Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups

Minimally Invasive Aortic Valve Replacement in Contemporary Practice: Clinical and Hemodynamic Performance from a Prospective Multicenter Trial

BACKGROUND

The advent of transcatheter aortic valve replacement (AVR) has led to an increased emphasis on reducing the invasiveness of surgical procedures. The aim of this study was to evaluate clinical outcomes and hemodynamic performance achieved with minimally invasive aortic valve replacement (MI-AVR) as compared with conventional AVR.

METHODS

Patients who underwent surgical AVR with the Avalus bioprosthesis, as part of a prospective multicenter non-randomized trial, were included in this analysis. Surgical approach was left to the discretion of the surgeons. Patient characteristics and clinical outcomes were compared between MI-AVR and conventional AVR groups in the entire cohort (n = 1077) and in an isolated AVR subcohort (n = 528). Propensity score adjustment was performed to estimate the effect of MI-AVR on adverse events.

RESULTS

Patients treated with MI-AVR were younger, had lower STS scores, and underwent concomitant procedures less often. Valve size implanted was comparable between the groups. MI-AVR was associated with longer procedural times in the isolated AVR subcohort. Postprocedural hemodynamic performance was comparable. There were no significant differences between MI-AVR and conventional AVR in early and 3-year all-cause mortality, thromboembolism, reintervention, or a composite of those endpoints within either the entire cohort or the isolated AVR subcohort. After propensity score adjustment, there remained no association between MI-AVR and the composite endpoint (hazard ratio: 0.86, 95% confidence interval: 0.47-1.55, p = 0.61).

CONCLUSION

Three-year outcomes after MI-AVR with the Avalus bioprosthetic valve were comparable to conventional AVR. These results provide important insights into the overall ability to reduce the invasiveness of AVR without compromising outcomes.

Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting

The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.

Economic Justification Analysis of Minimally Invasive versus Conventional Aortic Valve Replacement

There is no definitive consensus about the cost-effectiveness of minimally invasive aortic valve replacement (AVR) (MI-AVR) compared to conventional AVR (C-AVR). The aim of this study was to compare the rate of postoperative complications and total hospital costs of MI-AVR versus C-AVR overall and by the type of aortic prosthesis (biological or mechanical). Our single-center retrospective study included 324 patients over 18 years old who underwent elective isolated primary AVR with standard stented AV prosthesis at the Institute for Cardiovascular Diseases "Dedinje" between January 2019 and December 2019. Reintervention, emergencies, combined surgical interventions, and patients with sutureless valves were excluded. In both MI-AVR and C-AVR, mechanical valve implantation contributed to overall reduction of hospital costs with equal efficacy. The cost-effectiveness ratio indicated that C-AVR is cheaper and yielded a better clinical outcome with mechanical valve implantation (67.17 vs. 69.5). In biological valve implantation, MI-AVR was superior. MI-AVR patients had statistically significantly higher LVEF and a lower Euro SCORE than C-AVR patients (Mann-Whitney U-test, p = 0.002 and p = 0.002, respectively). There is a slight advantage to MI-AVR vs. C-AVR, since it costs EUR 9.44 more to address complications that may arise. Complications (mortality, early reoperation, cerebrovascular insult, pacemaker implantation, atrial fibrillation, AV block, systemic inflammatory response syndrome, wound infection) were less frequent in the MI-AVR, making MI-AVR more economically justified than C-AVR (18% vs. 22.1%).

