Minimal Access Aortic Valve Replacement: Is It Worth It?

Clinical and haemodynamic outcomes in 658 patients receiving the Perceval sutureless aortic valve: early results from a prospective European multicentre study (the Cavalier Trial)†

OBJECTIVES

The aim of the Cavalier trial was to evaluate the safety and performance of the Perceval sutureless aortic valve in patients undergoing aortic valve replacement (AVR). We report the 30-day clinical and haemodynamic outcomes from the largest study cohort with a sutureless valve.

METHODS

From February 2010 to September 2013, 658 consecutive patients (mean age 77.8 years; 64.4% females; mean logistic EuroSCORE 10.2%) underwent AVR in 25 European Centres. Isolated AVRs were performed in 451 (68.5%) patients with a less invasive approach in 219 (33.3%) cases. Of the total, 40.0% were octogenarians. Congenital bicuspid aortic valve was considered an exclusion criterion.

RESULTS

Implantation was successful in 628 patients (95.4%). In isolated AVR through sternotomy, the mean cross-clamp time and the cardiopulmonary bypass (CPB) time were 32.6 and 53.7 min, and with the less invasive approach 38.8 and 64.5 min, respectively. The 30-day overall and valve-related mortality rates were 3.7 and 0.5%, respectively. Valve explants, stroke and endocarditis occurred in 0.6, 2.1 and in 0.1% of cases, respectively. Preoperative mean and peak pressure gradients decreased from 44.8 and 73.24 mmHg to 10.24 and 19.27 mmHg at discharge, respectively. The mean effective orifice area improved from 0.72 to 1.46 cm(2).

CONCLUSIONS

The current 30-day results show that the Perceval valve is safe (favourable haemodynamic effect and low complication rate), and can be implanted with a fast and reproducible technique after a short learning period. Short cross-clamp and CPB times were achieved in both isolated and combined procedures. The Perceval valve represents a promising alternative to biological AVR, especially with a less invasive approach and in older patients.

Minimally invasive aortic valve replacement - pros and cons of keyhole aortic surgery

Over the last twenty years, minimally invasive aortic valve replacement (MIAVR) has evolved into a safe, well-tolerated and efficient surgical treatment option for aortic valve disease. It has been shown to reduce postoperative morbidity, providing faster recovery and rehabilitation, shorter hospital stay and better cosmetic results compared with conventional surgery. A variety of minimally invasive accesses have been developed and utilized to date. This concise review demonstrates and discusses surgical techniques used in contemporary approaches to MIAVR and presents the most important results of MIAVR procedures.

Minimally invasive aortic valve replacement: Comparison of long-term outcomes

Background

Minimally invasive aortic valve replacement tends to be performed in specialist centers. Little data exists with regard to long-term outcomes of the upper hemi-sternotomy technique. We sought to evaluate the short- and long-term outcomes of this procedure in our institution.

Methods

Data were collected from our cardiac surgical database. We compared the outcomes of all patients who underwent minimally invasive aortic valve replacement with all who underwent conventional aortic valve replacement between July 1999 and December 2013. Propensity-matching analysis was performed to evaluate hospital outcomes.

Results

There were 125 patients who underwent minimally invasive aortic valve replacement and 1446 who had conventional surgery. After propensity score matching, there were no differences in postoperative mortality or complications between the 2 groups. The only significant differences were longer bypass (62.69 ± 10.12 vs. 68.94 ± 14.79 min, p = 0.002) and crossclamp times (45.48 ± 8.08 vs. 52.30 ± 16.29 min, p < 0.001) in conventional surgery. Long-term survival after minimally invasive aortic valve replacement at 2, 6, and 10 years was 88% ± 3.0%, 79% ± 4.0%, and 66% ± 6.0%, respectively. Predictors of long-term survival were age, peripheral vascular disease, and low ejection fraction ( p < 0.005).

Conclusion

Minimally invasive aortic valve replacement has similar hospital outcomes compared to conventional aortic valve replacement. The operation is quicker and does not confer any significant increase in complications or length of hospital stay. The long-term outcomes are favorable and justify its continued use by specialist surgeons in the United Kingdom.

Minimally invasive aortic valve replacement: 12-year single center experience

BACKGROUND

This study reports the single center experience on minimally invasive aortic valve replacement (MIAVR), performed through a right anterior minithoracotomy or ministernotomy (MS).

