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Wilbring M, Arzt S, Taghizadeh-Waghefi A, Petrov A, Di Eusanio M, Matschke K, Alexiou K, Kappert U. The transaxillary concept for minimally invasive isolated aortic valve replacement: results of 1000 consecutive patients. Eur J Cardiothorac Surg 2024; 66:ezae427. [PMID: 39602603 DOI: 10.1093/ejcts/ezae427] [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: 08/28/2024] [Revised: 10/25/2024] [Accepted: 11/25/2024] [Indexed: 11/29/2024] Open
Abstract
OBJECTIVES The transaxillary concept for minimally invasive cardiac surgery-aortic valve replacement is a new and versatile approach with nearly no visible scars. Due to its novelty, available data in literature are scarce. This study reports clinical outcomes of 1000 consecutive patients. METHODS Between 2019 and 2023, 4394 patients underwent elective isolated aortic valve procedures, with 2958 (67.5%) transcatheter aortic valve implantation's and 1436 patients surgical aortic valve replacement's (32.5%). Within this period, 1st consecutive 1000 transaxillary isolated minimally invasive cardiac surgery-aortic valve replacement were enrolled. Endocarditis, redo's or combined procedures were excluded. Mean age was 67.9 ± 8.3 years, STS-PROM 1.39 ± 2.89% and EuroScore II 1.65 ± 1.12%. RESULTS Use of the transaxillary access increased from 18.7% (2019) to 97.8% (2023). Mean procedure time was 127 ± 31 min, and average cross-clamp time was 43 ± 14 min. Used prostheses were rapid deployment (81.1%), sutured biologic (14.5%) or sutured mechanical valves (4.1%). Conversion rate was 1.9%. No patient died intraoperatively. Thirty-day major adverse cardiac and cerebrovascular event was 1.9% including 0.9% mortality, 0.8% perioperative stroke and 0.6% myocardial infarction. Multivariate factors for major adverse cardiac and cerebrovascular event are intraoperative conversion [OR 1.08 (1.00-1.16); P = 0.04], intraoperative transfusions [OR 1.21 (1.07-1.38); P < 0.01] and respiratory failure [OR 1.39 (1.30-1.49); P < 0.01]. Corresponding factors for mortality are diabetes on insulin [OR 1.02 (1.00-1.04); P = 0.03], pure aortic regurgitation for primary indication [OR 1.03 (1.01-1.05); P < 0.01], intraoperative conversion [OR 1.11 (1.07-1.16); P < 0.01], renal failure [OR 1.08 (1.05-1.10); P < 0.01] and respiratory failure [OR 1.22 (1.17-1.26); P < 0.01]. CONCLUSIONS Transaxillary minimally invasive cardiac surgery-aortic valve replacement is a safe, effective and cosmetically convincing method for surgical aortic valve replacement, having the potential for >95.0% minimally invasive cardiac surgery rate in selected patients.
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Affiliation(s)
- Manuel Wilbring
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
| | - Sebastian Arzt
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
| | - Ali Taghizadeh-Waghefi
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
| | - Asen Petrov
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
| | - Marco Di Eusanio
- Department of Cardiac Surgery, Ospedali Riuniti, Polytechnic University of Marche, Ancona, Italy
| | - Klaus Matschke
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
| | - Konstantin Alexiou
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
| | - Utz Kappert
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden Heart Centre, Dresden, Germany
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Banerjee D, Feng J, Sellke FW. Strategies to attenuate maladaptive inflammatory response associated with cardiopulmonary bypass. Front Surg 2024; 11:1224068. [PMID: 39022594 PMCID: PMC11251955 DOI: 10.3389/fsurg.2024.1224068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/07/2024] [Indexed: 07/20/2024] Open
Abstract
Cardiopulmonary bypass (CPB) initiates an intense inflammatory response due to various factors: conversion from pulsatile to laminar flow, cold cardioplegia, surgical trauma, endotoxemia, ischemia-reperfusion injury, oxidative stress, hypothermia, and contact activation of cells by the extracorporeal circuit. Redundant and overlapping inflammatory cascades amplify the initial response to produce a systemic inflammatory response, heightened by coincident activation of coagulation and fibrinolytic pathways. When unchecked, this inflammatory response can become maladaptive and lead to serious postoperative complications. Concerted research efforts have been made to identify technical refinements and pharmacologic interventions that appropriately attenuate the inflammatory response and ultimately translate to improved clinical outcomes. Surface modification of the extracorporeal circuit to increase biocompatibility, miniaturized circuits with sheer resistance, filtration techniques, and minimally invasive approaches have improved clinical outcomes in specific populations. Pharmacologic adjuncts, including aprotinin, steroids, monoclonal antibodies, and free radical scavengers, show real promise. A multimodal approach incorporating technical, circuit-specific, and pharmacologic strategies will likely yield maximal clinical benefit.
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Affiliation(s)
| | | | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Brown University/Rhode Island Hospital, Providence, RI, United States
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Bratt S, Dimberg A, Kastengren M, Lilford RD, Svenarud P, Sartipy U, Franco-Cereceda A, Dalén M. Bleeding in minimally invasive versus conventional aortic valve replacement. J Cardiothorac Surg 2024; 19:349. [PMID: 38907320 PMCID: PMC11191138 DOI: 10.1186/s13019-024-02667-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/20/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Observational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting. METHODS This was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events. RESULTS Out of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition (p = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group (p = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion (p = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding. CONCLUSIONS Minimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy. CLINICAL TRIAL REGISTRATION http://www. CLINICALTRIALS gov . Unique identifier: NCT02272621.
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Affiliation(s)
- Sorosh Bratt
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Axel Dimberg
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Kastengren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Robert D Lilford
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
| | - Peter Svenarud
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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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: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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Kirmani BH, Akowuah E. Minimal Access Aortic Valve Surgery. J Cardiovasc Dev Dis 2023; 10:281. [PMID: 37504537 PMCID: PMC10380690 DOI: 10.3390/jcdd10070281] [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] [Received: 04/21/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable costs, and some benefits regarding hospital length of stay. The competing efforts of transcatheter aortic valve implantation for these same outcomes have provided an excellent range of treatment options for patients from cardiology teams. We describe the current state of the art, including technical considerations, caveats, and complications of minimal access aortic surgery and predict future directions in this space.