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

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Aortic Valve Surgery

Background and Objectives: Transaxillary access is one of the latest innovations for minimally invasive aortic valve replacement (MICS-AVR). This study compares clinical performance in a large transaxillary MICS-AVR group to a propensity-matched sternotomy control group. Materials and Methods: This study enrolled 908 patients undergoing isolated AVR with a mean age of 69.4 ± 18.0 years, logistic EuroSCORE of 4.0 ± 3.9%, and body mass index (BMI) of 27.3 ± 6.1 kg/m2. The treatment group comprised 454 consecutive transaxillary MICS-AVR patients. The control group was 1:1 propensity-matched out of 3115 consecutive sternotomy aortic valve surgeries. Endocarditis, redo, and combined procedures were excluded. The multivariate matching model included age, left ventricular ejection fraction, logistic EuroSCORE, pulmonary hypertension, coronary artery disease, chronic lung disease, and BMI. Results: Propensity-matching was successful with subsequent comparable clinical baselines in both groups. MICS-AVR had longer skin-to-skin time (120.0 ± 31.5 min vs. 114.2 ± 28.7 min; p < 0.001) and more frequent bleeding requiring chest reopening (5.0% vs. 2.4%; p < 0.010), but significantly less packed red blood cell transfusions (0.57 ± 1.6 vs. 0.82 ± 1.6; p = 0.040). In addition, MICS-AVR patients had fewer access site wound abnormalities (1.5% vs. 3.7%; p = 0.038), shorter intensive care unit stays (p < 0.001), shorter ventilation times (p < 0.001), and shorter hospital stays (7.0 ± 5.1 days vs. 11.1 ± 6.5; p < 0.001). No significant differences were observed in stroke > Rankin 2 (0.9% vs. 1.1%; p = 0.791), renal replacement therapy (1.5% vs. 2.4%; p = 0.4762), and hospital mortality (0.9% vs. 1.5%; p = 0.546). Conclusions: Transaxillary MICS-AVR is at least as safe as AVR by sternotomy and can be performed in the same time frame. Its advantages are fewer transfusions and quicker postoperative recovery with a significantly shorter hospital stay. The cosmetic result and unrestricted physical abilities due to the untouched sternum and ribs are unique advantages of transaxillary access.

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

Objective

This study aims to compare clinical outcomes between mini-sternotomy and full median sternotomy for aortic valve replacement using propensity-matching methods.

Methods

From 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.

Result

Occurrences 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.

Conclusions

Mini-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?

OBJECTIVE

Controversial 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.

METHODS

This 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.

RESULTS

After 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.

CONCLUSION

This 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.

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

BACKGROUND

There 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.

METHODS

This 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.

RESULT

There 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).

CONCLUSION

Mini-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.

Use of an Aortic Valve Replacement Simulation Model to Understand Hospital Costs and Resource Utilization Associated With Rapid-deployment Valves

PURPOSE

Aortic stenosis (AS) is the most common cause of adult valvular heart disease. In the past decade, minimally invasive surgery (MIS) to treat AS has gained popularity, especially if performed in combination with rapid deployment valves (RDVs), which shorten cross-clamp time (XCT). This study examines specific outcomes and related costs of aortic valve replacement (AVR) before and after the introduction of RDVs.

METHODS

We used the AVR simulator, an economic model developed to correlate cost and resource utilization associated with the adoption of RDVs, to compare 2 scenarios: (1) a current scenario based on standard AVR practices and (2) a proposed scenario based on increasing use of RDVs and an MIS approach. Both scenarios involved 3 subgroups of patients treated with (1) conventional AVR, (2) MIS, and (3) AVR combined with a coronary artery bypass graft. The current scenario (status quo) involved patients treated with traditional biological valves, and the proposed scenario involved patients who underwent implantation with an RDV. The AVR simulator was fed with real-world input data to estimate complication rates and resource consumption in the proposed scenario. Real-world input data for this analysis were obtained from patients diagnosed with a symptomatic heart valve disease between 2015 and 2018, at Clinica-San-Gaudenzio, Novara, Italy. Lastly, the AVR simulator estimated hospital savings by comparing the 2 scenarios.

FINDINGS

A total of 132 patients underwent implantation with a traditional biological valve, and 107 were treated with a commercial valve system. The RDV was associated with an increase of 52% of patients undergoing MIS, which generated a 6.1-h reduction of XCT and a total savings of €6695. RDVs also reduced intensive care unit (ICU) and hospital ward length of stay (LOS), leading to savings of €677 and €595 per patient, respectively. Mortality and blood transfusions also improved. The savings for the hospital (related to shorter XCT, hospital ward LOS, and ICU LOS) amounted to €144.111. Our findings were consistent with data gathered from our real-word setting, and results of a sensitivity analysis indicate that our findings were robust across different possible situations.

IMPLICATIONS

Switching to RDVs and MIS procedures for AVRs was associated with a reduction of costs related to XCT, hospital ward LOS, and ICU LOS. Hospitals can upload literature- and experience-based clinical and cost values to the AVR simulator to estimate a hospital's performance with the introduction of RDVs compared with standard biological valves. This study was not randomized, so more extensive studies could confirm our results in the future.

Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation?

Atrial fibrillation (AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restricting and susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation (POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more "malignant" than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy (MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy (FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association (AHA), the term "minimally invasive" refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.

