Sternotomy For Aortic Valve Replacement Research Articles

Postoperative quality of life and pain after upper hemisternotomy and conventional median sternotomy for aortic valve replacement: results of a randomized clinical trial.

Surgical aortic valve replacement through conventional sternotomy yields excellent results. Minimally invasive techniques are deemed equally safe and serve as a viable and less traumatic alternative. However, it is unclear how both surgical techniques affect patient reported outcomes. The objective of this trial is to compare postoperative cardiac-related quality of life and postoperative pain after upper hemisternotomy and conventional surgical aortic valve replacement. In this single centre, open-label, investigator-initiated randomized clinical trial, patients were randomized to upper hemisternotomy or conventional full median sternotomy. Patients unable to undergo randomization were monitored prospectively (registry group). Primary outcome was cardiac specific quality of life, measured with the Kansas City Cardiomyopathy Questionnaire up to one year postoperatively. Patients undergoing upper hemisternotomy had a significantly higher physical limitation domain score across all post-operative time points than patients undergoing conventional surgical aortic valve replacement (estimated mean difference 2.12 points; p = 0.014). Patients undergoing upper hemisternotomy were more likely to have a pain score <30 the first two days postoperatively than patients undergoing conventional surgical aortic valve replacement (Odds Ratio 2.63; p = 0.007). This was associated with reduced opioid analgesic intake. Postoperative surgical outcome did not differ between both groups. Surgical aortic valve replacement through both conventional sternotomy and upper hemisternotomy resulted in clinically similar and important improvements in quality of life, with a small advantage for upper hemisternotomy, while there was no compromise in safety.

Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case.

Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration. A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well. Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Minimally invasive versus conventional sternotomy for aortic valve replacement: A systematic review and meta-analysis

Minimally invasive versus conventional sternotomy for aortic valve replacement: A systematic review and meta-analysis

Mini-Aortic Valve Replacement versus Transcatheter Aortic Valve Implantation: A Propensity-Matched Study

Background. Total sternotomy for aortic valve replacement has been superseded by less invasive approaches such as mini-sternotomy or transcatheter procedures. There has been an exponential uptake in transcatheter aortic valve implantation (TAVI) in younger and lower risk patients following recent randomized trials. This study aims to compare the outcomes of patients with aortic stenosis treated with minimally invasive approaches: mini-sternotomy for aortic valve replacement (mini-AVR) and TAVI implantation. Methods. Between January 2015 and December 2021, a total of 1437 TAVI and 176 mini-AVR patients from 2 tertiary centers fulfilled the criteria and were included in the propensity matching model. Results. A total of 256 TAVIs and 146 mini-AVR were included in the matched cohort. There was no significant difference in 30-day mortality in the two groups (TAVI vs. mini-AVR 2.7% vs. 2.8%, p = 0.935 ). TAVI confers slightly lower gradients in the follow-up echo when compared with mini-AVR (peak gradient 20 ± 8.7 mmHg vs. 24.5 ± 10 mmHg, p &lt; 0.001 ; mean gradient 10.9 ± 5.6 mmHg vs. 13.2 ± 5.7 mmHg, p &lt; 0.001 ). On the other hand, mini-AVR exhibits remarkably lower rates of paravalvular leak (mild leak 8% vs. 41.5%, p &lt; 0.001 ; moderate leak 2.8% vs. 0%, p &lt; 0.001 ) and of need for permanent pacemaker implantation (2% vs. 12.2%, p &lt; 0.001 ). Unsurprisingly, TAVI has lower in-hospital stay 3 (2 to 6) days vs. 10 (8 to 13) days, p &lt; 0.001 ). Conclusions. For eligible aortic stenosis patients in the 7th decade of life, mini-AVR remains an excellent therapeutic option.