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Affiliation(s)
- Bilal H Kirmani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Enoch Akowuah
- Cardiac Surgery, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough TS4 3BW, UK
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6
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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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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: 0.3] [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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Incidence of postoperative pulmonary complications in patients undergoing minimally invasive versus median sternotomy valve surgery: propensity score matching. J Cardiothorac Surg 2021; 16:287. [PMID: 34627311 PMCID: PMC8501915 DOI: 10.1186/s13019-021-01669-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
Objective Postoperative pulmonary complications (PPCs) are common incidents associated with an increased hospital stay, readmissions into the intensive care unit (ICU), increased costs, and mortality after cardiac surgery. Our study aims to analyze whether minimally invasive valve surgery (MIVS) can reduce the incidence of postoperative pulmonary complications compared to the full median sternotomy (FS) approach. Methods We reviewed the records of 1076 patients who underwent isolated mitral or aortic valve surgery (80 MIVS and 996 FS) in our institution between January 2015 and December 2019. Propensity score-matching analysis was used to compare outcomes between the groups and to reduce selection bias. Results Propensity score matching revealed no significant difference in hospital mortality between the groups. The incidence of PPCs was significantly less in the MIVS group than in the FS group (19% vs. 69%, respectively; P < 0.0001). The most common PPCs were atelectasis (P = 0.034), pleural effusions (P = 0.042), and pulmonary infection (P = 0.001). Prolonged mechanical ventilation time (> 24 h) (P = 0.016), blood transfusion amount (P = 0.006), length of hospital stay (P < 0.0001), and ICU stay (P < 0.0001) were significantly less in the MIVS group. Cardiopulmonary bypass (CBP), aortic cross-clamping, and operative time intervals were significantly longer in the MIVS group than in the matched FS group (P < 0.001). A multivariable analysis revealed a decreased risk of PPCs in patients undergoing MIVS (odds ratio, 0.25; 95% confidence interval, 0.006–0.180; P < 0.0001). Conclusion MIVS for isolated valve surgery reduces the risk of PPCs compared with the FS approach.
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Mohamed MA, Ding S, Ali Shah SZ, Li R, Dirie NI, Cheng C, Wei X. Comparative Evaluation of the Incidence of Postoperative Pulmonary Complications After Minimally Invasive Valve Surgery vs. Full Sternotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity Score-Matched Studies. Front Cardiovasc Med 2021; 8:724178. [PMID: 34497838 PMCID: PMC8419439 DOI: 10.3389/fcvm.2021.724178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/27/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Postoperative pulmonary complications remain a leading cause of increased morbidity, mortality, longer hospital stays, and increased costs after cardiac surgery; therefore, our study aims to analyze whether minimally invasive valve surgery (MIVS) for both aortic and mitral valves can improve pulmonary function and reduce the incidence of postoperative pulmonary complications when compared with the full median sternotomy (FS) approach. Methods: A comprehensive systematic literature research was performed for studies comparing MIVS and FS up to February 2021. Randomized controlled trials (RCTs) and propensity score-matching (PSM) studies comparing early respiratory function and pulmonary complications after MIVS and FS were extracted and analyzed. Secondary outcomes included intra- and postoperative outcomes. Results: A total of 10,194 patients from 30 studies (6 RCTs and 24 PSM studies) were analyzed. Early mortality differed significantly between the groups (MIVS 1.2 vs. FS 1.9%; p = 0.005). Compared with FS, MIVS significantly lowered the incidence of postoperative pulmonary complications (odds ratio 0.79, 95% confidence interval [0.67, 0.93]; p = 0.004) and improved early postoperative respiratory function status (mean difference -24.83 [-29.90, -19.76]; p < 0.00001). Blood transfusion amount was significantly lower after MIVS (p < 0.02), whereas cardiopulmonary bypass time and aortic cross-clamp time were significantly longer after MIVS (p < 0.00001). Conclusions: Our study showed that minimally invasive valve surgery decreases the incidence of postoperative pulmonary complications and improves postoperative respiratory function status.
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Affiliation(s)
- Mohamed Abdulkadir Mohamed
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Ding
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sayed Zulfiqar Ali Shah
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Najib Isse Dirie
- Division of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cai Cheng
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang Wei
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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10
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Abstract
Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intra- and post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.
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Affiliation(s)
- Lorenzo Di Bacco
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
| | - Antonio Miceli
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
| | - Mattia Glauber
- U.O. Cardiochirurgia Mininvasiva, Istituto Clinico Sant'Ambrogio, Gruppo San Donato, Milano, Italy
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11
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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: 2.8] [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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12
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Chien S, Clark C, Maheshwari S, Koutsogiannidis CP, Zamvar V, Giordano V, Lim K, Pessotto R. Benefits of rapid deployment aortic valve replacement with a mini upper sternotomy. J Cardiothorac Surg 2020; 15:226. [PMID: 32847577 PMCID: PMC7448500 DOI: 10.1186/s13019-020-01268-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical aortic valve replacement (AVR) is currently deemed the gold standard of care for patients with severe aortic stenosis. Currently, most AVRs are safely performed through a full median sternotomy approach. With an increasingly elderly and high-risk patient population, major advances in valve technology and surgical technique have been introduced to reduce perioperative risk and post-operative complications associated with the full sternotomy approach, in order to ensure surgical AVR remains the gold standard. For example, minimally invasive approaches (most commonly via mini sternotomy) have been developed to improve patient outcomes. The advent of rapid deployment valve technology has also been shown to improve morbidity and mortality by reducing cardiopulmonary bypass and aortic cross-clamp times, as well as facilitating the use of minimal access approaches. Rapid deployment valves were introduced into our department at the Royal Infirmary of Edinburgh in 2014. The aim of this study is to investigate if utilising the combination of rapid deployment valves and a mini sternotomy minimally invasive approach resulted in improved outcomes in various patient subgroups. METHODS Over a 3-year period, we identified 714 patients who underwent isolated AVR in our centre. They were divided into two groups: 61 patients (8.5%) were identified who received rapid deployment AVR via J-shaped mini upper sternotomy (MIRDAVR group), whilst 653 patients (91.5%) were identified who received either a full sternotomy (using a conventional prosthesis or rapid deployment valve) or minimally invasive approach using a conventional valve (CONVAVR group). We retrospectively analysed data from our cardiac surgery database, including pre-operative demographics, intraoperative times and postoperative outcomes. Outcomes were also compared in two different subgroups: octogenarians and high-risk patients. RESULTS Pre-operative demographics showed that there were significantly more female and elderly patients in the MIRDAVR group. The MIRDAVR group had significantly reduced cardiopulmonary bypass (63.7 min vs. 104 min, p = 0.0001) and aortic cross-clamp times (47.3 min vs. 80.1 min, p = 0.0001) compared to the CONVAVR group. These results were particularly significant in the octogenarian population, who also had a reduced length of ICU stay (30.9 h vs. 65.6 h, p = 0.049). In high-risk patients (i.e. logistic EuroSCORE I > 10%), minimally invasive-rapid deployment aortic valve replacement is still beneficial and is also characterized by significantly shorter cardiopulmonary bypass time (69.1 min vs. 96.1 min, p = 0.03). However, post-operative correlations, such as length of ICU stay, become no more significant, likely due to serious co-morbidities in this patient group. CONCLUSION We have demonstrated that minimally invasive rapid deployment aortic valve replacement is associated with significantly reduced cardiopulmonary bypass and aortic cross-clamp times. This correlation is much stronger in the octogenarian population, who were also found to have significantly reduced length of ICU stay. Our study raises the suggestion that this approach should be utilised more frequently in clinical practice, particularly in octogenarian patients.
