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Caruso V, Bilkhu R, Young C, Roxburgh J, Bosco P, Lucchese G. Novel Techniques and Technologies for Surgical Aortic Valve Replacement: A Large Retrospective Cohort Analysis. J Clin Med 2024; 13:4126. [PMID: 39064166 PMCID: PMC11278247 DOI: 10.3390/jcm13144126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: In an era of growing evidence for transaortic valve implantation (TAVI), our research topic was the evaluation of how surgical aortic valve replacements (SAVRs) are performing in terms of short- and long-term outcomes in different risk categories. Methods: This was a single centre, prospective, and observational cohort study of consecutive patients with aortic valve stenosis, undergoing isolated aortic valve replacement using a biological or mechanical prosthesis, Freestyle™ (Medtronic, Minneapolis, MN, USA) graft, homograft, or Ross procedure. The participant data were collected by review of an internal database. The primary endpoints were all-cause operative mortality (in hospital and at 30 days) and late mortality at the follow-up date. The secondary composite endpoint was the incidence of postoperative complications. Results: 1501 patients underwent SAVR; the mean age was 67 years (SD: 12.6). The in-hospital mortality was 1% (n = 16). At a median follow-up of 60 months, the survival rate was 98.7%. The main predictors for mortality were operative urgency and cardiogenic shock. The overall incidence of PPM was 2.3% (n = 34). Patients who underwent Ross procedure were younger (mean age: 20 years (SD: 1.7)), had a lower incidence of postoperative complications, and were all alive at follow-up. Conclusions: SAVR shows an excellent survival rate and a low rate of postoperative complications despite an increasing surgical risk. Recent advancements in technology, like sutureless/rapid deployment prostheses and minimally invasive techniques, are shown to have favourable effects on outcomes.
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Affiliation(s)
- Vincenzo Caruso
- Cardiovascular Department, St. Thomas’ Hospital, London SE1 7EH, UK; (R.B.); (C.Y.); (J.R.); (P.B.); (G.L.)
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2
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Kang JJ, Fialka NM, El-Andari R, Watkins A, Hong Y, Mathew A, Bozso SJ, Nagendran J. Surgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis. Trends Cardiovasc Med 2024; 34:304-313. [PMID: 37121526 DOI: 10.1016/j.tcm.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/02/2023]
Abstract
This systematic review and meta-analysis aim to provide a comprehensive analysis of the literature directly comparing the outcomes of surgical aortic valve replacement (SAVR) and TAVR in patients with BAV stenosis. Medline, PubMed, and Scopus were systematically searched for articles published between 2000 and 2023, 1862 studies were screened, and 6 retrospective studies met the inclusion criteria. We included 6550 patients in the final analyses: 3,292 and 3,258 in the SAVR and TAVR groups, respectively. Both groups have similar rates of in-hospital mortality (odds ratio (OR) 1.11; 95% CI 0.59-2.10; p = 0.75) and stroke (OR 1.25; 95% CI 0.85-1.86; p = 0.26. Patients who underwent SAVR experienced lower rates of permanent pacemaker implantation (OR 0.54; 95% CI 0.35-0.83; p = 0.005) and paravalvular leak (OR 0.47; 95% CI 0.26-0.86; p = 0.02). On the other hand, patients who underwent TAVR displayed lower rates of acute kidney injury (OR 1.81; 95% CI 1.15-2.84; p = 0.010), major bleeding (OR 3.76; 95% CI 2.18-6.49; p < 0.00001), and pulmonary complications (OR 7.68; 95% CI 1.21-48.84; p = 0.03). Despite the early mortality data suggesting that TAVR may be a reasonable strategy for patients with bicuspid AS with low to intermediate surgical risk, the increased risk of PPI and PVL is concerning. A prospective, randomized, controlled trial reporting long-term outcomes with pre-defined subgroup analyses based on BAV morphology is paramount. In the interim, caution should be exercised in the widespread adoption of TAVR in lower surgical-risk patients.
