Abstract
BackgroundThe advantage of minimally invasive sternotomy (MS) over full sternotomy (FS) for isolated aortic valve replacement (AVR) is still controversial. We aimed to examine if J-shaped MS is a safe alternative to FS in patients undergoing primary isolated AVR. This study is a retrospective and restricted cohort study that included 137 patients who had primary isolated AVR from February 2013 to June 2015. Patients with previous cardiac operations, low ejection fraction (< 40%), infective endocarditis, EuroSCORE II predicted mortality > 10%, and patients who had inverted T or inverted C-MS or right anterior thoracotomy were excluded. Patients were grouped into the FS group (n=65) and MS group (n=72). Preoperative variables were comparable in both groups. The outcome was studied, balancing the groups by propensity score matching.ResultsSeven (9%) patients in the MS group were converted to FS. Cardiopulmonary bypass (98.5 ± 29.3 vs. 82.1 ± 13.95 min; p ≤ 0.001) and ischemic times (69.1 ± 23.8 vs. 59.6 ± 12.2 min; p = 0.001) were longer in MS. The MS group had a shorter duration of mechanical ventilation (10.1 ± 11.58 vs. 10.9 ± 6.43 h; p = 0.045), ICU stay (42.74 ± 40.5 vs. 44.9 ± 39.3; p = 0.01), less chest tube drainage (385.3 ± 248.6 vs. 635.9 ± 409.6 ml; p = 0.001), and lower narcotics use (25.14 ± 17.84 vs. 48.23 ± 125.68 mg; p < 0.001). No difference was found in postoperative heart block with permanent pacemaker insertion or atrial fibrillation between groups (p = 0.16 and 0.226, respectively). Stroke, renal failure, and mortality did not differ between the groups. Reintervention-free survival at 1, 3, and 4 years was not significantly different in both groups (p = 0.73).ConclusionJ-ministernotomy could be a safe alternative to FS in isolated primary AVR. Besides the cosmetic advantage, it could have better clinical outcomes without added risk.
Highlights
The advantage of minimally invasive sternotomy (MS) over full sternotomy (FS) for isolated aortic valve replacement (AVR) is still controversial
Study outcomes After adjustment of the operator, EuroSCORE, implant type, and size, we observed that total cardiopulmonary bypass and cross-clamp times were significantly longer in the ministernotomy group compared to the full sternotomy group (98.5 ± 29.3 versus 82.1 ± 13.95 min with p < 0.001 and 69.1 ± 23.8 vs. 59.6 ± 12.2 min with p = 0.001, respectively). (Table 3)
Seven patients in the MS group (9.7%) were converted to full sternotomy for several reasons including adhesions between the aorta and the pericardium (n= 1), obesity with a body mass index (BMI) of 38.34 kg/ m2 (n=1), difficult access to the aortic root and right atrial appendage which were either lying deep in the chest or rotated to the right side (n=4), and paravalvular leakage detected with transesophageal echocardiography (TEE) intraoperatively (n=1) that needed conversion to full sternotomy and resizing of the annulus and implantation of smaller aortic valve sized 23 mm instead of the 25 mm
Summary
The advantage of minimally invasive sternotomy (MS) over full sternotomy (FS) for isolated aortic valve replacement (AVR) is still controversial. Despite the recent advances in transcatheter aortic valve interventions, conventional surgery remains the gold standard because of its wellestablished efficacy and durability [2] It is still debated which approach is ideal for aortic valve replacement (AVR), median full sternotomy, or minimally invasive approaches. Minimally invasive approaches provide better cosmetic results with less surgical trauma that keeps most of the cardiac surface untouched and facilitates redo operations [7]. Their effects on the postoperative outcomes, including mechanical ventilation, intensive care unit (ICU) stay, pain, chest tube drainage, arrhythmias, stroke, renal failure, or mortality, are still being studied
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