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Affiliation(s)
- Siobhan Chien
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK.
| | - Callum Clark
- Department of General Medicine, University Hospital Hairmyres, East Kilbride, UK
| | | | | | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Vincenzo Giordano
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Kelvin Lim
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Renzo Pessotto
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
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13
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Rodríguez-Caulo EA, Guijarro-Contreras A, Guzón A, Otero-Forero J, Mataró MJ, Sánchez-Espín G, Porras C, Villaescusa JM, Melero-Tejedor JM, Jiménez-Navarro M. Quality of Life After Ministernotomy Versus Full Sternotomy Aortic Valve Replacement. Semin Thorac Cardiovasc Surg 2020; 33:328-334. [PMID: 32853740 DOI: 10.1053/j.semtcvs.2020.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/17/2020] [Indexed: 12/27/2022]
Abstract
Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomized trials. The QUALITY-AVR trial is a single-blind, single-center, independent, randomized clinical trial comparing ministernotomy to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients were randomized in a 1:1 computational fashion. The primary endpoint was a difference between intervention groups of ≥0.10 points in change from baseline quality of life Questionnaire EuroQOL-index, measured at 1, 6, or 12 months. Secondary endpoints were differences in change from other baseline EuroQOL-index utilities, cardiac surgery-specific satisfaction questionnaire (SATISCORE), a combined safety endpoint of 4 major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events, and acute renal failure), bleeding through drains within the first 24 hours, intubation time, and other minor endpoints. Clinical follow-up was scheduled at baseline, 1, 6, and 12 months after randomization. Change from baseline mean difference EQ-5D-index was +0.20 points (95% confidence interval 0.10-0.30, P < 0.001) and median difference +0.14 (95% confidence interval 0.06-0.22, P < 0.001), favoring the ministernotomy group at 1 month. Patient satisfaction was also better at 1 month (Satiscore 83 ± 9 vs 77 ± 13 points; P = 0.010). The ministernotomy group had significantly less bleeding in the first 24 hours (299 ± 140 vs 509 ± 251 mL, P = 0.001). Ministernotomy provides a faster recovery with improved quality of life and satisfaction at 1 month compared to full sternotomy.
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Affiliation(s)
- Emiliano A Rodríguez-Caulo
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Guijarro-Contreras
- UGC Heart Area, Cardiology Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Arantza Guzón
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Otero-Forero
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - María José Mataró
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Sánchez-Espín
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Porras
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - José M Villaescusa
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - José María Melero-Tejedor
- UGC Heart Area, Cardiovascular Surgery Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Jiménez-Navarro
- UGC Heart Area, Cardiology Department, Hospital Universitario Virgen de la Victoria de Málaga, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS), University of Málaga, CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
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14
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Sanad M, Beshir H. Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country. THE CARDIOTHORACIC SURGEON 2020; 28:9. [PMID: 38624293 PMCID: PMC7222165 DOI: 10.1186/s43057-020-00019-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 02/06/2020] [Indexed: 11/30/2022] Open
Abstract
Background Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra- and postoperative clinical outcomes and address health resource utilization after MIAVR. Results A total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; p = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; p = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; p = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; p = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); p < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); p = 0.048). Total operative mortality of 4.46% was recorded (n = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach (p < 0.0001). Conclusions With a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.
