Full Sternotomy Group Research Articles

Bleeding in minimally invasive versus conventional aortic valve replacement

BackgroundObservational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting.MethodsThis was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events.ResultsOut of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition (p = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group (p = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion (p = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding.ConclusionsMinimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy.Clinical Trial Registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT02272621.

The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis.

Minimally invasive approaches are being used increasingly in cardiac surgery and applied in a wider range of operations, including complex aortic procedures. The aim of this study was to examine the safety and feasibility of a partial upper sternotomy approach for isolated elective aortic root replacement (a modified Bentall procedure). We performed a retrospective analysis of 768 consecutive patients who had undergone isolated Bentall surgery between January 2000 and January 2021 at our institution, with the exclusion of re-operations, endocarditis, acute aortic dissections, and root replacement with major concomitant procedures such as multi-valve or coronary bypass surgery. A total of 98 patients were operated on via partial sternotomy (PS) and were matched 2:1 to 196 patients operated on via full sternotomy (FS). The procedure time was 12 min longer in the PS group (205 min vs. 192.5 min in the FS group, p = 0.002), however, cardiopulmonary bypass and aortic cross-clamp times were comparable between groups. Eight PS-procedures were converted to full sternotomy, predominantly for bleeding complications (n = 6). Re-exploration for acute bleeding was necessary in 11% of the PS group and 4.1% of the FS group (p = 0.02). Five FS patients and none in the PS group required emergency coronary bypass grafting for postoperative coronary obstruction (p = 0.2). PS patients were hospitalized for a significantly shorter period (9.5 days vs. 10.5 days in the FS group, respectively). There were no significant differences regarding in-hospital (p = 0.4) and mid-term mortality (p = 0.73), as well as for other perioperative complications. Performing Bentall operations via partial upper sternotomy is associated with similar perfusion and cross-clamp times, as well as overall mortality, when compared to a full sternotomy approach. A low threshold for conversion to full sternotomy should be accepted if limited access proves insufficient for the handling of intraoperative complications, particularly bleeding.

Transaxillary approach enhances postoperative recovery after mitral valve surgery.

Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection, and valve exposure in minimally invasive mitral valve surgery. The aim of this study is to compare the early outcomes of patients operated using a simplified minimally invasive approach through a right transaxillary (TAxA) access with those achieved with conventional full sternotomy (FS) operations. Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at 2 academic centres were reviewed. Among them, 454 patients were operated through minimally invasive mitral valve surgery TAxA access and 667 patients through FS; associated aortic and coronary arteries surgery (CABG) procedures, infective endocarditis, redo and urgent operations were excluded. A propensity-matched analysis was performed using 17 preoperative variables. Two well-balanced cohorts including a total of 804 patients were analysed. The rate of mitral valve repair was similar in both groups. Operative times were shorter in the FS group; nevertheless, in patients operated with a minimally invasive approach, there was a trend towards decreasing cross-clamp time over the study period (P = 0.07). In the TAxA group, 30-day mortality was 0.25%, and postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (P < 0.001) and intensive care unit stay (P < 0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home versus 5% in the FS group (P < 0.001). When compared with FS access, TAxA approach provides at least similar excellent early outcomes in terms of perioperative morbidity and mortality and allows shorter mechanical ventilation time, intensive care unit and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.

P46 TRANSAXILLARY MITRAL VALVE SURGERY IS ASSOCIATED WITH EARLY RECOVERY AND SHORTER ICU AND HOSPITAL STAY

Abstract Background and Aim Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure in minimally invasive mitral valve surgery (MIMVS). Aim of this study is to compare the early outcomes of patients operated through a right trans–axillary (TAxA) approach with those achieved in conventional full sternotomy (FS) operations. Methods Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at two academic centres were reviewed. Among them, 454 patients underwent MIMVS through TAxA access and 667 patients through FS (associated aortic and CABG procedures, infective endocarditis and urgent operations were excluded). A propensity match analysis was performed using seventeen preoperative and intraoperative variables. Results There was no difference in preoperative characteristics in matched populations. The rate of mitral valve repair was similar in both groups. Patients in TAxA group had a higher rate of repair using artificial chordae. Operative times were shorter in FS group but in patients operated in minimally invasive approach there was a trend towards decreasing CPB and cross–clamp time over the study period. Hospital mortality in TAxA group was 0.25%, postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (p&amp;lt;0.001) and ICU stay (p&amp;lt;0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home vs. 5% in the FS group (p&amp;lt;0.001). Conclusions TAxA approach is safe and effective. Compared to FS, it allows shorter mechanical ventilation, ICU and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.