Minimally invasive surgical aortic valve replacement

Minimally invasive aortic valve replacement (MIAVR) is defined as a surgical aortic valve replacement which involves smaller chest incisions as opposed to full sternotomy. It is performed using cardiopulmonary bypass with cardiac arrest. It benefits from potential advantages of a less invasive procedure. To date, over 14 000 MIAVR have been reported in the literature. Due to heterogeneity of the studies, different surgical techniques and mainly the non-randomised nature of these studies comparing MIAVR with conventional aortic valve replacement, it is difficult to draw definitive conclusions. The two main techniques of MIAVR are mini-sternotomy and right anterior mini-thoracotomy. Both techniques with other less common forms of MIAVR will be discussed in this review. The advantages, disadvantages and surgical pitfalls will be discussed. Some of the advantages include shorter intensive care and hospital stay, reduced perioperative blood loss, less pain, improved respiratory function and cosmesis. The possible disadvantage of longer bypass and cross-clamp times may be counter balanced by the recent sutureless and rapid deployment valves. Despite some of the benefits, MIAVR has not been adopted by a significant proportion of the surgeons possibly related to the learning curve and requirements for re-training. As MIAVR becomes more common, randomised trials comparing this technique with transcatheter aortic valve implantation is warranted. In addition, assessing quality of life including return to work and functional capacity is needed.

Minimally Invasive Versus Full-Sternotomy Septal Myectomy for Hypertrophic Cardiomyopathy

OBJECTIVE

Septal myectomy remains the criterion standard for the treatment of patients with hypertrophic obstructive cardiomyopathy refractory to medical therapy. There have been few reports of minimally invasive approaches. This study compared a minimally invasive septal myectomy performed at our institution with the traditional full-sternotomy approach.

METHODS

Patients receiving a stand-alone septal myectomy were retrospectively reviewed from November 1999 to December 2016 (N = 120). Patients were stratified by surgical approach: traditional full sternotomy (n = 34) and ministernotomy (n = 86). Preoperative and perioperative variables were compared as well as follow-up symptomatic and echocardiographic outcomes.

RESULTS

Both groups had a significant decrease in New York Heart Association class heart failure symptoms (P < 0.001). At a mean ± SD follow-up time of 2.0 ± 3.4 years, postoperative New York Heart Association class distribution was similar between ministernotomy and full sternotomy (P = 0.684). Follow-up resting left ventricular outflow tract gradient was also similar between ministernotomy and full sternotomy (11 mm Hg ± 15 vs 9 mm Hg ± 13, P = 0.381). Perioperatively, ministernotomy was not significantly different from full sternotomy in median cardiopulmonary bypass time (81 minutes vs 78 minutes, P = 0.101) but had a slightly longer median cross-clamp time (39 minutes vs 35 minutes, P = 0.017). Major complications were similar in the two groups. There was one 30-day mortality in the full-sternotomy group, but no in-hospital deaths.

CONCLUSIONS

Septal myectomy performed using a minimally invasive approach has similar outcomes to the criterion standard operation done through a full sternotomy. It represents a feasible option for patients with hypertrophic obstructive cardiomyopathy unresponsive to medications.

The Opportunities and Limitations of Minimally Invasive Cardiac Surgery

BACKGROUND

Over the past two decades, minimally invasive techniques for classic heart valve surgery and isolated bypass surgery have been developed that enable access to the heart via partial sternotomy for most aortic valve procedures and via sternotomy-free mini-thoracotomy for other procedures.

METHODS

We review the current evidence on minimally invasive cardiac surgery on the basis of pertinent randomized studies and database studies retrieved by a selective search in the MEDLINE and PubMed Central databases, as well as by the Google Scholar search engine.

RESULTS

A PubMed search employing the search term "minimally invasive cardiac surgery" yielded nearly 10 000 hits, among which there were 7 prospective, randomized, controlled trials (RCTs) on aortic valve replacement, with a total of 477 patients, and 3 RCTs on mitral valve surgery, with a total of 340 patients. Only limited reports of specified centers are currently available for multiple valvular procedures and multiple coronary artery bypass procedures. The RCTs reveal that the minimally invasive techniques are associated with fewer wound infections and faster mobilization, without any difference in survival. Minimally invasive procedures are technically demanding and have certain anatomical prerequisites, such as appropriate coronary morphology for multiple bypass operations and the position of the aorta in the chest for sternotomy-free aortic valve procedures. The articles reviewed here were presumably affected by selection bias, in that patients in the published studies were preselected, and there may have been negative studies that were not published at all.