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Affiliation(s)
- Jimmy Jh Kang
- Division of Cardiac Surgery, Department of Surgery, Minimally Invasive and Transcatheter Valve Surgery, Mazankowski Alberta Heart Institute, University of Alberta, 4-108A Li Ka Shing Health Research Center, 8602 - 112 Street, Edmonton, Alberta T6G 2E1, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ryaan El-Andari
- Division of Cardiac Surgery, Department of Surgery, Minimally Invasive and Transcatheter Valve Surgery, Mazankowski Alberta Heart Institute, University of Alberta, 4-108A Li Ka Shing Health Research Center, 8602 - 112 Street, Edmonton, Alberta T6G 2E1, Canada
| | - Abeline Watkins
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Yongzhe Hong
- Division of Cardiac Surgery, Department of Surgery, Minimally Invasive and Transcatheter Valve Surgery, Mazankowski Alberta Heart Institute, University of Alberta, 4-108A Li Ka Shing Health Research Center, 8602 - 112 Street, Edmonton, Alberta T6G 2E1, Canada
| | - Anoop Mathew
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, Minimally Invasive and Transcatheter Valve Surgery, Mazankowski Alberta Heart Institute, University of Alberta, 4-108A Li Ka Shing Health Research Center, 8602 - 112 Street, Edmonton, Alberta T6G 2E1, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, Minimally Invasive and Transcatheter Valve Surgery, Mazankowski Alberta Heart Institute, University of Alberta, 4-108A Li Ka Shing Health Research Center, 8602 - 112 Street, Edmonton, Alberta T6G 2E1, Canada.
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3
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Klop IDG, Van Putte BP, Kloppenburg GTL, Klautz RJM, Sprangers MAG, Nieuwkerk PT, Klein P. Postoperative quality of life and pain after upper hemisternotomy and conventional median sternotomy for aortic valve replacement: results of a randomized clinical trial. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae083. [PMID: 38751044 PMCID: PMC11109489 DOI: 10.1093/icvts/ivae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/13/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVES Surgical aortic valve replacement through conventional sternotomy yields excellent results. Minimally invasive techniques are deemed equally safe and serve as a viable and less traumatic alternative. However, it is unclear how both surgical techniques affect patient-reported outcomes. The objective of this trial is to compare postoperative cardiac-related quality of life and postoperative pain after upper hemisternotomy and conventional surgical aortic valve replacement. METHODS In this single-centre, open-label, investigator-initiated randomized clinical trial, patients were randomized to upper hemisternotomy or conventional full median sternotomy. Patients unable to undergo randomization were monitored prospectively (registry group). Primary outcome was cardiac-specific quality of life, measured with the Kansas City Cardiomyopathy Questionnaire up to 1 year postoperatively. RESULTS Patients undergoing upper hemisternotomy had a significantly higher physical limitation domain score across all postoperative time points than patients undergoing conventional surgical aortic valve replacement (estimated mean difference 2.12 points; P = 0.014). Patients undergoing upper hemisternotomy were more likely to have a pain score <30 the first 2 days postoperatively than patients undergoing conventional surgical aortic valve replacement (odds ratio 2.63; P = 0.007). This was associated with reduced opioid analgesic intake. Postoperative surgical outcome did not differ between both groups. CONCLUSIONS Surgical aortic valve replacement through both conventional sternotomy and upper hemisternotomy resulted in clinically similar and important improvements in quality of life, with a small advantage for upper hemisternotomy, while there was no compromise in safety.
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Affiliation(s)
- Idserd D G Klop
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Bart P Van Putte
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
- Department of Cardiothoracic Surgery, AMC Heart Centre, Amsterdam University Medical Center, Amsterdam, Netherlands
| | | | - Robert J M Klautz
- Department of Cardiothoracic Surgery, AMC Heart Centre, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Department of Mental Health, Amsterdam Public Health, Amsterdam, Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Patrick Klein
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
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El-Andari R, Fialka NM, Shan S, White A, Manikala VK, Wang S. Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis. Cardiol Rev 2024; 32:217-242. [PMID: 36728720 DOI: 10.1097/crd.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In recent years, minimally invasive cardiac surgery has increased in prevalence. There has been significant debate regarding the optimal approach to isolated aortic valve replacement between conventional midline sternotomy and minimally invasive approaches. We performed a systematic review of the contemporary literature comparing minimally invasive to full sternotomy aortic valve replacement. PubMed and Embase were systematically searched for articles published from 2010-2021. A total of 1215 studies were screened and 45 studies (148,606 patients total) met the inclusion criteria. This study found rates of in-hospital mortality were higher with full sternotomy than ministernotomy ( P = 0.02). 30-day mortality was higher with full sternotomy compared to right anterior thoracotomy ( P = 0.006). Renal complications were more common with full sternotomy versus ministernotomy ( P < 0.00001) and right anterior thoracotomy ( P < 0.0001). Rates of wound infections were greater with full sternotomy than ministernotomy ( P = 0.02) and right anterior thoracotomy ( P < 0.00001). Intensive care unit length of stay ( P = 0.0001) and hospital length of stay ( P < 0.0001) were shorter with ministernotomy compared to full sternotomy. This review found that minimally invasive approaches to isolated aortic valve replacement result in reduced early mortality and select measures of postoperative morbidity; however, long-term mortality is not significantly different based on surgical approach. An analysis of mortality alone is not sufficient for the selection of the optimal approach to isolated aortic valve replacement. Surgeon experience, individual patient characteristics, and preference require thorough consideration, and additional studies investigating quality of life measures will be imperative in identifying the optimal approach to isolated aortic valve replacement.