Minimally Invasive versus Conventional Aortic Root Surgery: Results of an Intermediate-Volume Center.

We evaluate the outcome of aortic root surgery via an upper J: -shaped mini-sternotomy (MS) versus full sternotomy (FS) in an intermediate-volume center. Between November 2011 and February 2019, 94 consecutive patients underwent aortic root surgery: 62 (66%) patients were operated via a J: -shaped MS (group A) and 32 (34%) patients via FS (group B). The primary endpoints were mortality, major adverse cardiac and cerebral events (MACCE), and reoperation in a 2-year follow-up. The secondary endpoints were perioperative complications and patient's satisfaction with the procedural results. Valve sparing root replacement (David procedure) was performed in 13 (21%) of the MS and 7 (22%) of the FS patients. The Bentall procedure in MS versus FS was 49 (79%) versus 25 (78%), respectively. Both groups presented similar mean operation, cardiopulmonary bypass, and cross-clamp times. Postoperative bleeding was 534 ± 300 and 755 ± 402 mL (p = 0.01) in MS and FS, respectively, erythrocyte concentrate substitution was 3 ± 3 and 5.3 ± 4.8 (p = 0.018) in MS and FS, respectively, and pneumonia rates were 0 and 9.4% (p = 0.03) in MS and FS, respectively. The 30-day mortality was 0% in both groups, whereas MACCE was 1.6 and 3% (p = 0.45) in MS and FS, respectively. After 2 years, the mortality and MACCE were 4.6 and 9.5% (p = 0.11) and 4.6 and 0% (p = 0.66) in MS and FS, respectively. The number of patients who were satisfied with the surgical cosmetic results in groups A and B was 53 (85.4%) and 26 (81%), respectively. Aortic root surgery via MS is a safe alternative to FS even in an intermediate-volume center. It offers a shorter recovery time and similar midterm results.

Do obese patients with type A aortic dissection benefit from total arch repair through a partial upper sternotomy?

Minimal research has been performed regarding total arch replacement through partial upper sternotomy in patients with acute type A aortic dissection who are obese, and the safety and feasibility of this procedure need to be further investigated. The present study investigated the potential clinical advantages of using a partial upper sternotomy versus a conventional full sternotomy for total arch replacement in patients who were obese. This was a retrospective study. From January 2017 to January 2020, a total of 65 acute type A aortic dissection patients who were obese underwent total arch replacement with triple-branched stent graft. Among them, 35 patients underwent traditional full sternotomy, and 30 patients underwent partial upper sternotomy. The perioperative clinical data and postoperative follow-up results of the two groups were collected, and the feasibility and clinical effect of partial upper sternotomy in total arch replacement were summarized. The in-hospital mortality rates of the two groups were similar. The total operative time, cardiopulmonary bypass, aortic cross-clamp, cerebral perfusion, and deep hypothermic circulatory arrest times were also similar in both groups. The thoracic drainage and postoperative red blood cell transfusion volumes in the partial upper sternotomy group were significantly lower than those in the full sternotomy group. Mechanical ventilation time was shorter in the partial upper sternotomy group than that in the full sternotomy group. Additionally, the incidences of pulmonary infection, hypoxemia, and sternal diaphoresis were lower in the partial upper sternotomy group than those in the full sternotomy group. This study showed that total arch replacement surgery through a partial upper sternotomy in patients with acute type A aortic dissection who are obese is safe, effective, and superior to full sternotomy in terms of blood loss, postoperative blood transfusion, and respiratory complications.

Totally endoscopic aortic valve replacement: Techniques and early results.