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Affiliation(s)
- Mohammed Sanad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University Hospitals, D17, F5. 60, El Gomhoria Street, Qism 2, Mansoura, Dakahlia 35516 Egypt
- Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Nasser Institute for Research and Treatment, Cairo, Egypt
| | - Hatem Beshir
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University Hospitals, D17, F5. 60, El Gomhoria Street, Qism 2, Mansoura, Dakahlia 35516 Egypt
- Department of Cardiothoracic Surgery, Egypt Ministry of Health and Population, Alexandria Directorate, Alexandria, Egypt
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15
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Vukovic PM, Milojevic P, Stojanovic I, Micovic S, Zivkovic I, Peric M, Milicic M, Milacic P, Milojevic M, Bojic M. The role of ministernotomy in aortic valve surgery—A prospective randomized study. J Card Surg 2019; 34:435-439. [DOI: 10.1111/jocs.14053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Petar M. Vukovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Predrag Milojevic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Ivan Stojanovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Slobodan Micovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Igor Zivkovic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Miodrag Peric
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Miroslav Milicic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Petar Milacic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Milan Milojevic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
| | - Milovan Bojic
- Department of Cardiac SurgeryDedinje Cardiovascular InstituteBelgrade Serbia
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Nair SK, Sudarshan CD, Thorpe BS, Singh J, Pillay T, Catarino P, Valchanov K, Codispoti M, Dunning J, Abu-Omar Y, Moorjani N, Matthews C, Freeman CJ, Fox-Rushby JA, Sharples LD. Mini-Stern Trial: A randomized trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement. J Thorac Cardiovasc Surg 2018; 156:2124-2132.e31. [DOI: 10.1016/j.jtcvs.2018.05.057] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 04/23/2018] [Accepted: 05/15/2018] [Indexed: 11/24/2022]
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Chang C, Raza S, Altarabsheh SE, Delozier S, Sharma UM, Zia A, Khan MS, Neudecker M, Markowitz AH, Sabik JF, Deo SV. Minimally Invasive Approaches to Surgical Aortic Valve Replacement: A Meta-Analysis. Ann Thorac Surg 2018; 106:1881-1889. [DOI: 10.1016/j.athoracsur.2018.07.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/18/2018] [Accepted: 07/03/2018] [Indexed: 11/25/2022]
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18
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Doenst T, Diab M, Sponholz C, Bauer M, Färber G. The Opportunities and Limitations of Minimally Invasive Cardiac Surgery. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:777-784. [PMID: 29229038 DOI: 10.3238/arztebl.2017.0777] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 04/05/2017] [Accepted: 09/13/2017] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller Universität Jena; Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller Universität Jena
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19
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Minimally invasive aortic valve replacement: is the effort justified? Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-017-0640-9] [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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20
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Rodríguez-Caulo EA, Guijarro-Contreras A, Otero-Forero J, Mataró MJ, Sánchez-Espín G, Guzón A, Porras C, Such M, Ordóñez A, Melero-Tejedor JM, Jiménez-Navarro M. Quality of life, satisfaction and outcomes after ministernotomy versus full sternotomy isolated aortic valve replacement (QUALITY-AVR): study protocol for a randomised controlled trial. Trials 2018; 19:114. [PMID: 29454380 PMCID: PMC5816540 DOI: 10.1186/s13063-018-2486-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 01/19/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND During the last decade, the use of ministernotomy in cardiac surgery has increased. Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomised trials. The aim of the study is to determine if this minimally invasive approach improves quality of life, satisfaction and clinical morbimortality outcomes. METHODS/DESIGN The QUALITY-AVR trial is a single-blind, single-centre, independent, and pragmatic randomised clinical trial comparing ministernotomy ("J" shaped upper hemisternotomy toward right 4th intercostal space) to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients will be randomised in a 1:1 computational fashion. Sample size was determined for the primary end point with alpha error of 0.05 and with power of 90% in detecting differences between intervention groups of ≥ 0.10 points in change from baseline quality of life Questionnaire EuroQOL-index (EQ-5D-5 L®), measured at 1, 6 or 12 months. Secondary endpoints are: the differences in change from other baseline EQ-5D-5 L® utilities (visual analogue scale, Health Index and Severity Index), cardiac surgery specific satisfaction questionnaire (SATISCORE®), a combined safety endpoint of four major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events and acute renal failure), bleeding through drains within the first 24 h, intubation time, postoperative hospital and intensive care unit length of stay, transfusion needs during the first 72 h and 1-year survival rates. Clinical follow up is scheduled at baseline, 1, 6, and 12 months after randomization. All clinical outcomes are recorded following the Valve Academic Research Consortium 2 criteria. DISCUSSION The QUALITY-AVR trial aims to test the hypothesis that ministernotomy improves quality of life, satisfaction and clinical outcomes in patients referred for isolated aortic valve replacement. Statistically significant differences favouring ministernotomy could modify the surgical "gold standard" for aortic stenosis surgery, and subsequently the need to change the control group in transcatheter aortic valve implantation trials. Recruitment started on 18 March 2016. In November 2017, 75 patients were enrolled. TRIAL REGISTRATION ClinicalTrials.gov , NCT02726087 . Registered on 13 March 2016.
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Affiliation(s)
- Emiliano A. Rodríguez-Caulo
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Guijarro-Contreras
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Otero-Forero
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - María José Mataró
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Sánchez-Espín
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Arantza Guzón
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Porras
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Such
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Ordóñez
- UGC Área del Corazón, Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen del Rocío de Sevilla, Red de Investigación Cardiovascular (RIC), Instituto de Salud Carlos III, Madrid, Spain
| | - José María Melero-Tejedor
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Jiménez-Navarro
- UGC Área del Corazón. Servicio de Cirugía Cardiovascular y Cardiología. Hospital Universitario Virgen de la Victoria de Málaga, Spain. Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud (FIMABIS). Universidad de Málaga. Spain. CIBERCV Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
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Calle-Valda CM, Aguilar R, Benedicto A, Sarraj A, Monguio E, Munoz D, De Antonio N, Reyes G. Outcomes of Aortic Valve Replacement According to Surgical Approach in Intermediate and Low Risk Patients: A Propensity Score Analysis. Heart Lung Circ 2017; 27:885-892. [PMID: 28918980 DOI: 10.1016/j.hlc.2017.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Previous trials have shown that, among high-risk patients with aortic stenosis, survival rates are similar for transcatheter aortic-valve implantation (TAVI) and surgical aortic valve replacement. The study aimed to compare the outcomes of aortic valve replacement according to the adopted surgical approach in intermediate and low risk patients. METHODS This is a retrospective, observational, cohort study of prospectively collected data from 421 patients undergoing isolated aortic valve replacement between 2011 and 2015. A multinomial logit propensity score model based on preoperative risk factors was used to match patients 1:1:1 between conventional replacement (CAVR), minimally invasive (MIAVR) and TAVI groups, resulting in 50 matched three cohorts. RESULTS After multinomial logit propensity score, the three groups were comparable in terms of preoperative characteristics. Mean age and Logistic EuroSCORE I of CAVR, MIAVR and TAVI groups were (84.2±5.1 vs. 82.3±4.8 vs. 85.6±4.9 years; p=0.002) and (11.4±3.6% vs. 8.3±3.4% vs. 15.8±5.4%; p<0.001) respectively. Overall mortality rates were similar for the three patient cohorts at one year. There were no significant differences related to stroke to 30 days. In the TAVI cohort, pacemaker implantation for new-onset total atrioventricular block became necessary in 30% of patients (p<0.001) and 16% of patients had some degree of paravalvular aortic regurgitation, which was more than mild (p<0.001). Total length of stay was shorter in the TAVI group when compared with surgical groups (11.5±5.3 vs. 10.1±6.9 vs 8.5±3.7 days; p=0.023). After discharge, the survival rate follow-up (average follow up: 46.7 months) was 70%, 84% and 72% for three cohorts (log Rank x2=2.40, p=0.3). CONCLUSIONS In our experience, the three aortic valve replacement approaches offer very good results. Differences in the rate of complications were found between groups. Depending on patient's characteristics the Heart-Team group must offer the best surgical approach for each patient.
