcirculation (sLDP) was monitored with a novel Laser Doppler Perfusion needle probe, while the ITA was skeletonized in a pig model. To mimic different levels of preparation quality, satellite veins were either coagulated or not during preparation. To show the effect of ideally avoiding any surgical manipulation on sLDP, the ITA was clipped in a third sham-harvested group. sLDP was reduced highly significant to 71 [standard deviation (SD): 9]% (P < 0.001) after skeletonized harvesting of the ITA. Coagulation of the satellite veins as a detrimental surgical factor resulted in a significantly stronger reduction of sLDP to 56 (SD: 11)% (P < 0.05) compared to sLDP with non-coagulated satellite veins. ITA clipping reduced sLDP highly significant to 71 (SD: 8)% (P < 0.001) in the sham-operated group. ITA harvesting markedly impairs microcirculation of the sternum but remains unavoidable when coronary artery bypass grafting should be performed. Nevertheless, excessive surgical damage and coagulation of satellite veins is avoidable and should be reduced to a minimum to minimize the risk of deep sternal wound healing complications.

Platelet-Rich Fibrin in Combination with Local Antibiotics Optimizes Wound Healing After Deep Sternal Wound Problems and Prevents Reinfection

Objective: Disturbed wound healing is a significant problem in patients after cardiac surgery. Problems with deep sternal wound healing are rare, but can be quite difficult to treat. Furthermore, the therapy is highly expensive and consumes many of the patient’s personal resources. Another major obstacle in this patient group is reinfection after secondary wound closure. We examined how to prevent early reinfection through the use of growth factors in combination with local antibiotics. Methods: Our study included 232 patients with a deep sternal wound healing problem. After initial vacuum therapy, we planned secondary wound closure. During wound closure, we used only platelet-rich fibrin in a PRF group (109 patients). In another group (123 patients), we covered the wounds intraoperatively with a combination of PRF and local antibiotics (PRF CoDelivery). All patients were observed for 30 days for signs of early surgical site infection. Results: After 30 days, 22 patients (20.2%) in the PRF group showed a persistent problem with wound healing with or without reinfection. In contrast, only 12 patients (9.8%) in the PRF CoDelivery group had this problem (p=0.023 PRF vs. PRF CoDelivery). Conclusion: The combination of growth factors and antibiotics was associated with a significantly reduced incidence of early reinfection and thus can be expected to have a positive impact on wound healing in complicated scenarios. Furthermore, the combination of PRF and local antibiotics was easy to use. Further studies are needed to verify these initial findings.

A Transplanted Broken Heart Healed with Time and Temporary Mechanical Circulatory Support

Introduction Takotsubo cardiomyopathy (TC), known as “broken heart syndrome” is a temporary, predominantly left ventricular dysfunction associated with emotional or physical triggers. Brain death (BD) can be a trigger through catecholamine storm and Cushing reflex. In case of heart transplantation (HTX) it can lead to donor heart dysfunction, a common cause of early postoperative mortality. Case Report A 50-year-old woman was listed for HTX following LVAD implantation in 2019 due to advanced heart failure caused by DCMP. In March 2020, a donor heart from a female 28-year-old brain-dead donor with occluding hydrocephalus was offered for her. The donor heart had a reduced EF of 40% with signs of TC with apical hypokinesia. Due to notorious organ shortage in Germany the TC heart was accepted. Following HTX weaning from cardiopulmonary bypass proved to be impossible due to biventricular dysfunction. A peripheral v-a-ECMO was implanted. Due to insufficient left ventricular unloading on v-a-ECMO, 9 hours after HTX, an Impella® 5.5 was implanted. Circulatory function improved and inotropes could be weaned during ICU stay. Improving LV function was documented on regular transesophageal echocardiographies. ST-segment elevations in the ECG were declining as well as CK levels and CK-MB/CK-ratio. V-A-ECMO was explanted 4 days after HTX and Impella® 5.5 explantation was performed the day after. By that time biventricular function had fully recovered. Myocardial biopsies showed no signs of rejection or inflammation. Acute on chronic renal failure made temporary hemodialysis necessary. Due to sternal wound healing complications the postoperative course was prolonged. The patient was discharged after 55 days. Significant stenosis of the coronary arteries was excluded during follow-up. Four months after discharge the patient is doing well and fully engages in everyday life. Summary Takotsubo cardiomyopathy is transient and there is evidence that inotropes play a role in the pathogenesis. Transplantation of such hearts with consecutive early temporary mechanical circulatory support is feasible. Subsequently it might be worth to reconsider criteria for rejection of donor hearts in cases of acutely reduced EF.

Effects of platelet-rich plasma on the healing of sternal wounds: A meta-analysis.