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Affiliation(s)
- Ryaan El-Andari
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shubham Shan
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Abigail White
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Vinod K Manikala
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Shaohua Wang
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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5
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Kirmani BH, Jones SG, Muir A, Malaisrie SC, Chung DA, Williams RJ, Akowuah E. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2023; 12:CD011793. [PMID: 38054555 PMCID: PMC10698838 DOI: 10.1002/14651858.cd011793.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Aortic valve disease is a common condition easily treatable with cardiac surgery. This is conventionally performed by opening the sternum ('median sternotomy') and replacing the valve under cardiopulmonary bypass. Median sternotomy is well tolerated, but as less invasive options become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access have raised safety concerns with regard to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. This is an update of a Cochrane review first published in 2017, with seven new studies. OBJECTIVES To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement. SEARCH METHODS We performed searches of CENTRAL, MEDLINE and Embase from inception to August 2021, with no language limitations. We also searched two clinical trials registries and manufacturers' websites. We reviewed references of primary studies to identify any further studies of relevance. SELECTION CRITERIA We included randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, transapical, transfemoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. We determined the certainty of evidence using the GRADE methodology and summarised results of patient-relevant outcomes in a summary of findings table. MAIN RESULTS The review included 14 trials with 1395 participants. Most studies had at least two domains at high risk of bias. We analysed 14 outcomes investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy. Upper hemi-sternotomy may have little to no effect on mortality versus full median sternotomy (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.45 to 1.94; 10 studies, 985 participants; low-certainty evidence). Upper hemi-sternotomy for aortic valve replacement may increase cardiopulmonary bypass time slightly, although the evidence is very uncertain (mean difference (MD) 10.63 minutes, 95% CI 3.39 to 17.88; 10 studies, 1043 participants; very low-certainty evidence) and may increase aortic cross-clamp time slightly (MD 6.07 minutes, 95% CI 0.79 to 11.35; 12 studies, 1235 participants; very low-certainty evidence), although the evidence is very uncertain. Most studies had at least two domains at high risk of bias. Postoperative blood loss was probably lower in the upper hemi-sternotomy group (MD -153 mL, 95% CI -246 to -60; 8 studies, 767 participants; moderate-certainty evidence). Low-certainty evidence suggested that there may be no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.19, 95% CI -0.43 to 0.04; 5 studies, 649 participants). Upper hemi-sternotomy may result in little to no difference in quality of life (MD 0.03 higher, 95% CI 0 to 0.06 higher; 4 studies, 624 participants; low-certainty evidence). Two studies reporting index admission costs concluded that limited sternotomy may be more costly at index admission in the UK National Health Service (MD 1190 GBP more, 95% CI 420 GBP to 1970 GBP, 2 studies, 492 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence was of very low to moderate certainty. Sample sizes were small and underpowered to demonstrate differences in some outcomes. Clinical heterogeneity was also noted. Considering these limitations, there may be little to no effect on mortality. Differences in extracorporeal support times are uncertain, comparing upper hemi-sternotomy to full sternotomy for aortic valve replacement. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from also performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality of life analyses to be included as end points, as well as quantitative measures of physiological reserve.