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Affiliation(s)
- Corazon M Calle-Valda
- Department of Cardiovascular Surgery, Hospital Universitario de La Princesa, Madrid, Spain.
| | - Rio Aguilar
- Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Amparo Benedicto
- Department of Cardiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Anas Sarraj
- Department of Cardiovascular Surgery, Hospital Universitario de La Princesa, Madrid, Spain
| | - Emilio Monguio
- Department of Cardiovascular Surgery, Hospital Universitario de La Princesa, Madrid, Spain
| | - Daniel Munoz
- Department of Cardiovascular Surgery, Hospital Universitario de La Princesa, Madrid, Spain
| | - Nieves De Antonio
- Department of Cardiovascular Surgery, Hospital Universitario de La Princesa, Madrid, Spain
| | - Guillermo Reyes
- Department of Cardiovascular Surgery, Hospital Universitario de La Princesa, Madrid, Spain
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Hoffmann CT, Heiner JA, Nguyen TC. Review of minimal access versus transcatheter aortic valve replacement for patients with severe aortic stenosis. Ann Cardiothorac Surg 2017; 6:498-503. [PMID: 29062745 PMCID: PMC5639223 DOI: 10.21037/acs.2017.09.02] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/30/2017] [Indexed: 11/06/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (miniAVR) have become alternatives to surgical aortic valve replacement via median sternotomy (SAVR) to treat severe aortic stenosis (AS). Despite increased interest and utilization, few studies have directly compared TAVR and miniAVR. A review of the current literature shows TAVR to be an indispensable tool for inoperable, high-risk, and perhaps intermediate-risk patients with severe AS. However, it is associated with a number of deleterious perioperative outcomes, such as valvular regurgitation and vascular complications. MiniAVR is associated with decreased intensive care unit (ICU) and hospital length of stay, a lower incidence of blood transfusions, decreased ventilation time, and improved cosmetic results. MiniAVR maintains potential advantages over SAVR, including the implantation of a durable prosthesis and low rates of perioperative myocardial infarction and paravalvular leak. It is associated with longer aortic cross clamp and cardiopulmonary bypass (CPB) times; however, the use of sutureless valve implants can circumvent this. Studies comparing TAVR and miniAVR demonstrate decreased postoperative mortality, valvular regurgitation, and incidence of stroke in the miniAVR cohorts. Few studies currently exist comparing TAVR and miniAVR, as it is hard to compare the typically low-risk miniAVR versus high-risk TAVR patient populations. It is clear that both strategies will be cornerstones in the modern AVR era, but the situations in which to apply each strategy have not yet been clearly delineated. This highlights the need for surgeons to adopt these minimally invasive techniques. We believe there is a compelling role for miniAVR in low- and intermediate-risk patients, but due to the paucity of data, neither TAVR nor miniAVR should be discounted before a randomized, risk-stratified trial is performed. More studies are needed to compare TAVR and miniAVR in low- and intermediate-risk patients.
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Affiliation(s)
- Carson T Hoffmann
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas, USA
| | - Jacob A Heiner
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas, USA
| | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas at Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas, USA
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Moore M, Barnhart GR, Chitwood WR, Rizzo JA, Gunnarsson C, Palli SR, Grossi EA. The economic value of rapid deployment aortic valve replacement via full sternotomy. J Comp Eff Res 2017; 6:293-302. [DOI: 10.2217/cer-2016-0064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare the economic value of EDWARDS INTUITY Elite™ (EIE) valve system for rapid-deployment aortic valve replacement (RDAVR) in a full sternotomy (FS) approach (EIE-FS-RDAVR) versus FS-AVR using conventional stented bioprosthesis. Data & methods: A simulation model to compare each treatment's 30-day inpatient utilization and complication rates utilized: clinical end points obtained from the TRANSFORM trial patient subset (EIE-FS-RDAVR) and a best evidence review of the published literature (FS-AVR); and costs from the Premier database and published literature. Results: EIE-FS-RDAVR costs $800 less than FS-AVR per surgery episode attributable to lowered complication rates and utilization. Combined with the lower mortality, EIE-FS-RDAVR was a superior (dominant) technology versus FS-AVR. Conclusion: This preliminary investigation of EIE-FS-RDAVR versus conventional FS-AVR found the EIE valve offered superior economic value over a 30-day period. Real-world analyses with additional long-term follow-up are needed to evaluate if this result can be replicated over a longer timeframe.