Safety and efficacy of two-port thoracoscopic aortic valve replacement

BackgroundPure aortic valve disease is common and has been treated with sternotomy aortic valve replacement for decades. Minimally invasive cardiac surgery has been widely used in atrioventricular valve lesions, but totally thoracoscopic aortic valve replacement has rarely been reported.MethodThe profiles of 9 patients who were diagnosed with severe aortic valve diseases and treated with two-port thoracoscopic aortic valve replacement between February 2021 and February 2022 were retrospectively reviewed. The clinical data, including baseline characteristics, operative data, postoperative complications, and short-term outcomes, were reported.ResultsAll nine patients successfully underwent two-port thoracoscopic aortic valve replacement, with a cardiopulmonary bypass time of 137.56 ± 27.99 min and an aortic cross-clamp time of 95.33 ± 17.96 min. Seven (77.78%) patients underwent mechanical valve replacement, and two (22.22%) patients underwent bioprosthetic valve replacement. Two (22.22%) patients underwent a concomitant aortic root enlargement procedure. There were no intraoperative or postoperative deaths. The incidence of procedural complications was 0%, while the results of ventilation time, intensive care unit stay length, blood transfusion, chest tube drainage, and kidney function were satisfactory.ConclusionTwo-port thoracoscopic aortic valve replacement is a safe and effective surgical treatment option for carefully selected patients with pure aortic valve diseases.

Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis.

In recent years, minimally invasive cardiac surgery has increased in prevalence. There has been significant debate regarding the optimal approach to isolated aortic valve replacement between conventional midline sternotomy and minimally invasive approaches. We performed a systematic review of the contemporary literature comparing minimally invasive to full sternotomy aortic valve replacement. PubMed and Embase were systematically searched for articles published from 2010-2021. A total of 1215 studies were screened and 45 studies (148,606 patients total) met the inclusion criteria. This study found rates of in-hospital mortality were higher with full sternotomy than ministernotomy ( P = 0.02). 30-day mortality was higher with full sternotomy compared to right anterior thoracotomy ( P = 0.006). Renal complications were more common with full sternotomy versus ministernotomy ( P < 0.00001) and right anterior thoracotomy ( P < 0.0001). Rates of wound infections were greater with full sternotomy than ministernotomy ( P = 0.02) and right anterior thoracotomy ( P < 0.00001). Intensive care unit length of stay ( P = 0.0001) and hospital length of stay ( P < 0.0001) were shorter with ministernotomy compared to full sternotomy. This review found that minimally invasive approaches to isolated aortic valve replacement result in reduced early mortality and select measures of postoperative morbidity; however, long-term mortality is not significantly different based on surgical approach. An analysis of mortality alone is not sufficient for the selection of the optimal approach to isolated aortic valve replacement. Surgeon experience, individual patient characteristics, and preference require thorough consideration, and additional studies investigating quality of life measures will be imperative in identifying the optimal approach to isolated aortic valve replacement.

Aortic valve replacement: same operation, same outcomes but a smaller incision.

Minimally invasive approaches are at the forefront of advancements in cardiac surgery and are playing key roles in our growing speciality. Despite the growing numbers of transcatheter aortic valve replacement, surgical aortic valve replacement (SAVR) remains at the core of treating aortic valve pathologies. SAVR remains the preferred choice for patients undergoing aortic valve surgery in young, fit patients under the age of 65 (USA)/75 (Europe). Different technical approaches have been identified to perform SAVR, such as hemi-sternotomy and right anterior thoracotomy [1]. Minimally invasive SAVR is an evolving subspeciality providing equivalent outcomes to SAVR performed through a median sternotomy whilst reducing invasiveness. Whilst these approaches are useful and reliable, careful patient selection and surgeon experience remain important factors in achieving good outcomes. In this issue of EJCTS, the study by Telyuk et al. [2] sheds light on comparing manubrium-limited mini-sternotomy versus conventional sternotomy for aortic valve replacement in the MAVRIC trial. The authors compare the long-term outcomes between hemi- and median sternotomy for surgical aortic valve replacement in 270 patients [2]. The MAVRIC trial published the trial protocol in 2017, with the primary outcome to compare the need for postoperative red cell transfusion within 7 days of index surgery between hemi- and median sternotomy for SAVR [3, 4]. Secondary outcomes included several key outcomes including but not limited to the proportion of patients receiving a red cell transfusion, volume in chest drains at 6 and 12 h, degree of aortic regurgitation using echocardiogram within 6 weeks, reoperation rates, conversion to median sternotomy intra-operatively, and postoperative quality of life using the EuroQol (EQ-5D-3 l, EQ-VAS) questionnaire at 2 days, 6 weeks and 12 weeks and, finally, cost-effectiveness analyses.

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.

Do obese patients benefit from isolated aortic valve replacement through a partial upper sternotomy?