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Affiliation(s)
- Bilal H Kirmani
- Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Sion G Jones
- Department of Cardiac Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Andrew Muir
- Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University, Chicago, IL, USA
| | | | | | - Enoch Akowuah
- Academic Cardiovascular Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
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Faerber G, Mukharyamov M, Doenst T. Is There a Future for Minimal Access and Robots in Cardiac Surgery? J Cardiovasc Dev Dis 2023; 10:380. [PMID: 37754809 PMCID: PMC10531980 DOI: 10.3390/jcdd10090380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/27/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
Minimally invasive techniques in cardiac surgery have found increasing use in recent years. Both patients and physicians often associate smaller incisions with improved outcomes (i.e., less risk, shorter hospital stay, and a faster recovery). Videoscopic and robotic assistance has been introduced, but their routine use requires specialized training and is associated with potentially longer operating times and higher costs. Randomized evidence is scarce and transcatheter treatment alternatives are increasing rapidly. As a result, the concept of minimally invasive cardiac surgery may be viewed with skepticism. In this review, we examine the current status and potential future perspectives of minimally invasive and robotic cardiac surgery.
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Affiliation(s)
| | | | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
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Frank D, Kennon S, Bonaros N, Romano M, Di Mario C, van Ginkel DJ, Bor W, Kasel M, De Backer O, Hachaturyan V, Lüske CM, Kurucova J, Bramlage P, Styra R. Quality of Life Measures in Aortic Stenosis Research: A Narrative Review. Cardiology 2023; 148:556-570. [PMID: 37442111 PMCID: PMC10733944 DOI: 10.1159/000531465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 05/31/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS. SUMMARY We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ). KEY MESSAGES There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.
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Affiliation(s)
- Derk Frank
- Department of Internal Medicine III (Cardiology, Angiology and Critical Care), UKSH University Clinical Center Schleswig-Holstein and DZHK (German Centre for Cardiovascular Research), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Simon Kennon
- Department of Cardiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, UK
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Mauro Romano
- Department of Thoracic and Cardiovascular Surgery, Department of Interventional Cardiology, Hôpital Privé Jacques Cartier, Massy, France
| | - Carlo Di Mario
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Dirk-Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Wilbert Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Markus Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ole De Backer
- Interventional Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark
| | | | - Claudia M. Lüske
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Rima Styra
- Department of Psychiatry, University Health Network, Toronto, ON, Canada
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Minimally Invasive Versus Full Sternotomy for Isolated Aortic Valve Replacement in Low-Risk Patients. Ann Thorac Surg 2022; 114:2124-2130. [PMID: 34958771 DOI: 10.1016/j.athoracsur.2021.11.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 11/19/2021] [Accepted: 11/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical aortic valve replacement can be performed through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI vs FS for isolated surgery among patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 3 low-risk trial. METHODS Patients with severe, symptomatic aortic stenosis at low surgical risk with anatomy suitable for transfemoral access were eligible for PARTNER 3 enrollment. The primary outcome was the composite end point of death, stroke, or rehospitalization (valve-, procedure-, or heart failure-related) at 1 year. Secondary outcomes included the individual components of the primary end point as well as patient-reported health status at 30 days and 1 year. RESULTS In the PARTNER 3 study, 358 patients underwent isolated valve replacement at 68 centers through an MI (n = 107) or FS (n = 251) approach (8 patients were converted from MI to FS). Mean age and Society of Thoracic Surgeons score were similar between groups. The Kaplan-Meier estimate of the primary outcome was similar in the MI vs FS groups (16.9% vs 14.9%; hazard ratio, 1.15; 95% CI, 0.66-2.03; P = .618). There were no significant differences in the 1-year rates of all-cause death (2.8% vs 2.8%), all stroke (1.9% vs 3.6%), or rehospitalization (13.3% vs 10.6%, P > .05 for all). Quality of life, as assessed by the Kansas City Cardiomyopathy Questionnaire score at 30 days or 1 year, was comparable in both groups. CONCLUSIONS For patients at low risk for isolated surgery, MI and FS approaches were associated with similar in-hospital and 1-year outcomes.