METHODS

Eight hundred and fifty-three patients, who underwent MIAVR from 2002 to 2014, were retrospectively analyzed. Survival was evaluated using the Kaplan-Meier method. The Cox multivariable proportional hazards regression model was developed to identify independent predictors of follow-up mortality.

RESULTS

Median age was 73.8, and 405 (47.5%) of patients were female. The overall 30-day mortality was 1.9%. Four hundred and forty-three (51.9%) and 368 (43.1%) patients received biological and sutureless prostheses, respectively. Median cardiopulmonary bypass time and aortic cross-clamping time were 108 and 75 minutes, respectively. Nineteen (2.2%) cases required conversion to full median sternotomy. Thirty-seven (4.3%) patients required re-exploration for bleeding. Perioperative stroke occurred in 15 (1.8%) patients, while transient ischemic attack occurred postoperative in 11 (1.3%). New onset atrial fibrillation was reported for 243 (28.5%) patients. After a median follow-up of 29.1 months (2,676.0 patient-years), survival rates at 1 and 5 years were 96%±1% and 80%±3%, respectively. Cox multivariable analysis showed that advanced age, history of cardiac arrhythmia, preoperative chronic renal failure, MS approach, prolonged mechanical ventilation and hospital stay as well as wound revision were associated with higher mortality.

CONCLUSIONS

MIAVR via both approaches is safe and feasible with excellent outcomes, and is associated with low conversion rate and low perioperative morbidity. Long term survival is at least comparable to that reported for conventional sternotomy AVR.

A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients

OBJECTIVES

Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy.

METHODS

Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed.

RESULTS

Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups.

CONCLUSION

Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.

Minimally invasive reoperative aortic valve replacement

The operative mortality associated with repeat heart valve surgery is supposedly higher than the mortality associated with the primary operation. However, controversy still surrounds the risk factors and optimal surgical approach for patients requiring repeat cardiac surgery, particularly for those requiring aortic valve replacements (AVR). While the standard approach generally utilizes full sternotomy and peripheral cannulation, alternative approaches such as minimally invasive sternotomy may play an increasingly important role in this field. This study compares the advantages and disadvantages of a minimally invasive approach in redo AVR with the standard approach, highlighting difficulties and potential solutions.

Minimally invasive concomitant aortic and mitral valve surgery: the "Miami Method"

Valve surgery via a median sternotomy has historically been the standard of care, but in the past decade various minimally invasive approaches have gained increasing acceptance. Most data available on minimally invasive valve surgery has generally involved single valve surgery. Therefore, robust data addressing surgical techniques in patients undergoing double valve surgery is lacking. For patients undergoing combined aortic and mitral valve surgery, a minimally invasive approach, performed via a right lateral thoracotomy (the "Miami Method"), is the preferred method at our institution. This method is safe and effective and leads to an enhanced recovery in our patients given the reduction in surgical trauma. The following perspective details our surgical approach, concepts and results for combined aortic and mitral valve surgery.

Minimally invasive aortic valve replacement: the Leipzig experience

BACKGROUND

Minimally invasive techniques are progressively challenging traditional approaches in cardiothoracic surgery. Minimally invasive aortic valve replacement (AVR) has become a routine procedure at our institution.

METHODS

We retrospectively analyzed all patients undergoing minimally invasive isolated AVR between January 2003 and March 2014, at our institution. Mean follow-up was 4.7±4.3 years (range: 0-18 years) and was 99.8% complete.

RESULTS

There were 1,714 patients who received an isolated minimally invasive AVR. The mean (± SD) patient age was 65±12.8 years, ejection fraction 60%±12% and log EuroSCORE 5.3%±5.1%. Mean cross-clamp time was 58±18 minutes and mean cardiopulmonary bypass (CPB) time was 82.9±26.7 minutes. Thirty-day survival was 97.8%±0.4%, and 69.4%±1.7% at 10-years. The multivariate analysis revealed age at surgery [P=0.016; odds ratio (OR), 1.1], length of surgery time (P=0.002; OR, 1.01), female gender (P=0.023; OR, 3.54), preoperative myocardial infarction (MI) (P=0.006; OR, 7.87), preoperative stroke (P=0.001; OR, 13.76) and preoperative liver failure (P=0.015; OR, 10.28) as independent risk factors for mortality. Cox-regression analysis revealed the following predictors for long term mortality: age over 75 years (P<0.001; OR, 3.5), preoperative dialysis (P<0.01; OR, 2.14), ejection fraction less than 30% (P=0.003; OR, 3.28) and urgent or emergency operation (P<0.001; OR, 2.3).