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Affiliation(s)
- Matt Moore
- Edwards Lifesciences, Inc., Irvine, CA, USA
| | | | | | | | | | - Swetha R Palli
- CTI Clinical Trial & Consulting Services, Inc., Cincinnati, OH, USA
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Kirmani BH, Jones SG, Malaisrie SC, Chung DA, Williams RJNN. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2017; 4:CD011793. [PMID: 28394022 PMCID: PMC6478148 DOI: 10.1002/14651858.cd011793.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards 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. 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, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance. SELECTION CRITERIA 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, trans-apical, trans-femoral 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. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table. MAIN RESULTS The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy.There was no evidence of any effect of upper hemi-sternotomy on mortality versus full median sternotomy (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.36 to 2.82; participants = 511; studies = 7; moderate quality). There was no evidence of an increase in cardiopulmonary bypass time with aortic valve replacement performed via an upper hemi-sternotomy (mean difference (MD) 3.02 minutes, 95% CI -4.10 to 10.14; participants = 311; studies = 5; low quality). There was no evidence of an increase in aortic cross-clamp time (MD 0.95 minutes, 95% CI -3.45 to 5.35; participants = 391; studies = 6; low quality). None of the included studies reported major adverse cardiac and cerebrovascular events as a composite end point.There was no evidence of an effect on length of hospital stay through limited hemi-sternotomy (MD -1.31 days, 95% CI -2.63 to 0.01; participants = 297; studies = 5; I2 = 89%; very low quality). Postoperative blood loss was lower in the upper hemi-sternotomy group (MD -158.00 mL, 95% CI -303.24 to -12.76; participants = 297; studies = 5; moderate quality). The evidence did not support a reduction in deep sternal wound infections (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (RR 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality). There was no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.33, 95% CI -0.85 to 0.20; participants = 197; studies = 3; I2 = 70%; very low quality), but there was a small increase in postoperative pulmonary function tests with minimally invasive limited sternotomy (MD 1.98 % predicted FEV1, 95% CI 0.62 to 3.33; participants = 257; studies = 4; I2 = 28%; low quality). There was a small reduction in length of intensive care unit stays as a result of the minimally invasive upper hemi-sternotomy (MD -0.57 days, 95% CI -0.93 to -0.20; participants = 297; studies = 5; low quality). Postoperative atrial fibrillation was not reduced with minimally invasive aortic valve replacement through limited compared to full sternotomy (RR 0.60, 95% CI 0.07 to 4.89; participants = 240; studies = 3; moderate quality), neither were postoperative ventilation times (MD -1.12 hours, 95% CI -3.43 to 1.19; participants = 297; studies = 5; low quality). None of the included studies reported cost analyses. AUTHORS' CONCLUSIONS The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. 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 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
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
| | - Sion G Jones
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
| | - S C Malaisrie
- Northwestern UniversityDivision of Cardiac Surgery201 E. Huron StreetGalter 11‐140Chicago, ILUSA60611
| | - Darryl A Chung
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
| | - Richard JNN Williams
- Liverpool Heart and Chest HospitalCardiothoracic SurgeryThomas DriveLiverpoolMerseysideUKL14 3PE
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Calles ACDN, Lira JLF, Granja KSB, Medeiro JDD, Farias AR, Cavalcanti RC. Pulmonary complications in patients undergoing coronary artery bypass grafting at a hospital in Maceio, Brazil. FISIOTERAPIA EM MOVIMENTO 2016. [DOI: 10.1590/1980-5918.029.004.ao01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: Despite technological advances aimed at reducing complications and hospital stay, pulmonary complications in the postoperative period of CABG surgery remain one of the most important causes of morbidity. These may be related to the patient's quality of life, the use of cardiopulmonary bypass, as well as a decline in postoperative respiratory muscle strength, contributing to the emergence of restrictive respiratory disorders. Objective: Assess pulmonary complications in patients undergoing coronary artery bypass graft surgery and identify their association with risk factors. Methods: A retrospective study with non-probability convenience sampling of 168 patients at the Hospital do Coração of Alagoas, undergoing CABG between January 2009 and October 2013. Results: The 168 patients undergoing CABG had a mean age of 60.08 ± 10.03 years, 24.4% women and 75.6% men. Among the cardiovascular risk factors were: Hypertension (89.9%); Heredity for cardiovascular disease (54.8%); Diabetes Mellitus (45.2%); Dyslipidemia (41.1%); Smoking (32.1%); and Stroke (1.2%). Pulmonary complications after surgery include pleural effusion (17.9%); atelectasis (5.4%); pneumothorax, pulmonary embolism, and acute respiratory failure (1.2%); and bronchopneumonia (0.6%). Female patients and those aged 70 years or older experienced more pulmonary complications after surgery. Conclusion: Women and patients older than 70 years had the most severe postoperative pulmonary complications, the most common being pleural effusion and atelectasis.
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Moore M, Barnhart GR, Chitwood WR, Rizzo JA, Gunnarsson C, Palli SR, Grossi EA. The economic value of INTUITY in aortic valve replacement. J Med Econ 2016; 19:1011-7. [PMID: 27549435 DOI: 10.1080/13696998.2016.1220949] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The recent development of the EDWARDS INTUITY Elite™ (EIE) valve system enables the rapid deployment of a prosthetic surgical heart valve in an aortic valve replacement (AVR) procedure via both the minimally invasive (MISAVR) and conventional (CAVR) approaches. In order to understand its economic value, this study performed a cost evaluation of the EIE valve system used in a MIS rapid-deployment approach (MIS-RDAVR) vs MISAVR and CAVR, respectively, compared to standard prosthetic aortic valves. METHODS A simulation model was developed using TreeAge (and validated with MS Excel) to compare the inpatient utilization and complication costs for each treatment arm. Thirty-day clinical end-points for the MIS-RDAVR (mortality and complications) were taken from the TRANSFORM trial; and a best evidence review of the published literature was used for the MISAVR and CAVR approaches. Studies were pooled and parameter estimates were weighted by sample size in order to compare the TRANSFORM patients. Cost data (2016 USD) were taken from the Premier database. Incremental cost and cost-effectiveness was assessed and one-way/probabilistic sensitivity analyses performed to gauge the robustness of the results. RESULTS MIS-RDAVR costs $2,621 less than CAVR and had lower mortality rates, making it a superior (dominant) technology relative to CAVR. MIS-RDAVR costs $4,560 more than MISAVR, but was associated with an additional 0.20 life years-per-patient. This implies a cost-effectiveness ratio of $22,903 per-life-year-gained. Thus, MIS-RDAVR is cost-effective compared to MISAVR. CONCLUSIONS The EIE valve system deployed in a MIS approach appears to be a cost-effective technology compared to MISAVR and CAVR. When compared to CAVR it may achieve cost savings as well. These results suggest that MIS-RDAVR confers superior economic value compared to both standard MISAVR and CAVR via lowered key complication rates (re-operation, renal complications, wound infection, TIA, endocarditis) and utilization (cross-clamp time, hospital ward days).
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Affiliation(s)
| | | | | | - John A Rizzo
- d Stony Brook University , Stony Brook , NY , USA
| | - Candace Gunnarsson
- e CTI Clinical Trial and Consulting Services, Inc. , Cincinnati , OH , USA
| | - Swetha R Palli
- e CTI Clinical Trial and Consulting Services, Inc. , Cincinnati , OH , USA
| | - Eugene A Grossi
- f New York University School of Medicine , New York , NY , USA
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Abstract
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.