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9
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Ogami T, Yokoyama Y, Takagi H, Serna-Gallegos D, Ferdinand FD, Sultan I, Kuno T. Minimally invasive versus conventional aortic valve replacement: The network meta-analysis. J Card Surg 2022; 37:4868-4874. [PMID: 36378939 DOI: 10.1111/jocs.17126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outcome comparisons after surgical aortic valve replacement (SAVR) with minimally invasive approaches including mini-sternotomy (MS) and right mini-thoracotomy (RMT) and full sternotomy (FS) have been conflicting. Furthermore, the synthesis of mid-term mortality has not been performed. METHODS MEDLINE and EMBASE were searched through April 2022 to identify propensity score matched (PSM) studies or randomized controlled trial (RCT) which compared outcomes following SAVR among three incisional approaches: FS, MS, or RMT. The network analysis was performed to compare these approaches with random effects model. Mid-term mortality was defined as 1-year mortality. RESULTS A total of 42 studies met the inclusion criteria enrolling 14,925 patients. RCT and PSM were performed in 13 and 29 studies, respectively. The operative mortality was significantly lower with MS compared to FS (risk ratio [RR]: 0.60, 95% confidence interval [CI]: 0.41-0.90, p = .01, I2 = 25.8%) or RMT (RR: 0.51, 95% CI: 0.27-0.97, p = .03, I2 = 25.8%). RMT had significantly higher risk of reoperation for bleeding compared to MS (RR: 1.65, 95% CI: 1.18-2.30, p = .003, I2 = 0%). Hospital length of stay was significantly shorter with MS compared to FS (mean difference: -0.89 days, 95% CI: -1.58 to -0.2, p = .01, I2 = 95.5%) while it was equivocal between FS and RMT. The mid-term mortality was similar among the three approaches. CONCLUSIONS While mid-term mortality was comparable among approaches, MS may be a safe and potentially more effective approach than FS and RMT for SAVR in the short term.
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Affiliation(s)
- Takuya Ogami
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Fountain Hill, Pennsylvania, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Cardiothroacic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Francis D Ferdinand
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Cardiothroacic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Cardiothroacic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pennsylvania, Pittsburgh, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York, USA
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10
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El-Andari R, White A, Fialka NM, Shan S, Manikala VK, Hong Y, Wang S. Mini-sternotomy versus full sternotomy for isolated aortic valve replacement: A single-center experience. J Card Surg 2022; 37:4579-4586. [PMID: 36378945 DOI: 10.1111/jocs.17158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/10/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Minimally invasive approaches to isolated aortic valve replacement (AVR) are well-described and widely utilized. While there are numerous proposed benefits, there is limited literature describing significant morbidity or mortality benefits for minimally invasive isolated AVR resulting in hesitancy in its universal adoption. In this retrospective study, we compare the 5-year outcomes of patients undergoing isolated AVR via full sternotomy (FS) or mini-sternotomy (MS). METHODS 756 patients underwent isolated AVR between 2014 and 2019. Propensity matching resulted in 142 matched pairs that received either FS or MS. The primary outcome was mortality during the follow-up period. Secondary outcomes included intraoperative variables and postoperative morbidity. RESULTS Intraoperative variables including total operative, cardiopulmonary bypass, and aortic cross-clamp times did not differ significantly between groups. Postoperative mortality was similar between the matched groups with nonsignificant differences at 30 days (2.12% vs. 1.4%, p = .657), 1 year (4.9% vs. 2.1%, p = .0.223), and 5 years (7.5% vs. 3.5%, p = .174). Rates of postoperative morbidity were comparable between groups with no significant differences. CONCLUSION This study examined the long-term outcomes of propensity-matched patients undergoing isolated AVR via FS or MS and identified no significant differences in outcomes over a 5-year follow-up period. The decision for surgical approach is multifactorial and should be decided on a case-by-case basis taking into consideration patient anatomy, surgeon experience, and comfort, as well as patient preference.