CONCLUSION

Specialized surgeons and centers can now carry out many cardiac valvular and bypass operations via minithoracotomy rather than sternotomy. According to current evidence, these minimally invasive techniques yield results that are at least as good as classic open-heart surgery.

Changes in the amount of physical activity in minimally invasive cardiac surgery

[Purpose] This study aimed to compare the amount of physical activity in a minimally invasive cardiac surgery (MICS) group with that in a conventional surgery (median sternotomy) group. [Subjects and Methods] Between November 2010 and December 2011, 39 consecutive patients who underwent elective surgery for valvular disease were prospectively enrolled. The amount of physical activity before and after surgery was measured in 22 cases. The daily in-hospital physical activity level was measured continuously using a triaxial accelerometer. The results were compared in terms of change in the amount of physical activity pre- and postoperatively. [Results] There was no significant difference between the two groups in the amount of physical activity before surgery. However, the amount of physical activity after surgery was significantly higher in the MICS group compared with the conventional surgery group. The number of steps after surgery was significantly increased in the MICS group, and the rate of change in the amount of physical activity was significantly higher in the MICS group than that in the conventional surgery group. [Conclusion] The MICS approach is associated with improvement in postoperative physical activity over median sternotomy.

International Expert Consensus on Sutureless and Rapid Deployment Valves in Aortic Valve Replacement Using Minimally Invasive Approaches

Objective

To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement.

Methods

A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach.

Results

No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed tomographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs.

Conclusions

Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Minimally Invasive Cardiovascular Surgery: Incisions and Approaches

Throughout the modern era of cardiac surgery, most operations have been performed via median sternotomy with cardiopulmonary bypass. This paradigm is changing, however, as cardiovascular surgery is increasingly adopting minimally invasive techniques. Advances in patient evaluation, instrumentation, and operative technique have allowed surgeons to perform a wide variety of complex operations through smaller incisions and, in some cases, without cardiopulmonary bypass. With patients desiring less invasive operations and the literature supporting decreased blood loss, shorter hospital length of stay, improved postoperative pain, and better cosmesis, minimally invasive cardiac surgery should be widely practiced. Here, we review the incisions and approaches currently used in minimally invasive cardiovascular surgery.

Minimally Invasive Aortic Valve Replacement via Right Anterior Minithoracotomy and Central Aortic Cannulation

Objective

This study reports the evolution of a minimally invasive aortic valve replacement (mini-AVR) technique that uses a right anterior minithoracotomy approach with central cannulation, for a 13-year period. This technique has become our standard approach for isolated primary AVR in nearly all patients.

Methods

This observational study evaluated perioperative clinical outcomes of patients 18 years or older who underwent mini-AVR from November 2003 to June 2015.

Results

The mini-AVR technique was used in 202 patients during two periods of 2003 to 2009 (n = 65, “early”) and 2010 to 2015 (n = 137, “late”). The mean ± SD age was 72.5 ± 12.9 years and 60% were male. Demographic parameters were statistically similar between the study periods, except for increased body weight in the later period (75.3 ± 14.7 vs 80.9 ± 20.8 kg, P = 0.03). The mean cardiopulmonary bypass and aortic cross-clamp times were significantly different by each year and Bonferroni adjustment, with significant decreases in cardiopulmonary bypass and aortic cross-clamp times beginning 2006. Compared with the early study period, late study period patients were more often extubated intraoperatively (52% vs 12%, P < 0.001), had less frequent prolonged ventilator use postoperatively (6% vs 16%, P = 0.018), required fewer blood transfusions (mean, 2.0 ± 2.3 U vs 3.6 ± 3.0 U; P = 0.011), and had shorter postoperative stay (6.3 ± 4.5 days vs 8.0 ± 5.9 days, P = 0.026). Numerically, fewer postoperative strokes (1% vs 6%, P = 0.09) and fewer reoperations for bleeding (3% vs 6%, P = 0.3) occurred in the late period. In-hospital mortality did not differ (1/65 early vs 3/137 late).

Conclusions

Overall mini-AVR intraoperative and postoperative clinical outcomes improved for this 13-year experience.

A comparison of minimally invasive and standard aortic valve replacement

OBJECTIVE

The study objective was to compare aortic valve replacement through a right anterior minithoracotomy with aortic valve replacement through a median sternotomy.

METHODS

With propensity score matching, we selected 211 patients after aortic valve replacement through a right anterior minithoracotomy and 211 patients after aortic valve replacement who underwent operation between January 2010 and December 2013. Perioperative outcomes were analyzed, and multivariable logistic regression analysis of risk factors of postoperative morbidity was performed.