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Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Julia A Collins
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
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Corona Perezgrovas MÁ, Sagahón Martínez JA, Hernández Mejía BI, Martínez Hernández HJ, Herrera Alarcón V. Abordaje mínimamente invasivo versus esternotomía total en la sustitución valvular aórtica: estudio comparativo de la evolución posoperatoria temprana. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Castedo Mejuto E, Martínez Cabeza P. Reemplazo valvular aórtico mínimamente invasivo. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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30
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Kaczmarczyk M, Szałański P, Zembala M, Filipiak K, Karolak W, Wojarski J, Garbacz M, Kaczmarczyk A, Kwiecień A, Zembala M. Minimally invasive aortic valve replacement - pros and cons of keyhole aortic surgery. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2015; 12:103-10. [PMID: 26336491 PMCID: PMC4550017 DOI: 10.5114/kitp.2015.52850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 04/13/2015] [Accepted: 05/22/2015] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Marcin Kaczmarczyk
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Michał Zembala
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Krzysztof Filipiak
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Wojciech Karolak
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Jacek Wojarski
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Marcin Garbacz
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Aleksandra Kaczmarczyk
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Anna Kwiecień
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Marian Zembala
- Department of Cardiac Surgery, Transplantation and Endovascular Surgery, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
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Lim JY, Deo SV, Altarabsheh SE, Jung SH, Erwin PJ, Markowitz AH, Park SJ. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg 2015; 30:125-34. [PMID: 25533177 DOI: 10.1111/jocs.12493] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Ju Y Lim
- Asan Medical Center, Seoul, South Korea
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Phan K, Xie A, Tsai YC, Black D, Di Eusanio M, Yan TD. Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis. Ann Cardiothorac Surg 2015; 4:3-14. [PMID: 25694971 PMCID: PMC4311162 DOI: 10.3978/j.issn.2225-319x.2014.08.01] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/01/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Establishing the relative merits of ministernotomy (MS) and minithoracotomy (MT) approaches to minimally invasive aortic valve replacement (MIAVR) is difficult given the limited available direct evidence. Network meta-analysis is a Bayesian approach that can combine direct and indirect evidence to better define the benefits and risks of MS and MT. METHODS Electronic searches were performed using six databases from their inception to June 2014. Relevant studies utilizing a minimally invasive approach for aortic valve replacement were identified. Data were extracted and analyzed according to predefined clinical endpoints. Both traditional and Bayesian meta-analysis approaches were conducted. RESULTS Compared to full sternotomy, MT was associated with longer cardiopulmonary bypass (CPB) duration (WMD, 9.99; 95% CI, 3.91, 16.07; I(2)=55%; P=0.001) and cross-clamp duration (WMD, 7.64; 95% CI, 2.86, 12.42; P=0.002; I(2)=74%). When compared to MS using network meta-analysis, no significant difference in duration was detected. Postoperative outcomes including 30-day mortality, stroke, and reoperation for bleeding and wound infection were comparable between MS and MT using both traditional and Bayesian meta-analysis techniques. CONCLUSIONS The current evidence demonstrates that MIAVR via MS or MT is a safe and efficacious alternative to conventional median sternotomy. MT may be associated with longer CPB and cross-clamp durations, but has similar post-operative outcomes compared to MS. An individualized approach tailored to both the patient and surgical team is likely to provide optimal outcomes.
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Phan K, Xie A, Di Eusanio M, Yan TD. A Meta-Analysis of Minimally Invasive Versus Conventional Sternotomy for Aortic Valve Replacement. Ann Thorac Surg 2014; 98:1499-511. [DOI: 10.1016/j.athoracsur.2014.05.060] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 05/03/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
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Wollersheim LW, Li WW, de Mol BA. Current status of surgical treatment for aortic valve stenosis. J Card Surg 2014; 29:630-7. [PMID: 24980691 DOI: 10.1111/jocs.12384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve.
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Affiliation(s)
- Laurens W Wollersheim
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Paredes FA, Cánovas SJ, Gil O, García-Fuster R, Hornero F, Vázquez A, Martín E, Mena A, Martínez-León J. Cirugía mínimamente invasiva para el recambio valvular aórtico. Una técnica segura y útil más allá de lo estético. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Minimally invasive aortic valve surgery. A safe and useful technique beyond the cosmetic benefits. ACTA ACUST UNITED AC 2013; 66:695-9. [PMID: 24773674 DOI: 10.1016/j.rec.2013.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 02/15/2013] [Indexed: 11/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. METHODS Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). RESULTS No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P<.001). Mean cross-clamp time was 77.31 (29.20) min vs 63.45 (17.71) min for the S and M groups, respectively (P<.001). Mortality in the E group was 4.88% (26). There were no deaths in the M group (P<.05). The E group was associated with longer intensive care unit and hospital stays: 4.17 (5.23) days vs 3.22 (2.01) days (P=.045) and 9.58 (7.66) days vs 7.27 (3.83) days (P<.001), respectively. E group patients had more postoperative respiratory complications (42 [8%] vs 1 [1.2%]; P<.05). There were no differences when postoperative hemodynamic, neurologic, and renal complications, systemic infection, and wound infection were analyzed. CONCLUSIONS In terms of morbidity, mortality, and operative times, outcomes after minimally invasive surgery for aortic valve replacement are at least comparable to those achieved with median sternotomy. The length of the hospital stay was reduced by minimally invasive surgery in our single-institution experience. The retrospective nature of this study warrants further randomized prospective trials to validate our results.
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Alassar Y, Yildirim Y, Pecha S, Detter C, Deuse T, Reichenspurner H. Minimal access median sternotomy for aortic valve replacement in elderly patients. J Cardiothorac Surg 2013; 8:103. [PMID: 23601376 PMCID: PMC3652735 DOI: 10.1186/1749-8090-8-103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 04/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We report our clinical experience with a approach for aortic valve replacement (AVR) via minimal access skin incision and complete median sternotomy. This approach was used in patients with higher age and multiple co-morbidities, facilitating an easy access with short bypass and cross clamp times. It was especially performed in patients asking for an excellent cosmetic result, who did not qualifying for minimally-invasive AVR via partial upper sternotomy. METHODS AVR via minimal-access median sternotomy, was performed in 58 patients between 01/2009 and 11/2011. Intra- and postoperative data including cross clamp time, cardiopulmonary bypass time, mortality, stroke, pacemaker implantation, re-operation for bleeding, ventilation time, ICU and hospital stay, wound infection, sternal dehiscence or fracture and 30 day mortality were collected. RESULTS Mean patients age was 76.1 +/-9.4 years, 72% were female. Minimal-access AVR could be performed with a mean length of midline skin incision of 7.8 cm. Aortic cross-clamping time was 54.6 +/-6.3 min, cardiopulmonary bypass time 71.2+/-11.3 min and time of surgery 154.1 +/-26.8 min. Re-operation for bleeding had to be performed in 1 case (1.7%). There were no strokes or pacemaker implantations needed. Mean ventilation time was 4.5 h, ICU stay was 2 days and mean length of hospital stay was 6 days. 6 months follow up showed mortality of 0% and no sternal dehiscence or wound infection was observed. CONCLUSION Minimal-access AVR via complete median sternotomy can be performed safely,in this elderly patient cohort without adding additional operative risk compared to conventional AVR. By avoidiance of large skin incisions this approach combines excellent cosmetic results with fast surgery time and excellent postoperative recovery.