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Affiliation(s)
- Ryaan El-Andari
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Abigail White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Shubham Shan
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Vinod K Manikala
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Yonghze Hong
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Shaohua Wang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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11
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Turner E, Piccinini F. Tratamiento moderno de la estenosis aórtica: reemplazo valvular aórtico 2022. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Almeida AS, Ceron RO, Anschau F, de Oliveira JB, Leão Neto TC, Rode J, Rey RAW, Lira KB, Delvaux RS, de Souza RORR. Conventional Versus Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:3-13. [PMID: 35044253 DOI: 10.1177/15569845211060039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: To assess the potential benefits of minimally invasive aortic valve replacement (MIAVR) compared with conventional AVR (CAVR) by examining short-term outcomes. Methods: A systematic search identified randomized trials comparing MIAVR with CAVR. To assess study limitations and quality of evidence, we used the Cochrane Risk of Bias tool and GRADE and performed random-effects meta-analysis. We used meta-regression and sensitivity analysis to explore reasons for diversity. Results: Thirteen studies (1,303 patients) were included. For the comparison of MIAVR and CAVR, the risk of bias was judged low or unclear and the quality of evidence ranged from very low to moderate. No significant difference was observed in mortality, stroke, acute kidney failure, infectious outcomes, cardiac events, intubation time, intensive care unit stay, reoperation for bleeding, and blood transfusions. Blood loss (mean difference [MD] = -130.58 mL, 95% confidence interval [CI] = -216.34 to -44.82, I2 = 89%) and hospital stay (MD = -0.93 days, 95% CI = -1.62 to -0.23, I2 = 81%) were lower with MIAVR. There were shorter aortic cross-clamp (MD = 5.99 min, 95% CI = 0.99 to 10.98, I2 = 93%) and cardiopulmonary bypass (CPB) times (MD = 7.75 min, 95% CI = 0.27 to 15.24, I2 = 94%) in the CAVR group. In meta-regression analysis, we found that age was the variable with the greatest influence on heterogeneity. Conclusions: MIAVR seems to be an excellent alternative to CAVR, reducing hospital stay and incidence of hemorrhagic events. Despite significantly greater aortic cross-clamp and CPB times with MIAVR, this did not translate into adverse effects, with no changes in the results found with CAVR.
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Affiliation(s)
- Adriana Silveira Almeida
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Health Technology Assessment Center (NATS), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rafael Oliveira Ceron
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Fernando Anschau
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Health Technology Assessment Center (NATS), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil.,Postgraduate Program in Technology Assessment for SUS (PPGATSUS/GHC), 581607Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Jeffchandler Belém de Oliveira
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
| | - Tércio Campos Leão Neto
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
| | - Juarez Rode
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rafael Antonio Widholzer Rey
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Kathize Betti Lira
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Renan Senandes Delvaux
- Cardiothoracic Surgery Division, 125208Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Rodrigo Oliveira Rosa Ribeiro de Souza
- Postgraduate Studies Program in Minimally Invasive Cardiovascular Surgery, Goiânia, Brazil.,Cardiothoracic Surgery Division, Hospital Ruy Azeredo, Goiânia, Brazil
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13
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Perrotti A, Francica A, Monaco F, Quintana E, Sponga S, El-Dean Z, Salizzoni S, Loizzo T, Salsano A, Di Cesare A, Benassi F, Castella M, Rinaldi M, Chocron S, Vendramin I, Faggian G, Santini F, Nicolini F, Milano AD, Ruggieri VG, Onorati F. Post-operative Quality of Life after Full-sternotomy and Mini-sternotomy Aortic Valve Replacement. Ann Thorac Surg 2021; 115:1189-1196. [PMID: 34971595 DOI: 10.1016/j.athoracsur.2021.11.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/16/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few longitudinal data exist comparing quality of life (QoL) after full sternotomy aortic valve replacement (fsAVR) vs mini-sternotomy AVR (msAVR) METHODS: 1844 consecutive AVR prospectively enrolled in a European multicentre Registry were dichotomized according to surgical access. A non-parsimonious propensity-score matching selected 187 pairs of fsAVR or msAVR with comparable baseline characteristics. Hospital outcome was compared in the two groups. QoL was assessed with Short Form-36, further detailed in its Physical Component Score (PCS) and Mental Component Score (MCS). QoL was investigated at hospital admission, discharge, 1 month, 6 months and 1 year thereafter. RESULTS There were 1654 fsAVR and 190 msAVR in the entire population. fsAVR showed a worse preoperative risk-profile, a longer ICU length of stay (59.7 hours vs 38.8, p=0.002), and a higher life-threatening/disabling bleeding (4.1% vs. 0%; p=0.011); msAVR reported a higher early reintervention for failed index intervention (2.1% vs. 0.5%, p=0.001). QoL showed better PCS and MCS at 1 month after fsAVR, but no temporal-trend differences (PCS group-time p=0.202; MCS group-time p=0.141). Propensity-matched pairs showed comparable baseline characteristics and hospital outcome (p=NS for all endpoints), and comparable improvements of PCS and MCS over time, but no between-group differences over time (PCS group-time p=0.834; MCS group-time p=0.737). CONCLUSIONS Patients with similar baseline profiles report comparable hospital outcome and comparable improvement of physical and mental health, up to 1 year after surgery, with both fsAVR and msAVR. As for QoL, mini-sternotomy does not seem to offer any advantage compared to the traditional approach.