Sternal wound infection (SWI) is a devastating complication after cardiac surgery. Platelet-rich plasma (PRP) may have a positive impact on sternal wound healing. A systematic review with meta-analyses was performed to evaluate the clinical effectiveness of topical application of autologous PRP for preventing SWI and promoting sternal wound healing compared to placebo or standard treatment without PRP. Relevant studies published in English or Chinese were retrieved from the Cochrane Central Register of Controlled Trials (The Cochrane Library), PubMed, Ovid EMBASE, Web of Science, Springer Link, and the WHO International Clinical Trials Registry Platform (ICTRP) using the search terms "platelet-rich plasma" and "sternal wound" or "thoracic incision." References identified through the electronic search were screened, the data were extracted, and the methodological quality of the included studies was assessed. The meta-analysis was performed for the following outcomes: incidence of SWI, incidence of deep sternal wound infection (DSWI), postoperative blood loss (PBL), and other risk factors. In the systematic review, totally 10 comparable studies were identified, involving 7879 patients. The meta-analysis for the subgroup of retrospective cohort studies (RSCs) showed that the incidence of SWI and DSWI in patients treated with PRP was significantly lower than that in patients without PRP treatment. However, for the subgroup of randomized controlled trials (RCTs), there was no significant difference in the incidence of SWI or DSWI after intervention between the PRP and control groups. There was no significant difference in PBL in both RCTs and RSCs subgroups. Neither adverse reactions nor in-situ recurrences were reported. According to the results, PRP could be considered as a candidate treatment to prevent SWI and DSWI. However, the quality of the evidence is too weak, and high-quality RCTs are needed to assess its efficacy on preventing SWI and DSWI.

Braided Polyester versus Standard Wire in Sternal Closure in High Risk Patients

Objective: The aim of this study was to compare braided polyester sternal closure versus standard wire closure in high-risk patients who are more susceptible to have deep sternal wound infections and mediastinitis after cardiac surgeries. Patients and Methods: Between February 2017 and December 2019 risk factors for postoperative deep wound infections and mediastinitis and mortality was collected for 100 adult patients undergoing open-heart surgery under cardiopulmonary bypass. Patients were divided to two groups, those who underwent sternal closure using either braided polyester or standard metal wire. Follow-up data on sternal wound healing and deep sternal wound infections were assessed for up to two months after surgery in the Outpatient Clinics. Results: The followingriskfactors wereassociatedwithahigherincidenceofdeepsternalwoundinfectionsandmediastinitis in both groups. There was no mortality in both groups, the number of deep sternal infection and mediastinitis with sternal dehiscence was 4 patients from group A (Ethibond) and 5 from group B (standard wire). Conclusion: This study showed that braided polyester could be used safely in sternal closure the same as standard wire in high risk patients.

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy.

Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization. We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6months following discharge. Mean age of patients was 52.5 ± 9.8years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent. Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Experience of negative pressure wound therapy over sternal wound healing: A retrospective review

Objectives The aim of this study was to retrospectively review the effectiveness of negative pressure wound therapy (NPWT) in sternal wound healing with the use of the validated Bates-Jensen Wound Assessment Tool (BWAT), and explore the role of NPWT over sternal wounds and future treatment pathways. Methods Data was gathered from patients' medical records and the institution's database clinical management system. Seventeen subjects, who had undergone cardiothoracic surgeries and subsequently consulted the wound care team in one year were reviewed. Fourteen of them were included in the analysis. Healing improvement of each sternal wound under continuous NPWT and continuous conventional dressings was studied. In total, 23 continuous NPWT and 13 conventional dressing episodes were analysed with the BWAT. Results Among conventional dressing episodes, sternal wound improvement was 2.5–3% over 10 days to 3.5 weeks, whereas 4–5% sternal healing was achieved in 5 days to 2 weeks with sternal wire presence. Better healing at 11% in 1 week by conventional dressing was attained after sternal wire removal. In NPWT episodes, 8–29%, 13–24%, and 15–46% of healing was observed in 2 weeks, 3.5 to 5 weeks and 6 to 7 weeks, respectively. Only 39% wound healing was acquired at the 13th week of NPWT in one subject. With sternal wire present, 6%–29% wound healing progress was achieved by NPWT in 1–4 weeks, and 16–23% wound improvement in 2 to 4.5 weeks by NWPT after further surgical debridement. After sternal wire removal, 6–34% sternal wound healing occurred by continuous NPWT for 1–2 weeks, and maximum healing at 46% after 2.5 weeks of NPWT were observed. Conclusions Better wound healing was achieved in the NPWT group in comparison to conventional dressings alone. However, suboptimal sternal wound healing by NPWT alone was observed. Removal of sternal wire may improve the effectiveness of NPWT. Successful tertiary closure after NPWT among subjects supports the important bridging role of NPWT in sternal wound healing. Factors causing stagnant sternal wound healing by NPWT alone are discussed.

