Quality of life, satisfaction and outcomes after ministernotomy versus full sternotomy isolated aortic valve replacement (QUALITY-AVR): study protocol for a randomised controlled trial

Measurement of health-related quality of life post aortic valve replacement via minimally invasive incisions

Background

Minimally invasive aortic surgery is growing in popularity among surgeons. Although many clinical reports have proven both the safety and efficacy from a surgical point of view, there are few data regarding its impact on patients’ quality of life and whether there is a difference between ministernotomy and minithoracotomy from the patient perspective.

Methods

This prospective, questionnaire-based, nonrandomized study included 189 patients who underwent aortic valve replacement via a minimally invasive incision between May 2014 and December 2020 and completed at least 1 year of follow-up. The study uses the RAND SF 36-Item Health Survey 1.0 to assess and compare health-related quality of life between ministernotomy and minithoracotomy.

Results

There was a statistically significant improvement in the minithoracotomy group with regard to physical functioning, role limitation due to a physical problem, and social functioning (79.69 ± 20.72, 75.28 ± 26.52, 87.91 ± 16.98) compared to the ministernotomy group (70.31 ± 22.88, 58.59 ± 31.17, 66.15 ± 27.32) with p values (0.0036, 0.0001, < 0.0001), respectively.

Conclusions

Both minimally invasive aortic valve incisions positively impacted patient quality of life. The minithoracotomy incision showed significant improvements in physical capacity and successful patient re-engagement in daily physical and social activities. This, in turn, positively improved their general health status compared to the 1-year preoperative status.

Trial registration: This study was approved by the Research Ethics Committee (REC) at the Faculty of Medicine, Ain Shams University, under the number code (FWA 000017585, FAMSU R 91 /2021).

Surgical outcomes associated with partial upper sternotomy in obese aortic disease patients

Background

Excellent partial upper sternotomy outcomes have been reported for patients undergoing aortic surgery, but whether this approach is particularly beneficial to obese patients remains to be established. This study was developed to explore the outcomes of aortic surgical procedures conducted via a partial upper sternotomy or a full median sternotomy approach in obese patients.

Methods

We retrospectively examined consecutive acute type A aortic dissection patients who underwent aortic surgery in our hospital between January 2015 to January 2021. Patients were divided into two groups based on body mass index: ‘non-obese’ and ‘obese’. We then further stratified patients in the obese and non-obese groups into partial upper sternotomy and full median sternotomy groups, with outcomes between these two sternotomy groups then being compared within and between these two body mass index groups.

Results

In total, records for 493 patients that had undergone aortic surgery were retrospectively reviewed, leading to the identification of 158 consecutive obese patients and 335 non-obese patients. Overall, 88 and 70 obese patients underwent full median sternotomy and partial upper sternotomy, respectively, while 180 and 155 non-obese patients underwent these respective procedures. There were no differences between the full median sternotomy and partial upper sternotomy groups within either BMI cohort with respect to preoperative baseline indicators and postoperative complications. Among non-obese individuals, the partial upper sternotomy approach was associated with reduced ventilation time (P = 0.003), shorter intensive care unit stay (P = 0.017), shorter duration of hospitalization (P = 0.001), and decreased transfusion requirements (Packed red blood cells: P < 0.001; Fresh frozen plasma: P < 0.001). Comparable findings were also evident among obese patients.

Conclusions

Obese aortic disease patients exhibited beneficial outcomes similar to those achieved for non-obese patients via a partial upper sternotomy approach which was associated with significant reductions in the duration of intensive care unit residency, duration of hospitalization, ventilator use, and transfusion requirements. This surgical approach should thus be offered to aortic disease patients irrespective of their body mass index.

Limited upper mini-sternotomy approach for closed heart surgery in the newborns and infants

BACKGROUND

The mini-sternotomy has become a common approach of choice for a wide range of congenital defects requiring minimally invasive surgery. Here, we aimed to present closed heart surgery results via limited upper mini-sternotomy in the newborn and infants.

METHODS

A total of 46 infants who underwent pulmonary artery banding, patent ductus arteriosus ligation, and aortopexy via limited upper mini-sternotomy between December 2017 and October 2020 were enrolled. Patients included 26 males and 20 females with ages ranging from 2 days to 12 months (median age 3.25 ± 0.9 months). The weight ranged from 0.7 kg to 8 kg (median weight 3.6 ± 1.8 kg). These patients were evaluated retrospectively in terms of clinical, preoperative, intraoperative, and postoperative parameters.