CONCLUSIONS

Minimally invasive AVR can be performed safely and effectively with very few perioperative complications. The early and long-term outcomes in these patients are acceptable.

Minimally invasive aortic valve surgery: state of the art and future directions

Minimally invasive aortic valve replacement (MIAVR) is defined as an aortic valve replacement (AVR) procedure that involves a small chest wall incision as opposed to conventional full sternotomy (FS). The MIAVR approach is increasingly being used with the aim of reducing the "invasiveness" of the surgical procedure, while maintaining the same efficacy, quality and safety of a conventional approach. The most common MIAVR techniques are ministernotomy (MS) and right anterior minithoracotomy (RT) approaches. Compared with conventional surgery, MIAVR has been shown to reduce postoperative mortality and morbidity, providing faster recovery, shorter hospital stay and better cosmetics results, requires less rehabilitations resources and consequently cost reduction. Despite these advantages, MIAVR is limited by the longer cross-clamp and cardiopulmonary bypass (CPB) times, which have raised some concerns in fragile and high risk patients. However, with the introduction of sutureless and fast deployment valves, operative times have dramatically reduced by 35-40%, standardizing this procedure. According to these results, the MIAVR approach using sutureless valves may be the "real alternative" to the transcatheter aortic valve implantation (TAVI) procedures in high risk patients "operable" patients. Prospective randomized trials are required to confirm this hypothesis.

Aortic valve replacement through full sternotomy with a stented bioprosthesis versus minimally invasive sternotomy with a sutureless bioprosthesis

OBJECTIVES

The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis.

METHODS

Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias.

RESULTS

In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups.

CONCLUSIONS

AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.

Anterolateral minithoracotomy versus median sternotomy for mitral valve disease: a meta-analysis

OBJECTIVE

Mitral valve disease tends to be treated with anterolateral minithoracotomy (ALMT) rather than median sternotomy (MS), as ALMT uses progressively smaller incisions to promote better cosmetic outcomes. This meta-analysis quantifies the effects of ALMT on surgical parameters and post-operative outcomes compared with MS.

METHODS

One randomized controlled study and four case-control studies, published in English from January 1996 to January 2013, were identified and evaluated.

RESULTS

ALMT showed a significantly longer cardiopulmonary bypass time (P=0.001) and aortic cross-clamp time (P=0.05) compared with MS. However, the benefits of ALMT were evident as demonstrated by a shorter length of hospital stay (P<0.00001). According to operative complications, the onset of new arrhythmias following ALMT decreased significantly as compared with MS (P=0.05); however, the incidence of peri-operative mortality (P=0.62), re-operation for bleeding (P=0.37), neurologic events (P=0.77), myocardial infarction (P=0.84), gastrointestinal complications (P=0.89), and renal insufficiency (P=0.67) were similar to these of MS. Long-term follow-up data were also examined, and revealed equivalent survival and freedom from mitral valve events.

CONCLUSIONS

Current clinical data suggest that ALMT is a safe and effective alternative to the conventional approach and is associated with better short-term outcomes and a trend towards longer survival.

Aortic valve replacement through right minithoracotomy: is it really biologically minimally invasive?

BACKGROUND

Minimally invasive aortic valve replacement through a right mini-thoracotomy is a procedure developed in the past few years. Currently, the main limits of this technique are longer cardiopulmonary bypass time compared with the standard approach and the need for peripheral cannulation.

METHODS

From January 2010 to March 2014, 206 patients underwent an aortic valve replacement using a minimally invasive technique through a right mini-thoracotomy. Mean age was 71.4 ± 12.0 years, and 129 (62.6%) were male. In the first series of 42 patients, the vacuum-assisted venous drainage was obtained percutaneously through the groin. A totally central arterial and venous cannulation was adopted in the subsequent 164 patients. Two hundred patients (97.1%) received a bioprosthesis implanted with three 2-0 Prolene running sutures; a mechanical valve was implanted in six patients. One patient required reoperation.