ObjectiveControversial opinions exist for aortic valve replacement (AVR) through partial upper sternotomy in obese patients. Moreover, this study sought to investigate the potential clinical advantage of partial upper sternotomy aortic valve replacement (mini-AVR) over conventional full sternotomy aortic valve replacement (con-AVR) in obese patients.MethodsThis was a retrospective and observational study. From January 2015 to December 2020, a total of 184 obese [body mass index (BMI) ≥ 30 kg m2] patients undergoing isolated primary AVR were included: 98 patients underwent conventional full sternotomy, and 86 patients underwent partial upper sternotomy. Propensity score (PS) matching was applied to eliminate the bassline imbalances in the mini-AVR and the con-AVR groups.ResultsAfter one-to-one propensity score matching, two groups of 60 patients were obtained. No in-hospital death occurred in the two groups. In addition, cardiopulmonary bypass time and total operative time were similar across the 2 groups, but the aortic cross-clamp time was significantly shorter in the con-AVR group (P = .0.022). The amount of mediastinal drainage at 48 h after surgery (P = 0.018) and postoperative blood transfusions (P = 0.014) were significantly lower in the mini-AVR group. There was no difference in ventilation time (P = .0.145), but a shorter intensive care unit stay time (P = 0.021) in the mini-AVR group.ConclusionThis study demonstrates that aortic valve replacement through a mini-AVR in obese patients is a safe and effective procedure. It outperformed con-AVR in terms of blood loss, blood product transfusion, and ICU stay.

Minimally invasive aortic valve replacement with an expandable bioprosthesis after LVAD implantation as redo surgery.

Left Ventricular Assist Device (LVAD) is currently implanted not only as a bridge to transplant or recovery but also as destination therapy. One factor, affecting the device performance and treatment adequacy negatively is the development of aortic valve insufficiency (AI) after the implantation. Herein, we introduce a minimally invasive partial sternotomy aortic valve replacement with an expandable bio-prosthesis in a 74-year-old LVAD patient with severe AI.

More for less - long-term survival modeling for surgical aortic valve replacement follow-up: The division between a ministernotomy and a full sternotomy approach.

This study aimed to assess long-term results after surgical AVR (sAVR) depending on the used surgical technique (ministernotomy vs. full sternotomy) and to determine which patient- and treatment-related attributes were most associated with shorter time to the main endpoint. Out of 2147 patients, who underwent sAVR from January 2006 to December 2017, 615 patients were treated minimally invasively (MIAVR) and 1532 patients received conventional full sternotomy aortic valve replacement (FSAVR). Multiple Cox regressive models corresponding to the four major endpoints were developed. Long-term survival and a time to re-hospitalization for acute coronary syndrome, stroke, and heart failure (HF) were analyzed independently. Kaplan-Meier actuarial analysis was performed for univariate comparison. The median follow-up time was 71.9 months. No significant difference in terms of long-term survival was found between MIAVR and FSAVR (hazard ratio [HR], 0.99; P = 0.91). Novel advantages of MIAVR in preventing re-hospitalization for late cerebrovascular events and the progression of HF were observed (HR, 0.53; P = 0.03; HR, 0.64, P = 0.005; respectively). Importantly, for the late mortality risk, early in-hospital complications dominated. However, the baseline atrial fibrillation (AF), diabetes, pulmonary disease, and impaired mobility showed the strongest patient-specific prediction for the other three long-run models. MIAVR through ministernotomy provides at least as good long-term survival as FSAVR. Nevertheless, it should be recommended for diabetic, poor-mobility patients with pre-existing AF to reduce their high cerebrovascular risk and to limit the progression of HF. MIAVR also needs to be considered in patients with chronic lung diseases to improve their extremely poor survival prognosis.

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.

44 Early and Long-Term Outcomes of Re-Sternotomy Aortic Valve Replacement (AVR) With Previous Coronary Artery Bypass Grafts (CABG)