RESULTS

For propensity score-matched patients, hospital mortality was 1.0% in the aortic valve replacement through a right anterior minithoracotomy group and 1.4% in the aortic valve replacement group (P = 1.000). Stroke occurred in 0.5% versus 1.4% (P = .615), myocardial infarction occurred in 1.4% versus 1.9% (P = 1.000), and new onset of atrial fibrillation occurred in 12.8% versus 24.2% (P = .003) of patients in the aortic valve replacement through a right anterior minithoracotomy and aortic valve replacement groups, respectively. Postoperative drainage was 353.5 ± 248.6 mL versus 544.3 ± 324.5 mL (P < .001) and blood transfusion was required for 48.8% versus 67.3% (P < .001) of patients in the aortic valve replacement through a right anterior minithoracotomy and aortic valve replacement groups, respectively. Mediastinitis occurred in 2.8% of patients after aortic valve replacement and in 0.0% of patients after aortic valve replacement through a right anterior minithoracotomy surgery (P = .040). Intensive care unit stay (1.3 ± 1.2 days vs 2.6 ± 2.6 days) and hospital stay (5.7 ± 1.6 days vs 8.7 ± 4.4 days) were statistically significantly shorter in the aortic valve replacement through a right anterior minithoracotomy group. Aortic valve replacement through a right anterior minithoracotomy surgery resulted in reduced postoperative morbidity (odds ratio, 0.4; P < .001) and postoperative bleeding and blood transfusion requirements (odds ratio, 0.4; P < .001).

CONCLUSIONS

Aortic valve replacement through a right anterior minithoracotomy surgery resulted in a reduced infection rate, diminished postoperative bleeding and blood transfusion requirements, reduced occurrence of new onset of atrial fibrillation, and shorter intensive care unit and hospital stays.

Exploring the learning curve for minimally invasive sutureless aortic valve replacement

OBJECTIVE

The study objective was to assess the learning process and quality of care of right minithoracotomy aortic valve replacement with a sutureless bioprosthesis at a single institution.

METHODS

We performed an analysis of the first 300 consecutive patients (aged 76 ± 6 years; logistic European System for Cardiac Operative Risk Evaluation 9 ± 6) who underwent sutureless valve implantation via a right minithoracotomy by 6 surgeons at the G. Pasquinucci Heart Hospital between 2011 and 2015. The learning curve was analyzed by dividing the study population into tertiles of 100 patients each. Departmental and individual learning curves were calculated using sequential probability cumulative sum failure analysis. Quality indicators were 2 composite end points reflecting the technical success and 30-day complications.

RESULTS

The overall mortality was 0.7% (2 patients). No significant differences were noted in terms of mortality and complications between tertiles. The sutureless valve was implanted successfully in 99% of patients (298/300). Cumulative sum analysis failed to identify any significant learning effects for technical success. Nevertheless, surgeons A, B, and C had a small initial learning curve, and surgeons D, E, and F did not, reflecting a trend toward a positive effect of cumulative institutional experience on the individual learning curve. The 30-day complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients' selection process. Consecutively, the procedure returned in control.

CONCLUSIONS

Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cumulative sum analysis is a valuable tool to describe and monitor the learning process. The analysis can identify periods of less than expected performance and alert the team to react.

Effects of MIAVS on Early Postoperative ELWI and Respiratory Mechanics

Background

The effects of minimally invasive aortic valve surgery (MIAVS) on the early postoperative extravascular lung water index (ELWI) and respiratory mechanics have rarely been studied.

Material/Methods

A total of 90 patients were divided into 3 groups: a conventional full sternotomy (CS) group (n=30), an upper ministernotomy (US) group (n=30), and a right anterior thoracotomy (RT) group (n=30). Hemodynamic and respiratory mechanics parameters were recorded at perioperative time points, including before skin incision (T(−1)); at sternum closing (T0); and 4 h (T4), 8 h (T8), 12 h (T12), and 24 h (T24) after the operation. The ventilator support time, ICU length of stay, and postoperative hospitalization time, as well as the thoracic drainage volume and blood transfusion volume, were recorded.

Results

The ELWI and pulmonary vascular permeability index (PVPI) increased at T4, and the values were significantly lower in the US group than in the RT group and CS group (P<0.05). At T8, the ELWI and PVPI in the US group and RT group were significantly lower than in the CS group. At T12, there were no significant differences among the 3 groups. In addition, at T4 static lung compliance decreased, plateau airway pressure increased, and airway resistance changed non-significantly. There were no significant differences between the US group and the RT group, but both groups showed better results than the CS group did.