RESULTS

Aortic valve replacement was performed through a 4-6-cm skin incision at the third intercostal space. Overall cardiopulmonary bypass was 64.8 ± 17.2 min, and aortic cross clamping was 51.8 ± 14.9 min. In-hospital mortality was 1.5% (3/206).

CONCLUSIONS

Our initial series confirms that aortic valve replacement performed through a right mini-thoracotomy is a safe procedure. When using running sutures, it is possible to obtain cardiopulmonary bypass and cross-clamping times comparable to those for the standard approach. A central cannulation can be performed easily to avoid groin incisions. In conclusion, we believe that this kind of surgery could really be a biologically minimally invasive approach, rather than just an aesthetic choice.

Trainees can learn minimally invasive aortic valve replacement without compromising safety

OBJECTIVES

Minimally invasive aortic valve replacement (Mini-AVR) is a technically advanced procedure. However, it results in equivalent operative mortality, less bleeding and reduced intensive care/hospital stay when compared with conventional AVR. Our aim was to assess the impact of trainee performance on short-term outcomes of patients undergoing elective and urgent Mini-AVR where a significant proportion were performed by trainees.

METHODS

All patients undergoing non-emergency, elective and urgent, isolated Mini-AVR between September 2005 and December 2012 were studied. Operative details and short-term outcomes, with particular attention to trainee performance, were analysed.

RESULTS

During the study period, there were 205 Mini-AVR with a median age of 67 years (range 29-86); 74 (36%) operations were performed by trainees. The overall median cross-clamp and bypass times were 42 (range 33-63) and 59 min (range 59-94) for the attending surgeon and 52 (range 42-63) and 71 min (range 59-94) for the trainee (P = 0.03). Five Mini-AVR patients (2.4%) required conversion to full sternotomy for ascending aortic replacement, right ventricular bleeding, coronary artery bypass graft surgery and failure to cardiovert. None of these cases were performed by trainees. Median lengths of intensive care and hospital stay were 1 and 5 days and were not different for attending surgeon and trainee. Only 1 (0.5%) patient died in hospital.

CONCLUSIONS

Mini-AVR can be performed with a low conversion rate and hospital stay and taught to trainees without compromising safety.

Review of Minimally Invasive Aortic Valve Surgery

Minimally invasive aortic valve surgery (MIAVS) has been developed for the last 20 years. The improvements in techniques have permitted cardiac surgeons to perform aortic valve replacement safely and efficiently with minimally incisions. Patients have become older and have multiple comorbidities and this is expected to grow in number. Less-invasive procedures are known to reduce the number of complications, together with smaller incisions, less pain, less blood loss and reduced length of hospital stay. Selective preoperative planning with computed tomography is key to the pre-investigation stage. Hybrid and staged procedures with interventional cardiologists are part of the armamentarium and may be appealing for the present and near future. Despite the nature of demanding procedures and longer learning curve with increased cardiopulmonary bypass times, the outcomes are comparable with same quality as conventional open surgery. Patient recovery is the ultimate purpose of these approaches.

Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis

BACKGROUND

Establishing the relative merits of ministernotomy (MS) and minithoracotomy (MT) approaches to minimally invasive aortic valve replacement (MIAVR) is difficult given the limited available direct evidence. Network meta-analysis is a Bayesian approach that can combine direct and indirect evidence to better define the benefits and risks of MS and MT.

METHODS

Electronic searches were performed using six databases from their inception to June 2014. Relevant studies utilizing a minimally invasive approach for aortic valve replacement were identified. Data were extracted and analyzed according to predefined clinical endpoints. Both traditional and Bayesian meta-analysis approaches were conducted.

RESULTS

Compared to full sternotomy, MT was associated with longer cardiopulmonary bypass (CPB) duration (WMD, 9.99; 95% CI, 3.91, 16.07; I(2)=55%; P=0.001) and cross-clamp duration (WMD, 7.64; 95% CI, 2.86, 12.42; P=0.002; I(2)=74%). When compared to MS using network meta-analysis, no significant difference in duration was detected. Postoperative outcomes including 30-day mortality, stroke, and reoperation for bleeding and wound infection were comparable between MS and MT using both traditional and Bayesian meta-analysis techniques.

CONCLUSIONS

The current evidence demonstrates that MIAVR via MS or MT is a safe and efficacious alternative to conventional median sternotomy. MT may be associated with longer CPB and cross-clamp durations, but has similar post-operative outcomes compared to MS. An individualized approach tailored to both the patient and surgical team is likely to provide optimal outcomes.