To demonstrate the technical details of total endoscopic aortic valve replacement using a standard prosthesis, compare the clinical effect and safety of endoscopic aortic valve replacement and traditional aortic valve replacement. From 2020 to 2021, 60 consecutive patients underwent elective isolated aortic valve replacement (AVR). They were divided into two groups: the total endoscopic AVR group (TE-AVR group, 29 patients, nine women, aged 51.65 ± 11.79 years), and the traditional full-sternotomy group (AVR group, 31 patients, 13 women, aged 54.23 ± 12.06 years). Three working ports were adopted in the TE-AVR procedure. No patient died in either group. The cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time in the TE-AVR group were longer than those in the AVR group (CPB time: 177.6 ± 43.2 vs. 112.1 ± 18.1 min, p < 0.001; ACC time: 118.3 ± 29.7 vs. 67.0 ± 13.2 min, p < 0.001). However, the mechanical ventilation duration (14.2 ± 9.3 vs. 24.0 ± 18.9 h, p = 0.015) and postoperative hospital stay (6.0 ± 1.7 vs. 8.0 ± 4.5 days, p = 0.025) were shorter in patients of TE-AVR group than those of AVR group. Although the ICU stay (55.1 ± 26.9 vs. 61.5 ± 44.8 h, p = 0.509) and post-operative chest drainage of the first 24 h (229.8 ± 125.0 vs. 273.2 ± 103.2 ml, p = 0.146) revealed no statistical difference, there was a decreasing trend in the TE-AVR group. Among the patients of the TE-AVR group, two patients were converted to thoracotomy because of mild to moderate paravalvular leakage identified by intraoperative transesophageal echocardiography. Total endoscopic aortic valve replacement is safe and feasible, with less trauma and quicker recovery.

Ministernotomy in Aortic Root and Arch Surgery: Early Outcomes.

Minimally invasive methods have become more preferred in cardiac surgery today. In this study, the comparative results of patients who underwent an aortic root, arch or hemiarch replacement by ministernotomy and full sternotomy in our clinic are presented. Between January 2017 and October 2019, a series of operations including aortic root, ascending aorta, and aortic arch replacements were performed on 278 patients. The ministernotomy technique was used in 25 of them. Twenty patients who underwent full sternotomy were selected and matched to this group for comparison. The ministernotomy group had a longer cross-clamping time (128.3±30.8 vs. 104.7±23.4 min, P=0.007) but the total operating time was similar in the two groups (249.76±28.56 vs. 248.25±37.53 min, P=0.879). The number of red blood cell (RBC) transfusions per patient was higher in the full sternotomy group (4.65±3.74 vs. 2.44±1.85 unit, P=0.020). The ministernotomy group had shorter ventilation times (7.60±4.88 vs. 32.30±32.25 h, P<0.001) and shorter ICU stay (1.56±0.58 vs. 3.35±1.46 d, P<0.001). The 30-day mortality was 0% in the ministernotomy group. Early results of our study show that, in combined or isolated aortic root, ascending aorta, and aortic arch surgeries, ministernotomy can be applied with relatively safety and low mortality and morbidity rates.

Comparing mini-sternotomy to full median sternotomy for aortic valve replacement with propensity-matching methods.

ObjectiveThis study aims to compare clinical outcomes between mini-sternotomy and full median sternotomy for aortic valve replacement using propensity-matching methods.MethodsFrom August 2014 to July 2021, a total of 1,445 patients underwent isolated aortic valve surgery, 1,247 via full median sternotomy and 198 via mini-sternotomy. To reduce the impact of potential confounding factors, a propensity score based on 18 variables is used to obtain 198 well-matched case pairs, which include 231 aortic valve regurgitations and 165 aortic stenosis cases.ResultOccurrences of in-hospital mortality (P = 0.499), stroke (P > 0.999), renal failure (P = 0.760), and paravalvular leakage (P = 0.224) are similar between the two groups. No significant difference in operation, cardiopulmonary bypass, and aortic cross-clamp times are found between the two groups. However, compared with the full sternotomy group, the mini-sternotomy group has less postoperative 24-hour drainage (131.7 ± 82.8 ml, P < 0.001) and total drainage (459.3 ± 306.3 ml, P < 0.001). The median mechanical ventilation times are 9.4 [interquartile range (IQR) 5.4–15.6] and 9.8 (IQR 6.1–14.4) in mini-sternotomy and full sternotomy groups (P = 0.284), respectively. There are no significant differences in intensive care unit stay and postoperative stay between the two groups. For either aortic valve regurgitations or aortic stenosis patients, significantly less postoperative 24-h and total drainage are still found in the mini-sternotomy group compared with the full sternotomy group.ConclusionsMini-sternotomy for aortic valve replacement is a safe procedure, with not only cosmetic advantages but less postoperative drainage compared with full sternotomy. Mini-sternotomy should be considered for most aortic valve operations.