Conclusions

The ELWI and PVPI may transiently increase after aortic valve surgery with cardiopulmonary bypass. Compared with the 12 h required to recover from a conventional sternotomy operation, it may only take 8 h to recover from MIAVS.

Early outcomes after isolated aortic valve replacement with rapid deployment aortic valve

OBJECTIVE

Minimal access aortic valve replacement is associated with favorable clinical outcomes; however, several meta-analyses have reported significantly longer crossclamp times compared with a full sternotomy. We examined the procedural and early safety outcomes after isolated rapid deployment aortic valve replacement by surgical approach in patients enrolled in the Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve trial.

METHODS

The Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve trial was a prospective, multicenter, single-arm study, with successful implants in 287 patients with aortic valve stenosis who underwent rapid deployment aortic valve replacement using the EDWARDS INTUITY Valve System (Edwards Lifesciences, Irvine, Calif). Patients were evaluated perioperatively for procedural times and technical success rates; at discharge, for hospital length of stay; and, at 30 days, for early adverse events.

RESULTS

A total of 158 patients underwent isolated aortic valve replacement through a full sternotomy (n = 71), upper hemisternotomy (n = 77), or right anterior thoracotomy (n = 10). Mean age at baseline was 75.7 ± 7.2 years. Mean aortic crossclamp and cardiopulmonary bypass times (minutes) were similar for full sternotomy and upper hemisternotomy, 43.5 ± 32.5/71.6 ± 41.8 and 43.1 ± 13.1/69.6 ± 19.1, respectively, and significantly longer for right anterior thoracotomy, 88.3 ± 18.6/122.2 ± 22.1 (P < .000). Early adverse event rates were similar, and in-hospital mortality rates were low regardless of surgical approach.

CONCLUSIONS

These data suggest that isolated rapid deployment aortic valve replacement through an upper hemisternotomy can lead to shorter crossclamp times than has been reported historically in the literature. This may facilitate minimal access aortic valve replacement by eliminating the issue of prolonged crossclamp times. Further, low in-hospital mortality and new permanent pacemaker implant rates were observed regardless of surgical approach.

Minimally Invasive Aortic Valve Replacement

With the advent of transcatheter aortic valve replacement and the emergence of rapid deployment aortic valves, there is a resurgent interest in minimizing the trauma of surgical aortic valve replacement (AVR). The present review summarizes the history of minimal access AVR and attempts to collate the existing evidence regarding minimal access AVR.

Concurrent Minimally Invasive Aortic Valve Replacement and Coronary Artery Bypass via Limited Right Anterior Thoracotomy

An 89-year-old man and an 80-year-old woman were treated surgically for critical aortic stenosis secondary to senile calcific aortic disease and high-grade calcified lesions in the ostium of the right coronary artery. Minimally invasive aortic valve replacement and concurrent coronary artery bypass grafting were performed concurrently through a 5-cm right anterior thoracotomy in the second intercostal space. Surgery was uncomplicated in both cases, with no adverse events. Both patients were alive and well at midterm follow-up. Concurrent minimally invasive aortic valve replacement and coronary artery bypass grafting can be performed successfully through a limited right anterior thoracotomy.

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.

Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer

Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.

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.

Minimally invasive aortic valve surgery: Cleveland Clinic experience

BACKGROUND

Minimally invasive surgery has become a routine approach for aortic valve disease over the last 18 years at the Cleveland Clinic. It is performed in isolation or in combination with other procedures. The objective of this study is to review trends and outcomes in these patients.

METHODS

Cleveland Clinic Cardiovascular Information Registry (CVIR) was searched for aortic valve procedures from 1996 to 2013. All patients undergoing isolated or combined aortic valve operations were included for analysis. The incision type and procedure type were reviewed and trends were evaluated over time. Cleveland Clinic outcomes with minimally invasive approaches to the aortic valve are reviewed.

RESULTS

A total of 22,766 aortic valve surgical procedures were performed in this 18-year timeframe. Of these, 3,385 (14.9%) were minimally invasive procedures (MIPs) and 2,379 (10.5%) were isolated minimally invasive aortic valves. MIPs increased from 12.4% to 29.6% of the total aortic valve volume over the period of the study. Combined procedures, including concomitant surgery on the aorta, mitral valve, tricuspid valve, and arrhythmia surgery increased over time as well. Overall mortality for primary and reoperative aortic valve operations continues to decline and has consistently been less than 1% for several years.