Ministernotomy versus full sternotomy aortic valve replacement with a sutureless bioprosthesis: a multicenter study

BACKGROUND

The aim of this study was to analyze early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) with the sutureless Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Salluggia, Italy) performed through ministernotomy compared with full sternotomy.

METHODS

This was a study of 267 consecutive patients who underwent isolated AVR with the sutureless Perceval bioprosthesis between 2007 and 2014 at 6 European centers. Of these, 189 (70.8%) were performed through ministernotomy and 78 through a full sternotomy. Propensity score matching was used to reduce selection bias.

RESULTS

In the overall cohort of ministernotomy and full sternotomy patients, in-hospital mortality was 1.1% and 2.6% and 2-year survival was 92% and 91%, respectively. Propensity score matching resulted in 56 pairs with similar characteristics and operative risk. Aortic cross-clamp (44 minutes in both groups, p = 0.931) and cardiopulmonary bypass time (69 vs 74 minutes, p = 0.363) did not differ between the groups. Apart from higher values in the ministernotomy group for postoperative peak gradients (28.1 vs 23.3 mm Hg, p = 0.026) and mean aortic valve gradients (15.2 vs 11.7 mm Hg, p = 0.011), early postoperative outcomes did not differ in the propensity-matched cohort. There were no differences in the in-hospital mortality rate or 2-year survival between the groups.

CONCLUSIONS

AVR with the sutureless Perceval bioprosthesis through a ministernotomy was a safe and reproducible procedure that was not associated with prolonged aortic cross-clamp or cardiopulmonary bypass time compared with a full sternotomy. Early postoperative outcomes and 2-year survival were comparable between patients undergoing ministernotomy and full sternotomy.

Right anterior thoracotomy aortic valve replacement is associated with less cost than sternotomy-based approaches: a multi-institution analysis of 'real world' data

BACKGROUND

Large institutional analyses demonstrating outcomes of right anterior mini-thoracotomy (RAT) for isolated aortic valve replacement (isoAVR) do not exist. In this study, a group of cardiac surgeons who routinely perform minimally invasive isoAVR analyzed a cross-section of US hospital records in order to analyze outcomes of RAT as compared to sternotomy.

METHODS

The Premier database was queried from 2007-2011 for clinical and cost data for patients undergoing isoAVR. This de-identified database contains billing, hospital cost, and coding data from >600 US facilities with information from >25 million inpatient discharges. Expert rules were developed to identify patients with RAT and those with any sternal incision (aStern). Propensity matching created groups adjusted for patient differences. The impact of surgical approach on outcomes and costs was modeled using regression analysis and, where indicated, adjusting for hospital size and geographical differences.

RESULTS

AVR was performed in 27,051 patients. Analysis identified isoAVR by RAT (n = 1572) and by aStern (n = 3962). Propensity matching created two groups of 921 patients. RAT was more likely performed in southern hospitals (63% vs 36%; p < 0.01), teaching hospitals (66% vs 58%; p < 0.01) and larger hospitals (47% vs 30%; p < 0.01). There was significantly less blood product cost associated with RAT ($1381 vs $1912; p < 0.001). After adjusting for hospital differences, RAT was associated with lower cost than aStern ($38,769 vs $42,656; p < 0.01).

CONCLUSIONS

Outcomes analyses can be performed from hospital administrative collective databases. This real world analysis demonstrates comparable outcomes and less cost and ICU time with RAT for AVR.

Current status of surgical treatment for aortic valve stenosis

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve.

Two alternative sutureless strategies for aortic valve replacement: a two-center experience

OBJECTIVE

Important comorbid conditions in patients referred for aortic valve replacement (AVR) require less invasive strategies. We describe our initial experience with the Perceval S (Sorin Group, Saluggia, Italy) and 3f Enable (Medtronic, Minneapolis, MN USA) sutureless aortic bioprostheses.

METHODS

We compared intraoperative data, postoperative clinical outcomes, and echocardiographic results from patients receiving a Perceval S (P group; n = 97) or a 3f Enable (E group; n = 32) prosthesis in two cardiac surgery departments (Nuremberg, Germany, and Massa, Italy).