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Affiliation(s)
- Yousuf Alassar
- Department of Cardiovascular Surgery, Univeity Heart Center Hamburg, Martinistr, 52, Hamburg, 20246, Germany.
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Santana O, Reyna J, Benjo AM, Lamas GA, Lamelas J. Outcomes of minimally invasive valve surgery in patients with chronic obstructive pulmonary disease. Eur J Cardiothorac Surg 2012; 42:648-52. [PMID: 22555309 DOI: 10.1093/ejcts/ezs098] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We hypothesize that minimally invasive valve surgery in patients with chronic obstructive pulmonary disease (COPD) is superior to the conventional median sternotomy approach. METHODS We retrospectively reviewed 2846 consecutive surgery performed at our institution between January 2005 and September 2010, and identified 165 patients with COPD who underwent isolated valve surgery. In-hospital mortality, composite complication rates, intensive care unit and total hospital length of stay of those who had undergone a minimally invasive approach were compared with a cohort that underwent a standard median sternotomy approach. RESULTS Of the 165 patients, 100 underwent a minimally invasive approach and 65 had a median sternotomy. Baseline characteristics did not differ between the two groups. The mean age was 71 ± 11 years for the minimally invasive group and 68 ± 12 years for the median sternotomy group, (P = 0.31). In-hospital mortality was 1 (1%) in the minimally invasive group and 3 (5%) in the median sternotomy group, P = 0.14. Composite postoperative complications were significantly reduced in the minimally invasive group (30 versus 54%, P = 0.002). The median intensive care unit length of stay was 47 h (IQR 40-70) versus 73 h (IQR 51-112), P < 0.001, and the median postoperative length of stay was 6 days (IQR 5-9) versus 9 days (IQR 7-13), P < 0.001, for the minimally invasive and the median sternotomy groups, respectively. CONCLUSIONS Minimally invasive valve surgery in patients with COPD is associated with excellent short-term results, and thus should be considered an option in these patients.
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Affiliation(s)
- Orlando Santana
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL 33140, USA.
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Mazzeffi M, Khelemsky Y. Poststernotomy Pain: A Clinical Review. J Cardiothorac Vasc Anesth 2011; 25:1163-78. [DOI: 10.1053/j.jvca.2011.08.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Indexed: 11/11/2022]
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Khoshbin E, Prayaga S, Kinsella J, Sutherland FWH. Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials. BMJ Open 2011; 1:e000266. [PMID: 22116090 PMCID: PMC3225590 DOI: 10.1136/bmjopen-2011-000266] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Mini-sternotomy for isolated aortic valve replacement aims to reduce operative trauma hastening recovery and improving the cosmetic outcome of cardiac surgery. The short-term clinical benefits from the mini-sternotomy are presumed to arise because the incision is less extensive and the lower half of the chest cage remains intact. The basic conduct of virtually all other aspects of the aortic valve replacement procedure remains the same. Therefore, similar long-term outcomes are to be expected. Objectives To conduct a meta-analysis of the only available randomised controlled trials (RCT) in the published English literature. Data sources Electronic search for relevant publications in MEDLINE, EMBASE and CENTRAL databases were performed. Four studies met the criteria. Study eligibility criteria RCT comparing minimally invasive (inverted C or L (J)-shaped) hemi-sternotomy versus conventional sternotomy for adults undergoing isolated aortic valve replacement using standard cardiopulmonary bypass technique. Methods Outcome measures were the length of positive pressure ventilation, blood loss, intensive care unit (ICU) and hospital stay. Results The length of ICU stay was significantly shorter by 0.57 days in favour of the mini-sternotomy group (CI -0.95 to -0.2; p=0.003). There was no advantage in terms of duration of ventilation (CI -3.48 to 0.36; p=0.11). However, there was some evidence to suggest a reduction in blood loss and the length of stay in hospital in the mini-sternotomy group. This did not prove to be statistically significant (154.17 ml reduction (CI -324.51 to 16.17; p=0.08) and 2.03 days less (CI -4.12 to 0.05; p=0.06), respectively). Limitations This study includes a relatively small number of subjects (n=220) and outcome variables. The risk of bias was not assessed during this meta-analysis. Conclusion Mini-sternotomy for isolated aortic valve replacement significantly reduces the length of stay in the cardiac ICU. Other short-term benefits may include a reduction in blood loss or the length of hospital stay.
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Affiliation(s)
- E Khoshbin
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital and Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, Scotland, UK
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Ramlawi B, Ramchandani M, Reardon MJ. Surgical Approaches to Aortic Valve Replacement and Repair-Insights and Challenges. Interv Cardiol 2011; 9:32-36. [PMID: 29588775 DOI: 10.15420/icr.2011.9.1.32] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Since 1960, surgical aortic valve replacement (sAVR) had been the only effective treatment for symptomatic severe aortic stenosis until the recent development of transcatheter aortic valve replacement (TAVR). TAVR has offered an alternative, minimally invasive treatment approach particularly for patients whose age or co-morbidities make them unsuitable for sAVR. The rapid and enthusiastic utilization of this new technique has triggered some speculation about the imminent demise of sAVR. We believe that despite the recent advances in TAVR, surgical approach to aortic valve replacement has continued to develop and will continue to be highly relevant in the future. This article will discuss the recent developments and current approaches for sAVR, and how these approaches will keep pace with catheter-based technologies.
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Affiliation(s)
- Basel Ramlawi
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Mahesh Ramchandani
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Michael J Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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Raja SG, Navaratnarajah M. Impact of Minimal Access Valve Surgery on Clinical Outcomes: Current Best Available Evidence. J Card Surg 2009; 24:73-9. [DOI: 10.1111/j.1540-8191.2008.00744.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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