CONCLUSIONS

A programmed approach to minimally invasive aortic valve surgery (MIAVS) with careful patient selection, appropriate use of preoperative imaging, and selective conversion to sternotomy when necessary, allows for aortic valve replacement (AVR) and a wide range of concomitant procedures to be performed safely in a large number of patients.

Sutureless prostheses and less invasive aortic valve replacement: just an issue of clamping time?

BACKGROUND

Recently, sutureless aortic bioprostheses have been increasingly adopted to facilitate minimally invasive aortic valve replacement. We aimed at evaluating the impact of the transition from conventional bioprostheses to the routine use of the 3f Enable prosthesis (Medtronic ATS Medical, Minneapolis, MN) for aortic valve replacement through ministernotomy.

METHODS

Between November 2009 and November 2012, 83 consecutive minimally invasive aortic valve replacement procedures were performed in our institution by the same surgeon through an upper T-shaped ministernotomy. The earliest 42 patients (group A) received a conventional bioprosthesis, and the later 41 patients (group B) received the sutureless 3f Enable valve. Aortic clamping and cardiopulmonary bypass times, early outcomes, and valve hemodynamics were compared.

RESULTS

There was no statistical intergroup difference in baseline characteristics. In-hospital mortality was 1% (a single nonvalve-related death). Average aortic clamping times in group A and group B were, respectively, 85 ± 17 and 47 ± 11 minutes (p < 0.0001); the cardiopulmonary bypass time was 108 ± 21 and 69 ± 15 minutes, respectively (p < 0.0001). There were three paravalvular leakages in group A (grade I) and four in group B (two grade I, and two grade II); three pacemaker implantations occurred in group B (p = 0.07); mean transvalvular gradient at discharge was 16.9 ± 9.1 mm Hg in group A and 11.4 ± 4.3 mm Hg in group B (p = 0.0007). During follow-up (average 25.5 ± 12.9 months), one structural valve deterioration was registered in group A, and was treated with a valve-in-valve procedure.

CONCLUSIONS

In our initial experience, the sutureless 3f Enable technology significantly reduced the clamping and cardiopulmonary bypass times, as well as the mean transvalvular gradient in aortic valve replacement through ministernotomy.

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.

Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data

BACKGROUND

Minimally invasive aortic valve replacement (mAVR) is increasingly preferred over conventional AVR (cAVR). However, data comparing these procedures present conflicting results. Hence, we conducted a systematic review and meta-analysis comparing clinical results in these cohorts.

METHOD

Only randomized controlled trials (RCT) and propensity-matched observational studies (POS) (1998-2013) comparing clinical outcome of patients subjected to mAVR or cAVR were pooled. Continuous data was compared using mean/standardized mean difference (MD/SMD) while categorical results were pooled to obtain an odds ratio (OR) with a 95% confidence interval.

RESULTS

A total of 18 studies (6 RCT and 12 POS) (1973 mAVR patients; 2697 cAVR patients) were analyzed. The mean ischemic time was significantly longer with mAVR (MD 9.42 minutes [4.25-14.59]; p < 0.01). However, early mortality (mAVR [1.8%] and cAVR [3%]) was comparable (OR 0.70 [0.46-1.06]; p = 0.09). Postoperative ventilation time was slightly shorter after mAVR (7.5 vs 11.1 hours; p = 0.07), and hospital discharge was earlier after mAVR (MD -1.05 [-1.64 to -0.46]; p < 0.01). However, mAVR failed to reduce transfusion requirement (OR 0.77 [0.51-1.14]; p = 0.19) or pain scores (SMD -0.25 [-0.65 to 0.13]; p = 0.20). Postoperative atrial fibrillation (p = 0.67) and stroke (p = 0.79) rates were comparable. Pooled rate of conversion to full sternotomy was 2.5%. Cosmetic satisfaction could not be pooled due to reporting heterogeneity.

CONCLUSION

Minimally invasive aortic valve replacement can be performed safely despite the longer ischemic time. While minimally invasive surgery does demonstrate some advantages in postoperative recovery, we failed to find any other substantial improvement in outcome over conventional aortic valve replacement.