C13 COMPARISON OF MINIMALLY INVASIVE VERSUS CONVENTIONAL THORACIC AORTIC OPERATIONS: EARLY AND MID–TERM RESULTS IN A SERIES OF 624 PATIENTS

Abstract Objective Despite minimally invasive techniques have gained wider clinical application in cardiac surgery, current evidence on mini thoracic aortic surgery is still limited. The aim of this study was to compare early and mid–term outcomes of patients undergoing proximal thoracic aortic interventions through mini–sternotomy (MS) versus full sternotomy (FS). Methods Data from 624 consecutive patients undergoing proximal aortic operations through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at 2 aortic centers, were analysed. Patients with prior cardiac operations and active endocarditis, and those who underwent emergency operation and combined procedures were excluded. Treatment selection bias was addressed by the use of propensity score matching (MS vs FS). After matching, 2 well–balanced groups of 202 patients each were created. Surgical procedures involved aortic valve replacement/repair and ascending aorta replacement in 190 patients (47%), aortic root replacement in 110 patients (27.2%) and isolated ascending aorta replacement in 104 patients (25.7%). Results The median cardiopulmonary bypass and cross clamp times were 88 and 68 minutes, respectively, with no difference between groups. Overall 30–day mortality was 0.7%, being 1% (n = 2) in patients underwent MS and 0.5% (n = 1) in those underwent FS (p = 0.6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4,2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%) (Table 1). Patients receiving MS were associated with a lower incidence of respiratory insufficiency compared with those receiving FS (0% vs. 2.5%, p = 0.03). The median intensive care unit length of stay was 24 and 25 hours in MS and FS group, respectively (p = 0.3), and in–hospital stay was 7 days both in MS and FS group (p = 0.9). Three–year survival rate was 96.6% in patients receiving MS and 95.7% in those receiving FS (p = 0.9). Conclusions Our findings showed that mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Partial upper sternotomy for aortic valve replacement provides similar mid-term outcomes as the full sternotomy.

BackgroundMinimally invasive aortic valve replacement via upper partial sternotomy (MiniAVR) provides very good short-term results and delivers certain advantages in the postoperative course. There is limited data regarding the mid-term mortality and morbidity following this minimally invasive surgery.MethodsWe provide a retrospective analysis of the patients, undergoing MiniAVR versus full sternotomy (FS) for aortic valve replacement with biological prosthesis. As the primary combined end-point the combination of death, stroke, and rehospitalization within 3 years postoperatively was defined. Data have been collected from National Cardiac Surgery Registry and insurance companies.ResultsTwo hundred consecutive patients with aortic valve replacement (100 ministernotomy in MiniAVR group and 100 full sternotomy in FS group) with biological prosthesis were included in this study. Ministernotomy had longer cross-clamp and bypass times (median difference 6.5 min, P=0.005, and 8.5 min, P=0.002 respectively). Patients operated via upper partial sternotomy had a lower postoperative bleeding [300 mL (IQR, 290) vs. 365 mL (IQR, 207), P=0.031]. There was no difference in the 3-year mortality (14% vs. 11%, P=0.485). The mean number of readmission 3 years after surgery per capita was almost the same in both groups (1.65 vs. 1.60, P=0.836). Median time to the first readmission was longer in the MiniAVR group (difference 8.9 months). The incidence of combined end-point during 3 years postoperatively in both groups was not statistically different (P=0.148), as well as readmissions from cardio-vascular reasons (subhazard ratio 0.90, P=0.693).ConclusionsUpper partial sternotomy can be performed safely for aortic valve replacement, without increased risk of death, stroke or re-admission in 3 years postoperatively.

