1
|
El-Andari R, Fialka NM, Shan S, White A, Manikala VK, Wang S. Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis. Cardiol Rev 2024; 32:217-242. [PMID: 36728720 DOI: 10.1097/crd.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In recent years, minimally invasive cardiac surgery has increased in prevalence. There has been significant debate regarding the optimal approach to isolated aortic valve replacement between conventional midline sternotomy and minimally invasive approaches. We performed a systematic review of the contemporary literature comparing minimally invasive to full sternotomy aortic valve replacement. PubMed and Embase were systematically searched for articles published from 2010-2021. A total of 1215 studies were screened and 45 studies (148,606 patients total) met the inclusion criteria. This study found rates of in-hospital mortality were higher with full sternotomy than ministernotomy ( P = 0.02). 30-day mortality was higher with full sternotomy compared to right anterior thoracotomy ( P = 0.006). Renal complications were more common with full sternotomy versus ministernotomy ( P < 0.00001) and right anterior thoracotomy ( P < 0.0001). Rates of wound infections were greater with full sternotomy than ministernotomy ( P = 0.02) and right anterior thoracotomy ( P < 0.00001). Intensive care unit length of stay ( P = 0.0001) and hospital length of stay ( P < 0.0001) were shorter with ministernotomy compared to full sternotomy. This review found that minimally invasive approaches to isolated aortic valve replacement result in reduced early mortality and select measures of postoperative morbidity; however, long-term mortality is not significantly different based on surgical approach. An analysis of mortality alone is not sufficient for the selection of the optimal approach to isolated aortic valve replacement. Surgeon experience, individual patient characteristics, and preference require thorough consideration, and additional studies investigating quality of life measures will be imperative in identifying the optimal approach to isolated aortic valve replacement.
Collapse
Affiliation(s)
- Ryaan El-Andari
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shubham Shan
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Abigail White
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Vinod K Manikala
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Shaohua Wang
- From the Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
2
|
Hlavicka J, Gettwart L, Landgraf J, Salem R, Hecker F, Salihi E, Van Linden A, Walther T, Holubec T. Minimally Invasive and Full Sternotomy Aortic Valve Replacements Lead to Comparable Long-Term Outcomes in Elderly Higher-Risk Patients: A Propensity-Matched Comparison. J Cardiovasc Dev Dis 2024; 11:112. [PMID: 38667730 PMCID: PMC11050264 DOI: 10.3390/jcdd11040112] [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: 01/21/2024] [Revised: 03/22/2024] [Accepted: 03/30/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Minimally invasive aortic valve replacement (AVR) via upper ministernotomy (MiniAVR) is a standard alternative to full sternotomy access. Minimally invasive cardiac surgery has been proven to provide a number of benefits to patients. The aim of this study was to compare the short- and long-term outcomes after MiniAVR versus conventional AVR via full sternotomy (FS) using a biological prosthesis in an elderly higher-risk population. METHODS Between January 2006 and July 2009, 918 consecutive patients received AVR ± additional procedures with different prostheses at our center. Amongst them, 441 received isolated AVR using a biological prosthesis (median age of 74.5; range: 52-93 years; 50% females) and formed the study population (EuroSCORE II: 3.62 ± 5.5, range: 0.7-42). In total, 137 (31.1%) of the operations were carried out through FS, and 304 (68.9%) were carried out via MiniAVR. Follow-up was complete in 96% of the cases (median of 7.6 years, 6610 patient-years). Propensity score matching (PSM) resulted in two groups of 68 patients with very similar baseline profiles. The primary endpoints were long-term survival, freedom from reoperation, and endocarditis, and the secondary endpoints were early major adverse cardiac and cerebrovascular events (MACCEs). RESULTS FS led to shorter cardio-pulmonary bypass and aortic cross-clamp durations: 90 (47-194) vs. 100 (46-246) min (p = 0.039) and 57 (33-156) vs. 69 (32-118) min (p = 0.006), respectively. Perioperative stroke occurred in three patients (4.4%; FS) vs. one patient (1.5%; MiniAVR) (p = 0.506). The 30-day mortality was similar in both groups (2.9%, p = 1.000). Survival at 1, 5, and 10 years was 94.1 ± 3% (FS and MiniAVR), 80.3 ± 5% vs. 75.7 ± 5%, and 45.3 ± 6% vs. 43.8 ± 6%, respectively (p = 0.767). There were two (2.9%) reoperations in each group and two thrombo-embolic events (2.9%) vs. one (1.5%) thrombo-embolic event in the MiniAVR and FS groups, respectively (p = 0.596). CONCLUSIONS In comparison to FS, MiniAVR provided similar short- and long-term outcomes in a higher-risk elderly population receiving biological prostheses. In particular, long-term survival, freedom from reoperation, and the incidence of endocarditis were comparable. These results clearly advocate for the routine use of MiniAVR as a standard procedure for AVR, even in a high-risk population.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60596 Frankfurt/Main, Germany; (J.H.); (L.G.); (J.L.); (R.S.); (F.H.); (E.S.); (A.V.L.); (T.W.)