Dealing with Sternal Wound Healing Disorders after Cardiac Surgery: Bacterial Spectrum and Implications for Antibiotic Therapy

Dealing with Sternal Wound Healing Disorders after Cardiac Surgery: Bacterial Spectrum and Implications for Antibiotic Therapy

Human Mesenchymal Stromal Cells (MSCs) from Adult Thymus Propagated in Pooled Human Platelet Lysate as Potential Cell Source for Sternal Wound Healing

Human Mesenchymal Stromal Cells (MSCs) from Adult Thymus Propagated in Pooled Human Platelet Lysate as Potential Cell Source for Sternal Wound Healing

Sternal wound infections following cardiac surgery and their management: a single-centre study from the years 2016-2017.

IntroductionDespite improvements in surgical management, sternal wound infection (SWI) following cardiac surgery remains a significant complication.AimTo evaluate pathogens involved in SWI following median sternotomy.Material and methodsWe enrolled 164 patients who experienced prolonged sternal wound healing following open-heart surgery. The inclusion criteria were as follows: prolonged sternal wound healing following cardiac surgery via median sternotomy and complete results of microbiological culture obtained from the sternal swab. The exclusion criteria were as follows: partial sternotomy, patients with mechanical sternum dehiscence and incomplete clinical data. Swabs provided information on the type of microorganism present in the wound and the susceptibility of the microorganism to specific antibiotics.ResultsOne hundred and fourteen (69.5%) patients aged 68 (interquartile range: 60–76) years developed SWI with positive culture. The in-hospital mortality rate was 21.0% in this group. The most common pathogens included Staphylococcus epidermidis (26.6%), Enterococcus faecium (12.2%), Staphylococcus aureus (11.4%), Klebsiella pneumoniae (8.4%), and Pseudomonas aeruginosa (6.8%). In most of the cases the isolated Staphylococcus epidermidis was methicillin-resistant (n = 57, 43.5%). Enterococcus faecium was vancomycin-resistant in 11 (8.3%) cases and high-level aminoglycoside resistant (HLAR) in 13 (9.9%) cases. Klebsiella pneumoniae had the extended-spectrum β-lactamase (ESBL) mechanism in 14 (10.6%) cases. Among 114 culture-positive patients, 48 (42.1%) had polymicrobial infection of the sternal wound.ConclusionsMicroorganisms associated with SWI in our study were mainly commensals, with the most common pathogen being Staphylococcus epidermidis.

Invited Commentary

Invited Commentary

One-year costs of bilateral or single internal mammary grafts in the Arterial Revascularisation Trial

ObjectiveCoronary artery bypass grafting (CABG) using bilateral internal mammary arteries (BIMA) may improve survival over CABG using single internal mammary arteries (SIMA), but may be surgically more complex (and therefore...

Evaluation of feasibility and outcome of isolated aortic valve replacement surgery through J-shaped upper ministernotomy: A comparative study versus full sternotomy

ObjectivesTo evaluate intraoperative (IO) and postoperative (PO) outcome of isolated aortic valve replacement (AVR) surgery through mini-sternotomy (MSAVR) versus full-sternotomy (FSAVR). Patients & methodsSixty-six patients were divided into two equal groups. For MSAVR, a “J” shaped sternal incision with the transverse limb at level of the 4th intercostals space was made. In the other group, aortic valve replacement was done through full median sternotomy. IO and PO data were collected. Patients' functional status was assessed using New York Heart Association (NYHA) classification. At 6-month PO patients' satisfaction by the skin incision outcome was evaluated using a 4-point scale questionnaire. ResultsSkin wound for FSAVR was significantly longer. MSAVR consumed significantly longer total operative time, but the need for blood transfusion was significantly less. Patients of MSAVR group had significantly lower amount of 1st PO day mediastinal tube drainage, and significantly shorter durations of mechanical ventilation, ICU stay and PO hospital stay with significantly lower pain scores. Mean functional scores determined at time of discharge significantly improved in both groups, but were significantly better in MSAVR patients. Wound satisfaction score was significantly high in MSAVR patients. ConclusionMSAVR is a feasible procedure despite of the narrow operative field that induced long operative times but it significantly reduced amount of postoperative drainage and improved recovery items. MSAVR is safe with minimal PO morbidities and allowed early rehabilitation and free sleep position without affection of sternal wound healing. Moreover, MSAVR provided cosmetically better wound that was strongly satisfying patients.