Bridging INTERMACS Profile 1 Patients to Left Ventricular Assist Device: The Right Device, the Right Time, and the Best Surgical Approach

<h3>Purpose</h3> The purpose of this study was to investigate the factors related to temporary mechanical support (tMCS) and surgical approach influencing post-LVAD outcomes in INTERMACS 1 patients. <h3>Methods</h3> We performed a retrospective review of all INTERMACS 1 patients implanted with the fully magnetically levitated LVAD in our institution from September 2015 through March 2021. Influence of the following factors on in-hospital survival were analyzed: type and time on tMCS; change in the tMCS level (<i>step-up:</i> IABP→ECMO and/or Impella, Impella→ ECMO±Impella; <i>step-down:</i> ECMO+Impella→ ECMO or Impella); heart failure acuity; and surgical approach. <h3>Results</h3> Of 287 implanted patients, 102 (35.5%) were INTERMACS profile 1 and included in the study. Full sternotomy (FS) was used in 25 (24.5%) patients and less invasive surgery (LIS) in 77 (75.5%) patients. Patients in the FS group were more frequently bridged with IABP in contrast to LIS patients supported with Impella. Postoperatively, LIS patients bled less, required shorter mechanical ventilation, and had a lower incidence of severe right ventricular failure. In-hospital survival was similar (Table 1). Multivariate analysis demonstrated a positive correlation between IABP and in-hospital survival while FS demonstrated a negative effect (Figure 1). <h3>Conclusion</h3> Patients presenting with cardiogenic shock should be expeditiously evaluated for LVAD therapy while supported with adequate tMCS tailored to the patient's requirements. Less invasive LVAD implantation may alleviate some of the perioperative risks. Future trials are required to confirm our data.

Impact of Surgical Approach on Outcome in Patients with History of Previous Sternotomy Underwent LVAD Implantation

<h3>Purpose</h3> The purpose of this study is to investigate the impact of the surgical approach on the outcome of patients with previous history of sternotomy. <h3>Methods</h3> Between January 2015 und September 2021, a total of 73 patients with a previous history of sternotomy received LVAD Implantation through two different approaches (less invasive and full sternotomy). The J-Sternotomy and anterolateral thoracotomy was used in all LIS patients. Data collection included baseline demographics, hemodynamic and implant data, adverse events and survival. The outcomes of the LIS and Sternotomy approaches were compared. <h3>Results</h3> Our cohort included 73 patients who underwent LVAD implantation. A total of 60 patients were operated using the old sternotomy approach, the remaining patients underwent LVAD-implantation through a LIS approach. Reexploration rate for bleeding was necessary in 25 % (15/60) in the full sternotomy group compared with 8.3 % (1/12) the less-invasive surgery group. Intensive care unit (ICU) stay for the LIS group was lower than for the sternotomy group (17.3 days vs. 18.2 days). The LIS group had less postoperative blood transfusion. The median operative time was also lower in the LIS group compared to the FS group (85 min vs. 96 min). Finally, the LIS group showed a lower rate of severe right heart failure with the need of right ventricular assist device (RVAD) Implantation (8.3 % vs. 18.3%). <h3>Conclusion</h3> The less-invasive surgery approach is a safe technique for left ventricular assist device implantation also in patients with history of previous sternotomy. Less-invasive surgery was associated with a reduction in the postoperative bleeding complications, duration of ICU stay, and RVAD implantation.

Partial upper sternotomy for extensive arch repair in older acute type A aortic dissection patients

ObjectivesThe partial upper sternotomy (PUS) approach is acceptable for aortic valve replacement, and even aortic root operation. However, the efficiency of PUS for extensive arch repair of acute type A aortic dissection (AAAD) in older adult patients has not been well investigated.MethodsBetween January 2014 and December 2019, 222 older adult patients (≥ 65 years) diagnosed with AAAD went through extensive arch repair, among which 127 received PUS, and 95 underwent full sternotomy (FS). Logistic regression analysis was used to identify risk factors for early death, and negative binomial regression analysis was applied to explore risk factors related to post-operative ventilator-supporting time and intensive care unit stay time.ResultsTotal early mortality was 8.1% (18/222 patients). The PUS group had shorter Cardiopulmonary bypass time (133.0 vs.155.0 min, P < 0.001), cross-clamp time (44.0 vs. 61.0 min, P < 0.001) and shorter selective cerebral perfusion time (11.0 vs. 21.0 min, P < 0.001) than the FS group. Left ventricle ejection fraction < 50% (odds ratio [OR] 17.05; 95% confidence interval [CI] 1.87–155.63; P = 0.012) and malperfusion syndromes (OR 65.83; 95% CI 11.53–375.86; P < 0.001) were related to early death. In the multivariate model, the PUS approach contributed to shorter ventilator-supporting time (incidence rate ratio [IRR] 0.76; 95% CI 0.64–0.91; P = 0.003), when compared with the FS group.ConclusionsThe early results of emergency extensive arch repair of AAAD via PUS in older adult patients were satisfactory. However, the long-term results remain to be investigated.