RESULTS

Baseline patient characteristics were similar in both groups, except for mean ± SD body surface area (P group = 2.01 ± 2.9 m, E group = 1.83 ± 3.8 m; P < 0.001). Sixty-five patients (67%) in the P group and 19 patients (59.5%) in the E group (P = 0.22) underwent minimally invasive AVR with either ministernotomy or right anterior minithoracotomy approach. Concomitant procedures were performed in 37 patients (38%) in the P group and 9 patients (28%) in the E group (P = 0.56). In-hospital mortality was 2%. The mean ± SD prosthesis diameter was 23.5 ± 1.4 mm (P group) compared with 22.1 ± 2 mm (E group) (P < 0.001). In isolated AVR, aortic cross-clamp time was 36 ± 12.7 minutes in the P group and 66 ± 18 minutes in the E group (P < 0.001). At a mean ± SD follow-up of 8.3 ± 4.5 months, survival was 97% (one death in the P group). In five patients (P group = 1, E group = 4), a moderate paravalvular leak was present (P = 0.013). The mean ± SD transvalvular gradient was 9.1 ± 3.3 mm Hg with the Perceval S and 11.2 ± 5.2 mm Hg with the 3f Enable (P = 0.017).

CONCLUSIONS

Aortic valve replacement with sutureless aortic bioprosthesis is feasible, also with a minimally invasive approach. The Perceval S showed lower operative times and moderate paravalvular leaks and lower mean transvalvular gradients than did the 3f Enable, related to the larger diameter of the Perceval S implanted. Both prostheses showed an excellent hemodynamic performance. This new technology needs long-term follow-up.

Minimal access aortic valve replacement via limited skin incision and complete median sternotomy

Surgical aortic valve replacement (AVR) via complete median sternotomy is a safe and time-tested technique associated with excellent short- and long-term outcome. Over the last two decades, different minimally-invasive approaches for AVR have been developed and are increasingly being utilized. All these approaches have been developed with the main objective of decreased invasiveness and less surgical trauma. Advantages of minimal invasive AVR have been shown as better cosmesis, shorter ventilation time, decreased blood loss, shorter intensive care unit and hospital length of stay, and less postoperative pain with mortality and morbidity comparable to conventional complete median sternotomy. One well-recognized but less practiced surgical technique for surgical AVR is the complete median sternotomy via limited skin incision. This review article provides a detailed insight into the technical aspects, outcomes, advantages and disadvantages associated with minimal access AVR via limited skin incision and complete median sternotomy.

Minimal-access median sternotomy for aortic valve replacement

A variety of minimally-invasive approaches for aortic valve replacement (AVR) have been developed and are increasingly being utilized. The different approaches described, such as partial upper sternotomy, right parasternal thoracotomy or transverse sternotomy have the aim to decrease invasiveness and reduce surgical trauma. Whereas port access surgery with remote cannulation has the attendant risks inherent with peripheral cardiopulmonary bypass and limitations in terms of myocardial protection and adequate cardiac dearing, partial sternotomies or thoracotomies may be associated with suboptimal chest wall reconstruction. Here described is a technique of minimal-access aortic valve replacement, which entails limited skin incision and full median sternotomy. Advantages of the present approach include a superior cosmetic result, when compared to standard sternotomy incision, and the safety of the midline access, which may be immediately converted into standard approach, in case of need, and is associated with stable chest wall reconstruction. Selective indications and outcome of minimal-access AVR are discussed.

Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison

OBJECTIVES

To compare early and long-term outcomes of minimally invasive surgery (MIS) versus full sternotomy (FS) isolated aortic valve replacement (AVR).

METHODS

We retrospectively analysed all patients who underwent isolated bioprosthetic AVR between 2003 and March 2012 at our institution. Matching was performed based on a propensity score, which was obtained using the output of a logistic regression on relevant preoperative risk factors. Mean follow-up was 3.1±2.7 years (range 0-9.0 years) and was 99.8% complete.