Abstract Introduction With the wider use of biological prosthetic valves and increasing life expectancy, the number of patients requiring redo surgery for aortic valve replacement (AVR) is increasing. This carries its own risks particularly in those with previous cardiac surgery - from graft injury and myocardial jeopardy. Transcatheter valve replacement provides a safer option for high-risk patients that do not require any additional cardiac surgery. This project aims to evaluate the early and long-term outcomes of redo-sternotomy AVR after previous CABG. Method Retrospective study of patients that underwent redo sternotomy AVR with (Group 1) or without (Group 2) concomitant cardiac procedure(s) from 2000–2019. Pre-operative, operative and post-operative data collected for each patient. Statistical analysis done with significance p-value &amp;lt;0.15. Results 178 patients included during this time-period (Group 1 = 90 and Group 2 = 88). Mean age of 75 years and EuroSCORE of 17. In hospital-mortality was 7.8% with key contributing factors of heart failure (NYHA III-V), perioperative IABP insertion and cardiovascular injury - 12% of cases and most commonly effecting the left internal mammary artery (LIMA). Survival at 5 years in both groups is significantly worse for patients with post-operative complications and cardiovascular injury. However, long-term survival is better in Group 1 than in Group 2. Conclusions Risk of injury to LIMA increases operative mortality. Peripheral cannulation and pre-sternotomy cardiopulmonary bypass can help manage this - although numbers in this study too small. Alternatives to redo valve surgery are to be considered in high-risk patients and a multidisciplinary approach continued to be adopted for each case.

A comparative study between mini versus full sternotomy aortic valve replacement

BackgroundAortic valve replacement for treatment of aortic valve diseases is quite common. Minimally invasive procedures have gained a lot of popularity in recent years with the claimed better early postoperative outcomes in comparison with conventional techniques.ObjectiveThe aim was to compare early postoperative outcomes after ministernotomy versus conventional median sternotomy aortic valve replacement.Patients and methodsThe authors prospectively studied 60 patients who underwent aortic valve replacement surgery at the National Heart Institute between the period of May 2020 and July 2021. A total of 30 patients had aortic valve replacement via upper ministernotomy approach, whereas the other 30 patients had aortic valve replacement using conventional median sternotomy. Early postoperative results were compared with each other.ResultsThere was no morality throughout the study. The mean age was 45.8 ± 15.13 years in the conventional group and 51.13 ± 17.8 in the ministernotomy group. Perioperative data showed no significant difference between the two groups, except for aortic orifice (root) diameter, which was wider in the ministernotomy group. The cross-clamp time was 60.33 ± 8.27 in the conventional group and 70.66 ± 6.91 in the ministernotomy group, and the total bypass time was 77.0 ± 8.46 and 88.1 ± 9.55, respectively, with significant difference between the two groups. Postoperative pain levels showed a statistically significant difference and were less severe in the ministernotomy group, and the total hospital stay was shorter in the ministernotomy group, with significant difference between the two groups.ConclusionThe use of upper ministernotomy approach to replace a diseased aortic valve is safe and can be compared with the conventional median sternotomy approach.

Ministernotomy for aortic valve replacement improves early recovery and facilitates proper wound healing - forced propensity score matching design with reference full sternotomy.

IntroductionWith the development of less invasive techniques ministernotomy has become an increasingly popular choice for minimally invasive aortic valve replacement (MIAVR). However, a large discrepancy in the published results, often derived from the center’s own experience, intensifies the need for further re-evaluation in order to better define the real impact of the ministernotomy approach on postoperative clinical condition in short- and long-term observation.AimTo assess the safety and efficacy of MIAVR in comparison to a reference full sternotomy AVR (FSAVR).Material and methodsBetween January 2004 and January 2018, 2386 patients underwent isolated surgical aortic valve replacement (AVR) at our institution. 620 patients were treated minimally invasively (MIAVR) and 1766 patients received FSAVR. Forced propensity score 1 : 1 matching and conditional regressive methods were introduced, ensuring valid comparison and correct estimation. Ultimately, 557 well allocated pairs of treated and control patients were included.ResultsIn-hospital mortality was low and comparable (1.26% for MIAVR, 1.62% for FSAVR). No significant differences in terms of serious adverse events were found, although in patients undergoing MIAVR there tended to be lower incidence of neurological complications (OR = 0.72; p = 0.09) and low output syndrome (OR = 0.66; p = 0.13). In addition to a much faster extubation and discharge from the ICU as well as improved blood management, MIAVR significantly reduced the risk of wound complications (OR = 0.31; p < 0.0010).ConclusionsMIAVR is a safe, effective and reproducible procedure providing at least as good results as FSAVR. Nevertheless, it should be especially recommended to obese, diabetic patients with pulmonary and mobility disorders in order to improve their early recovery.

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.