Minimally Invasive versus Full Sternotomy SAVR in the Era of TAVR: An Institutional Review.

In the era of advancing transcatheter aortic valve replacement (TAVR) technology, traditional open surgery remains a valuable intervention for patients who are not TAVR candidates. We sought to compare perioperative variables and postoperative outcomes of minimally invasive and full sternotomy surgical aortic valve replacement (SAVR) at a single institution. A retrospective analysis of 113 patients who underwent isolated SAVR via full sternotomy or upper hemi-sternotomy between January 2015 and December 2019 at the University of Utah Hospital was performed. Preoperative comorbidities and demographic information were not different among groups, with the exception of diabetes, which was significantly more common in the full sternotomy group (p = 0.01). Median procedure length was numerically shorter in the minimally invasive group but was not significant following the Bonferroni correction (p = 0.047). Other perioperative variables were not significantly different. The two groups showed no difference in the incidence of postoperative adverse events (p = 0.879). As such, minimally invasive SAVR via hemi-sternotomy remains a safe and effective alternative to full sternotomy for patients who meet the criteria for aortic valve replacement.

Low-Risk Surgical Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation.

Open surgical aortic valve replacement (SAVR) is a viable alternative to transcatheter implantation in low-risk patients. In this light, we evaluated the safety and effectiveness of SAVR performed through conventional and less invasive surgical approaches in a high-volume center. We retrospectively reviewed the records of 395 consecutive patients who underwent open SAVR from January 2019 through December 2019 in our center. We evaluated and compared the operative results and postoperative major adverse outcomes of 3 surgical approaches: full median sternotomy (n=267), upper ministernotomy (ministernotomy) (n=106), and right anterior thoracotomy (minithoracotomy) (n=22). Overall, the 30-day all-cause mortality rate was 0.8% (3 patients). Stroke occurred in 8 patients (2%), disabling stroke in 4 patients (1%), myocardial infarction in 1 (0.2%), and surgical site infection in 13 (3.2%). There was no difference in 30-day mortality rate or incidence of postoperative major adverse events among the 3 surgical groups. Stroke and surgical site infection occurred more frequently, but not significantly so, in the full-sternotomy group. The mean hospital stay was longer after full sternotomy (9.1 ± 5.5 d) than after ministernotomy (7.5 ± 2.9 d) or minithoracotomy (7.4 ± 1.9 d) (P=0.012). Our findings suggest that open SAVR performed in a high-volume center is associated with a low early mortality rate and that less invasive approaches result in faster postoperative recovery and shorter hospital stays.

Comparative Early and Long Term Results of Mitral Valve Surgery between Right Mini Thoracotomy and Full Sternotomy Approach

Background: Conventional mitral valve surgery (MVS) requires median sternotomy. Right mini thoracotomy (RMT) MVS is an alternative non sternotomy approach aiming for less bleeding, pain reduction, rapid recovery, cosmetic satisfaction, safety and effectiveness of the procedure. Objectives: To report early and late clinical results comparing RMT versus full sternotomy (FS) MVS. Materials and Methods: 574 consecutive patients underwent MVS were prospectively non randomized reviewed during January 2002 to October 2018. There were 241 in FS group and 241 in RMT group by age and Euro II score matching. Baseline characteristics were compared. Early and late clinical outcomes of 30 days mortality, reoperation for bleeding, stroke, prolonged ventilation, renal failure, permanent pacemaker, and echocardiographic hemodynamic performance were assessed and compared between two groups. All patient follow-up to December 2020. Results: Similar results were found between RMT and FS MVS groups including age 58.8+13.6, 57.2+14.2, p=0.2, new AF 5 (2%), 4 (1.7%), p=1.0), except for more degenerative valve pathology (79%, 50%, p&lt;0.001). There were more re operation for bleeding 2 (0.8%), 1 (0.3%), p=0.9, less aortic cross clamp time (107+37.3, 115.4+36.4, p=0.017), less cardiopulmonary bypass time (157.6+51.2, 171.3+53.4, p=0.005), less bleeding and blood transfusion requirement in the RMT group. Early clinical results of 30 days mortality, stroke, renal failure, new pacemaker, and hemodynamic performance at one month, three to six month, and one year were comparable in both groups. Mean follow-up (year) was 5.2+2.5 (RMT) and 10.2+4.0 (FS). Survival probability and freedom from MACCE at ten years in RMT and FS group were 94.05%, 95.44% and 99.5%, 90.46%, p&lt;0.001, respectively. Conclusion: RMT approach for MVS is associated with cosmetic satisfaction, less bleeding, similar effective hemodynamic performance and non-inferiority early and late clinical results to FS approach. Keywords: Mitral valve surgery; Right mini thoracotomy

J-ministernotomy for aortic valve replacement: a retrospective cohort study

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.

