Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country

Mohammed Sanad,Hatem Beshir

doi:10.1186/s43057-020-00019-y

Abstract

BackgroundMinimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra- and postoperative clinical outcomes and address health resource utilization after MIAVR.ResultsA total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; p = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; p = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; p = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; p = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); p < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); p = 0.048). Total operative mortality of 4.46% was recorded (n = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach (p < 0.0001).ConclusionsWith a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.

Highlights

Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding
Our study was conducted on 112 patients, who were operated for aortic valve replacement during the study period, and divided into 2 groups
Fifty-two patients were operated through inverted T-shaped ministernotomy (MS); sixty-two patients were operated through a full median sternotomy (FS)

Summary

Introduction

Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. Few centers have started using these approaches with standard equipment because of the limited resources. Rheumatic heart disease remains the leading cause of aortic valve disease, and surgical aortic valve replacement (SAVR) through full sternotomy is the standard approach [1]. Several minimally invasive techniques for cardiac surgery had been presented to our country since 2011 to lessen the intrusiveness of the surgical procedures, reduce pain, and shorten hospital stays while sustaining equivalent quality and safety of SAVR with a better quality of life and few complications as compared with conventional SAVR while maintaining cost-effectiveness. The lack of subsidy, high expenses linked to surgical equipment, and lengthier training curve make minimally invasive SAVR difficult as a standard of care and place a burden on the healthcare systems. Upper J-shaped sternotomy, inverted T-shaped mini-sternotomy, C-shaped sternotomy, and right anterior thoracotomy (RAT) approaches were described [2]

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