Clinical study of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision: The first Chinese experience

BackgroundThere is an increasing demand for minimally invasive aortic valve replacement. This study aimed to investigate the safety and feasibility of minimally invasive aortic valve replacement through a right parasternal second intercostal transverse incision. MethodsThis was a retrospective study, and we collected information from 111 patients who underwent isolated aortic valve replacement surgery performed by the same surgeon from January 2018 to December 2019. According to the operative approach, the patients were divided into a sternotomy aortic valve replacement (SAVR) group (n = 62) and a minimally invasive aortic valve replacement (Mini-AVR) group (n = 49). We compared the intraoperative and postoperative data between the two groups. ResultThere was no difference in preoperative data between the Mini-AVR and SAVR. The postoperative ventilator-assisted time, CSICU time and postoperative hospital stay of the Mini-AVR were shorter than those of the SAVR [(15.45 ± 5.75) VS (18.51 ± 6.71) h; (1.77 ± 0.31) VS (2.04 ± 0.63) d; (8.69 ± 2.75) VS (10.77 ± 2.94) d], and the difference was statistically significant (P < 0.05). Mini-AVR had lower postoperative drainage and blood transfusion rates in the first 24 h than SAVR [(109.86 ± 125.98) VS (508.84 ± 311.70) ml; 22.4% VS 46.8%], and the differences were statistically significant (P < 0.05). The incidence of postoperative AF in the Mini-AVR group was also lower than that in the SAVR group (10.2% VS 30.6%), and the differences were statistically significant (P < 0.05). ConclusionMini-AVR has the advantages of less ventilator time, a reduced need for blood transfusion, less AF and a faster recovery. Mini-AVR is a safe and feasible surgical technique that is worthy of clinical application.

Mini-sternotomy versus conventional sternotomy for aortic valve replacement: a randomised controlled trial

ObjectiveTo compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care).DesignA single-blind, randomised controlled trial.SettingSingle centre UK National Health Service tertiary hospital.ParticipantsAdult patients undergoing...

TAVR for severe aortic stenosis and papillary fibroelastoma in a high-risk setting.

Papillary fibroelastomas (PFE) are rare benign cardiac tumours mainly originating on aortic and mitral valvular surfaces. Management is individualised, but most recommend surgical excision due to thromboembolic risk. We report a 75-year-old man with symptomatic severe aortic stenosis compounded by PFE. Redo sternotomy aortic valve replacement was deferred in favour of the trans-apical (TAVR) approach. This report highlights, for the first time, the application of TAVR as a strategy for aortic valve stenosis and PFE to mitigate risk posed by injury to patent internal mammary arterial graft in close proximity to the manubrium, and complications due to the patient's multiple comorbidities.

Does Blood Transfusion Have an Effect on Outcomes After Aortic Valve Replacement Surgery?

Long-term outcomes following surgical aortic valve replacement (AVR) are excellent. However, there is a significant early morbidity burden. Red cell transfusion is common in the perioperative period and deleterious effects of receiving a transfusion on early postoperative morbidity are well described in observational studies. This study aimed to assess the effect of transfusion on ischaemic or infective outcomes after aortic valve replacement. Data from 270 patients enrolled in the Manubrium-limited ministernotomy versus conventional sternotomy for aortic valve replacement (MAVRIC) randomised controlled trial was used to create two cohorts, patients that received red cell transfusions following AVR and those that did not. Propensity score matching was performed to limit the effect of confounding variables. Strict transfusion thresholds were maintained, with patients receiving a transfusion if haemoglobin concentration fell below 80 g/L, or if significant bleeding or haemodynamic instability occurred. The primary outcome was a composite of ischaemic event (myocardial infarction, permanent stroke, gut ischaemia or acute kidney injury) or serious infection (sepsis, endocarditis, respiratory tract or wound infection). Patients were followed for 12 weeks following surgery. Sixty-three (63) of 270 patients received a red cell transfusion (23.3%). Transfused patients had significantly lower body mass index (BMI), a higher proportion of females, a lower preoperative haemoglobin and haematocrit, a higher EuroSCORE II score, worse renal function and were more likely to have undergone urgent surgery compared to the unadjusted control cohort. Once matched, there was no difference in the primary outcome between cohorts. There was a significantly increased length of hospital stay in the transfused group (median 7 days transfused, median 5 days not-transfused, p=0.001). Red cell transfusion, using a transfusion threshold of 80 g/L, does not appear to be associated with adverse ischaemic or infective outcomes after aortic valve replacement.