Partial Upper Sternotomy is a Safe Alternative in Mitral Annulus Decalcification

In patients with major annulus calcifications (MAC) requiring en-bloque decalcification anterolateral minithoracotomy is not suitable for safe and reproducible mitral valve surgery (MVS) procedures. In these cases, full sternotomy (FS) is still the preferred approach. Alternatively, less invasive MVS via partial upper sternotomy (PS) and transseptal access can be used in experienced centers. After reviewing the records of 1741 patients, who were treated with either isolated MVS or combined procedures, we identified 32 patients who had undergone en-bloque decalcification for MAC. The 2 techniques (PS-group n=17, FS-cohort n=15) were presented in terms of 1-year mortality as well as intra- and perioperative outcome. In the PS group, the age was 60.06 ± 7.56 patients, 64.7% were female and had a STS Predicted Risk of Mortality (PROM) score of 1.01 ± 1.06. In the FS group the patients (53.3% female) mean age was 58.47 ± 14.45 and had a STS PROM score 2.35 ± 2.73%. Rates of mitral repair were in the PS and FS cohort 64.7% and 46.7%, respectively. One-year mortality for PS-MVS was 5.9% (n=1) and 20% (n=3) for FS-MVS. The cardiopulmonary bypass (FS: 181.60 ± 49.99 minutes, PS: 192.83 ± 77.32 minutes and the cross-clamp times (FS: 119.67 ± 46.06, PS: 136.94 ± 54.37 minutes). The observed ventilation times in the PS and FS group were 5 hours (IQR 3.5-9) and 10 hours (IQR 5-15), respectively. A permanent pacemaker implantation was not necessary in any patient. In patients with MAC and en-bloque decalcification PS seems to be a safe access and might be a valid less invasive alternative to minithoracotomy.

Comparative study between aortic valve replacement through full sternotomy versus mini-sternotomy

Background: The superiority of minimally invasive aortic valve replacement (AVR) over the standard approach is the subject of ongoing research. The aim of this study was to compare the outcomes of AVR through full sternotomy versus mini-sternotomy.&#x0D; Methods: We included 60 patients who had AVR; 30 patients underwent AVR through J- or T-shaped mini-sternotomy, and 30 patients had a full sternotomy. We included patients who had isolated AVR and excluded patients who had a concomitant cardiac procedure, redo surgery, or those who needed annular dilatation. All patients had aortic and right atrial cannulation for cardiopulmonary bypass. Study endpoints were operative times, postoperative complications and duration of ICU and hospital stays.&#x0D; Results: There were no differences between the two groups preoperatively. Cardiopulmonary bypass time was longer in the mini-sternotomy group (median: 100 (range: 65- 170) vs. 85 (55-160) min, respectively; p= 0.024). Operative time was non-significantly longer in the mini-sternotomy group 5 (4-6) hours vs. 4.5 (4-6) hours in the full sternotomy group (p=0.62). Ventilation time was 10 (4- 50) hours in the mini-sternotomy group vs. 14 (8- 45) hours in the full sternotomy group (p&lt;0.001). ICU stay was shorter in the mini-sternotomy group (2 (1-6.5) vs. 2.5 (1-7) days, respectively, p= 0.014). The total mediastinal drainage was 100 (50 400) ml in the mini-sternotomy group vs. 275 (50- 1000) ml in the full sternotomy group (p= &lt;0.001). There was no difference in wound infection (p= 0.35), tamponade (p˃0.99), and hemothorax (p˃0.99) between both groups.&#x0D; Conclusion: Mini-sternotomy AVR had longer cardiopulmonary bypass times; however, there were no differences in the postoperative complications compared to the full sternotomy approach. Mini-sternotomy could be a safe alternative approach to the full median sternotomy for aortic valve replacement.