RESULTS

Closed heart surgery procedures were corrected successfully without adverse events intraoperatively. The median operation time was 32 min (32 ± 7 min). The limited upper mini-sternotomy was performed on 46 patients, including the pulmonary banding (18 patients), PDA ligation (16 patients), and aortopexy (12 patients). No patients required conversion to full sternotomy or to extend the incision. Re-intervention to adjust the tightness of the band was required in 1 patient. There were 4 cases of mortality (8.6%). All four death cases had comorbidity and low birth weight (2500 g or less).

CONCLUSION

Limited upper mini-sternotomy is a technically feasible, safe, and effective approach that providing an adequately surgical view in closed heart surgery to reduce the invasiveness of the closed heart surgical repair via median sternotomy or thoracotomy approach.

Bedside surgical ligation of the patent ductus arteriosus in very-low-birth-weight premature infants: Limited upper ministernotomy as an alternative approach

BACKGROUND

Patent ductus arteriosus (PDA) is an important cause of morbidity and mortality, especially in very-low-birth-weight infants. The aim of the present study was to evaluate the outcomes of bedside surgical ligation of PDA via limited upper ministernotomy as an alternative approach to thoracotomy.

MATERIALS AND METHODS

A total of 23 low-birth-weight premature infants, who underwent bedside ligation of PDA in the neonatal intensive care unit between January 2017 and April 2020, were enrolled. The patients were divided into two groups: those with thoracotomy (n = 13) and those with limited upper ministernotomy (n = 10). These patients were evaluated retrospectively in terms of clinical and preoperative, intraoperative, postoperative parameters between the groups.

RESULTS

Mean birth weight was 1059 ± 275 g in the thoracotomy group and 1035 ± 285 g in the ministernotomy group. There was no statistically significant difference in the age at surgery, weight at surgery, preoperative mechanical ventilation (MV) support, inotropic score onset of surgery, and total procedure time between the groups. There was a statistically significant difference in the hospital length of stay, postoperative MV time, and complications in the intensive care unit in favor of the ministernotomy group (p = .04, p = .03, p = .034, respectively). The study showed no statistically significant difference in the mortality rate between the two groups (two patients in the thoracotomy group and one patient in the ministernotomy group).

CONCLUSION

The limited upper ministernotomy is an anatomically and technically feasible alternative to classical left posterolateral thoracotomy for bedside surgical PDA ligation.

The Effect of Minimally Invasive Surgery and Sternotomy on Physical Activity and Quality of Life

AIM

The aim of this study was to compare minimally invasive surgery (MI) and median sternotomy (MS) in terms of post-procedure health-related quality of life (HRQoL) and functional outcome.

METHOD

We conducted a multicentre prospective cohort study that enrolled patients from January 2015 until February 2017. Combined cardiac procedures were performed with MS and isolated valve procedures with either MS or MI, depending on patient preference and surgeon experience. HRQoL was measured using the five-level version of the EQ-5D (EQ-5D-5L) and physical activity before and after surgery was evaluated using a wearable accelerometer. Activity patterns and intensity recorded by the accelerometer in each period were classified as "sedentary", "light physical activity", "moderate physical activity", and "vigorous physical activity" for each patient. We also conducted a sub-analysis of frail patients in each group, as identified by the Reported Edmonton Frail Scale (>10 points). Patients were followed for 1 year.

RESULTS

The study included 100 consecutive patients who underwent MI (n=50) or MS (n=50) during the study period. Patients in the MI group showed a faster recovery of physical activity in the immediate postoperative period and superior HRQoL in the first 3 months (both p<0.001) versus the MS group. Differences between the MI and MS group were indistinguishable over a longer follow-up. A similar correlation was observed in the frailty subanalysis. Overall, the MS group had a higher cumulative incidence of events than the MI group (p<0.001).

CONCLUSIONS

Compared to conventional MS, MI was associated with better HRQoL and early functional outcome, even in frail patients.

Quality of Life After Ministernotomy Versus Full Sternotomy Aortic Valve Replacement

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.