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Affiliation(s)
- Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Monaco
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Edward Quintana
- Division of Cardiac Surgery, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Sandro Sponga
- Division of Cardiac Surgery, Azienda Ospedaliero Universitaria di Udine, Udine, Italy
| | - Zein El-Dean
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Stefano Salizzoni
- Department of Cardiac Surgery, Città della Salute e della Scienza, University of Turin Medical School, Turin, Italy
| | - Tommaso Loizzo
- Cardiac Surgery Unit, Department of Emergency and Organ Transplants, Bari, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Alessandro Di Cesare
- Cardiovascular and Thoracic Surgery Unit, Robert Debre University Hospital, Reims, France; Université de Reims Champagne-Ardennes, Reims, France
| | - Filippo Benassi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Manuel Castella
- Division of Cardiac Surgery, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Mauro Rinaldi
- Department of Cardiac Surgery, Città della Salute e della Scienza, University of Turin Medical School, Turin, Italy
| | - Sidney Chocron
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Igor Vendramin
- Division of Cardiac Surgery, Azienda Ospedaliero Universitaria di Udine, Udine, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | | | - Aldo Domenico Milano
- Cardiac Surgery Unit, Department of Emergency and Organ Transplants, Bari, Italy
| | - Vito Giovanni Ruggieri
- Cardiovascular and Thoracic Surgery Unit, Robert Debre University Hospital, Reims, France; Université de Reims Champagne-Ardennes, Reims, France
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy.
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14
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Hancock HC, Maier RH, Kasim A, Mason J, Murphy G, Goodwin A, Owens WA, Akowuah E. Mini-sternotomy versus conventional sternotomy for aortic valve replacement: a randomised controlled trial. BMJ Open 2021; 11:e041398. [PMID: 33514577 PMCID: PMC7849899 DOI: 10.1136/bmjopen-2020-041398] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care). DESIGN A single-blind, randomised controlled trial. SETTING Single centre UK National Health Service tertiary hospital. PARTICIPANTS Adult patients undergoing aortic valve replacement (AVR) surgery. INTERVENTIONS Intervention was manubrium-limited mini-sternotomy performed using a 5-7 cm midline incision. Usual care was median sternotomy performed using a midline incision from the sternal notch to the xiphisternum. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of patients who received a red cell transfusion postoperatively and within 7 days of index surgery. Secondary outcomes included proportion of patients receiving a non-red cell blood component transfusion and number of units transfused within 7 days and during index hospital stay, quality of life and cost-effectiveness analyses. RESULTS 270 patients were randomised, received surgery and contributed to the intention to treat analysis. No difference between mini and conventional sternotomy in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, OR 1.0 (95% CI 0.5 to 2.0) and risk difference 0.0 (95% CI -0.1 to 0.1). Mini-sternotomy reduced chest drain losses (mean 181.6 mL (SD 138.7) vs conventional, mean 306·9 mL (SD 348.6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between mini-sternotomy and conventional groups; 23 mm vs 24 mm and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass (82.7 min (SD 23.5) vs 59.6 min (SD 15.1)) and cross-clamp times (64.1 min (SD 17.1) vs 46·3 min (SD 10.7)). Conventional sternotomy was more cost-effective with only a 5.8% probability of mini-sternotomy being cost-effective at a willingness to pay of £20 000/QALY (Quality Adjusted Life Years). CONCLUSIONS AVR via mini-sternotomy did not reduce red blood cell transfusion within 7 days following surgery when compared with conventional sternotomy. TRIAL REGISTRATION NUMBER ISRCTN29567910; Results.
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Affiliation(s)
- Helen C Hancock
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Rebecca H Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Adetayo Kasim
- Wolfson Research Institute for Health and Wellbeing, Durham University, Stockton-on-Tees, Durham, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gavin Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew Goodwin
- Department of Cardiothoracic Surgery, James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - W Andrew Owens
- Department of Cardiothoracic Surgery, James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Enoch Akowuah
- Department of Cardiothoracic Surgery, James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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15
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Creber RMM, Robinson NB, Gaudino M. Commentary: Randomized Trials Must Provide New and Important Information. Semin Thorac Cardiovasc Surg 2020; 33:335-336. [PMID: 32853739 DOI: 10.1053/j.semtcvs.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ruth M Masterson Creber
- Division of Health Informatics, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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