Minimally invasive aortic valve replacement provides equivalent outcomes at reduced cost compared with conventional aortic valve replacement: A real-world multi-institutional analysis

BACKGROUND

Several single-center studies have reported excellent outcomes with minimally invasive aortic valve replacement (mini-AVR). Although criticized as requiring more operative time and complexity, mini-AVR is increasingly performed. We compared contemporary outcomes and cost of mini-AVR versus conventional AVR in a multi-institutional regional cohort. We hypothesized that mini-AVR provides equivalent outcomes to conventional AVR without increased cost.

METHODS

Patient records for primary isolated AVR (2011-2013) were extracted from a regional, multi-institutional Society of Thoracic Surgeons database and stratified by conventional versus mini-AVR, performed by either partial sternotomy or right thoracotomy. To compare similar patients, a 1:1 propensity-matched cohort was performed after adjusting for surgeon; operative year; and Society of Thoracic Surgeons risk score, including age and risk factors (n = 289 in each group). Differences in outcomes and cost were analyzed.

RESULTS

A total of 1341 patients underwent primary isolated AVR, of which 442 (33%) underwent mini-AVR at 17 hospitals. Mortality, stroke, renal failure, and other major complications were equivalent between groups. Mini-AVR was associated with decreased ventilator time (5 vs 6 hours; P = .04) and decreased blood product transfusion (25% vs 32%; P = .04). A greater percentage of mini-AVR patients were discharged within 4 days of the operation (15.2% vs 4.8%; P < .001). Consequently, total hospital costs were lower in the mini-AVR group ($36,348 vs $38,239; P = .02).

CONCLUSIONS

Mortality and morbidity outcomes of mini-AVR are equivalent to conventional AVR. Mini-AVR is associated with decreased ventilator time, blood product use, early discharge, and reduced total hospital cost. In contemporary clinical practice, mini-AVR is safe and cost-effective.

Aortic valve replacement via right minithoracotomy versus median sternotomy: a propensity score analysis

OBJECTIVE

The aim of this study was to define the relative role of a right minithoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR).

METHODS

A retrospective analysis was performed of all 1348 patients undergoing isolated, open AVR at a single institution during a 14-year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n = 20), all redo patients (n = 209) were excluded, leaving 1139 patients available for analysis. Patients converting from RT to ST approach (n = 15) were analyzed separately.

RESULTS

Relative to ST (n = 672), the RT patients (n = 452) were older with more stenosis but with more recent operation year, lower rate of congestive heart failure, higher ejection fraction, lower rate of endocarditis, and lower rate of renal disease than the ST AVR patients (all P < 0.0001). Right minithoracotomy AVR was associated with longer cardiopulmonary bypass times [157 (25) vs 131 (38), P = 0.0004] and clamp times [103 (20) vs 85 (27), P < 0.0001] but less transfusion (1.4 vs 3.4 U, P = 0.0003), less chest tube output (405 vs 950 mL, P < 0.0001), fewer reoperations for bleeding (0.4% vs 4%, P < 0.0001), shorter length of stay (6 vs 8 days, P = 0.03), and lower rate of atrial fibrillation (15% vs 20%, P = 0.03). Stroke, operative mortality, and survival were not significantly different between the groups.

CONCLUSIONS

Given the biases of retrospective propensity-adjusted analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients, with advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times.

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.

Evaluation of Aortic Valve Replacement via the Right Parasternal Approach without Rib Removal

BACKGROUND

Although right parasternal approach (RPA) decreases the incidence of mediastinal infection, this approach is associated with lung hernia and flail chest. Our RPA employs thoracotomy with bending rib cartilages and wound closure performed by repositioning the ribs with underlying sheet reinforcement.

METHODS

We evaluated 16 patients who underwent aortic valve replacement via the RPA from January 2010 to August 2013. We compared outcomes of 15 male patients had the RPA with 30 male patients had full median sternotomy.

RESULTS

One patient with a history of radical breast cancer treatment underwent RPA with concomitant right coronary artery bypass grafting. No hospital deaths occurred. Four patients developed hospital-associated morbidity (re-exploration for bleeding, prolonged ventilation, cardiac tamponade, and perioperative myocardial infarction). There were no conversions to full median sternotomy, mediastinal infections, and lung hernias. Preoperative computed tomography showed that the distance from the right sternal border to the aortic root was significantly associated with operation times. With RPA, there was no significant difference in outcomes, despite significantly longer operation times compared with full median sternotomy.

CONCLUSION

Our RPA provides satisfactory outcomes without lung hernia, especially in patients unsuitable for sternotomy. Preoperative computed tomography is useful for identifying appropriate candidates for the RPA.