RESULTS

A total of 2051 patients (FS, 1572; MIS, 479) underwent isolated bioprosthetic AVR during the study period. MIS patients were significantly younger (67.8±11.2 vs 70.4±9.4 years) and had a lower logistic EuroSCORE (6.6±6.4 vs 11.2±13.4%, both P<0.001). Propensity matching resulted in 477 matched patients from each group, with no significant differences in any of the preoperative variables. Aortic cross-clamp times were significantly longer in MIS patients (59.4±16.0 vs 56.9±14.6 min, P=0.008). Nonetheless, MIS AVR was associated with a significantly lower incidence of intra-aortic balloon pump usage (0.4 vs 2.1%, P=0.042) and in-hospital mortality (0.4 vs 2.3%, P=0.013), while FS patients had a lower rate of re-exploration for bleeding (1.5 vs 4.2%, P=0.019). Five- and 8-year survival post-AVR was significantly higher in MIS patients (89.3±2.4% and 77.7±4.7% vs 81.8±2.2% and 72.8±3.1%, respectively, P=0.034). Cox regression analysis revealed MIS (hazard ratio: 0.47, 95% confidence interval: 0.26-0.87) as an independent predictor of long-term survival.

CONCLUSION

MIS AVR is associated with very good early and long-term survival, despite longer myocardial ischaemic times. MIS AVR can be performed safely with results that are at least equivalent to those achieved through an FS.

Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits

INTRODUCTION AND OBJECTIVES

The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy.

METHODS

Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group).

RESULTS

No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed.

CONCLUSIONS

In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.

Minimal access median sternotomy for aortic valve replacement in elderly patients

BACKGROUND

We report our clinical experience with a approach for aortic valve replacement (AVR) via minimal access skin incision and complete median sternotomy. This approach was used in patients with higher age and multiple co-morbidities, facilitating an easy access with short bypass and cross clamp times. It was especially performed in patients asking for an excellent cosmetic result, who did not qualifying for minimally-invasive AVR via partial upper sternotomy.

METHODS

AVR via minimal-access median sternotomy, was performed in 58 patients between 01/2009 and 11/2011. Intra- and postoperative data including cross clamp time, cardiopulmonary bypass time, mortality, stroke, pacemaker implantation, re-operation for bleeding, ventilation time, ICU and hospital stay, wound infection, sternal dehiscence or fracture and 30 day mortality were collected.

RESULTS

Mean patients age was 76.1 +/-9.4 years, 72% were female. Minimal-access AVR could be performed with a mean length of midline skin incision of 7.8 cm. Aortic cross-clamping time was 54.6 +/-6.3 min, cardiopulmonary bypass time 71.2+/-11.3 min and time of surgery 154.1 +/-26.8 min. Re-operation for bleeding had to be performed in 1 case (1.7%). There were no strokes or pacemaker implantations needed. Mean ventilation time was 4.5 h, ICU stay was 2 days and mean length of hospital stay was 6 days. 6 months follow up showed mortality of 0% and no sternal dehiscence or wound infection was observed.

CONCLUSION

Minimal-access AVR via complete median sternotomy can be performed safely,in this elderly patient cohort without adding additional operative risk compared to conventional AVR. By avoidiance of large skin incisions this approach combines excellent cosmetic results with fast surgery time and excellent postoperative recovery.

Outcomes of minimally invasive mitral valve surgery in patients with an ejection fraction of 35% or less

OBJECTIVE

We evaluated the outcomes of minimally invasive mitral valve surgery via a right anterior thoracotomy approach in patients with isolated severe mitral regurgitation and severely reduced left ventricular systolic function.

METHODS

We retrospectively reviewed all minimally invasive mitral valve surgeries for mitral regurgitation in patients with an ejection fraction of 35% or less performed at our institution between December 2008 and June 2011. The operative times, lengths of stay, postoperative complications, and mortality were analyzed.

RESULTS

We identified a total of 71 patients with severe mitral regurgitation and an ejection fraction of 35% or less who underwent minimally invasive mitral valve surgery. The mean ± SD age was 67 ± 10 years, and 44 of the patients were men (62%). The mean ± SD left ventricular ejection fraction was 27% ± 6%, and 28 patients (39%) had previous heart surgery. The median aortic cross-clamp and cardiopulmonary bypass times were 62 [interquartile range (IQR), 50-80) and 98 minutes (IQR, 92-124), respectively. There was no mitral regurgitation noted in any patient on postoperative transesophageal echocardiogram. The median intensive care unit length of stay was 51 hours (IQR, 42-86), and the median postoperative length of stay was 6 days (IQR, 5-9).

CONCLUSIONS

Minimally invasive mitral valve surgery for severe functional mitral regurgitation in patients with severe left ventricular dysfunction can be performed with a low morbidity and mortality.