| |
Collapse
|
3
|
Bociański M, Puślecki M, Olasińska-Wiśniewska A, Perek B, Stefaniak S, Buczkowski P, Jemielity M. A comparative study of minimally invasive aortic valve replacement with sutureless biological versus mechanical prostheses. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2023; 20:77-82. [PMID: 37564970 PMCID: PMC10410630 DOI: 10.5114/kitp.2023.129542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/25/2023] [Indexed: 08/12/2023]
Abstract
Introduction The ministernotomy approach with sutureless aortic bioprosthesis may provide an attractive and safe option for aortic valve disease patients. Aim To assess the early and mid-term outcomes of minimally invasive aortic valve replacement (miniAVR) with sutureless vs. standard prostheses. Material and methods The study involved 76 consecutive patients (51 males and 25 females) with mean age of 63.2 years who were treated with miniAVR between 2015 and 2022. They were divided into 2 subgroups: group I (n = 40) subjects with sutureless bioprostheses and group II (n = 36) with standard prostheses implanted. Early and mid-term outcomes were evaluated. A probability of survival was estimated by means of the Kaplan-Meier method. Results No conversion to complete sternotomy was necessary. The median (minimum; maximum) aorta cross clamping and cardio-pulmonary bypass times were 49 (27; 84) and 70 (40; 188) minutes in group I whereas 69 (50; 103) and 95 (69; 170) minutes in group II, respectively (p < 0.001). In-hospital mortality was 5.0% (n = 2) and 2.8% (n = 1) in group I vs. II, respectively (ns). Permanent ICD implantation was performed in 8 (20.0%) in group I and in 3 (8.3%) subjects in group II. In the discharge echocardiography, the function of all prostheses was correct. Five-year probability of survival was much lower in group I (0.75 ±0.10) than in group II (0.94 ±0.04). No wound infection or sternum instability was noted. Conclusions Intraoperative advantages of miniAVR procedures for aortic valve patients with sutureless bioprostheses do not translate directly into improved early and middle-term outcomes.
Collapse
Affiliation(s)
- Michał Bociański
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puślecki
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
- Department of Medical Rescue, Chair of Rescue Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Olasińska-Wiśniewska
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| |
Collapse
|
4
|
Oo S, Khan A, Chan J, Juneja S, Caputo M, Angelini G, Rajakaruna C, Vohra HA. Propensity matched analysis of minimally invasive versus conventional isolated aortic valve replacement. Perfusion 2023; 38:261-269. [PMID: 34515578 PMCID: PMC9932618 DOI: 10.1177/02676591211045802] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyse the early and mid-term outcome of patients undergoing conventional aortic valve replacement (AVR) versus minimally invasive via hemi-sternotomy aortic valve replacement (MIAVR). METHODS A single centre retrospective study involving 653 patients who underwent isolated aortic valve replacement (AVR) either via conventional AVR (n = 516) or MIAVR (n = 137) between August 2015 and March 2020. Using pre-operative characteristics, patients were propensity matched (PM) to produce 114 matched pairs. Assessment of peri-operative outcomes, early and mid-term survival and echocardiographic parameters was performed. RESULTS The mean age of the PM conventional AVR group was 71.5 (±8.9) years and the number of male (n = 57) and female (n = 57) patients were equal. PM MIAVR group mean age was 71.1 (±9.5) years, and 47% of patients were female (n = 54) and 53% male (n = 60). Median follow-up for PM conventional AVR and MIAVR patients was 3.4 years (minimum 0, maximum 4.8 years) and 3.4 years (minimum 0, maximum 4.8 years), respectively. Larger sized aortic valve prostheses were inserted in the MIAVR group (median 23, IQR = 4) versus conventional AVR group (median 21, IQR = 2; p = 0.02, SMD = 0.34). Cardiopulmonary bypass (CPB) time was longer with MIAVR (94.4 ± 19.5 minutes) compared to conventional AVR (83.1 ± 33.3; p = 0.0001, SMD = 0.41). Aortic cross-clamp (AoX) time was also longer in MIAVR (71.6 ± 16.5 minutes) compared to conventional AVR (65.0 ± 52.8; p = 0.0001, SMD = 0.17). There were no differences in the early post-operative complications and mortality between the two groups. Follow-up echocardiographic data showed significant difference in mean aortic valve gradients between conventional AVR and MIAVR groups (17.3 ± 8.2 mmHg vs 13.0 ± 5.1 mmHg, respectively; p = 0.01, SMD = -0.65). There was no significant difference between conventional AVR and MIAVR in mid-term survival at 3 years (88.6% vs 92.1%; log-rank test p = 0.31). CONCLUSION Despite the longer CPB and AoX times in the MIAVR group, there was no significant difference in early complications, mortality and mid-term survival between MIAVR and conventional AVR.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Hunaid A Vohra
- Hunaid A Vohra, Department of
Cardiovascular Sciences, Bristol Heart Institute, University of Bristol, Upper
Maudlin Street, Bristol BS2 8HW, UK. Emails:
;
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Thet MS, Kyaw Tun J, Oo AY, Lopez-Marco A. Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion. BMJ Case Rep 2022; 15:e247809. [PMID: 35459649 PMCID: PMC9036171 DOI: 10.1136/bcr-2021-247809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 60s was referred for urgent coronary artery bypass grafting (CABG) procedure following acute coronary syndrome. After induction of general anaesthesia, right jugular venous catheterisation under two-dimensional ultrasound guidance was planned as part of perioperative management. While obtaining vascular access, the pulsatile flow was noted once the dilator was inserted, having to abandon the procedure and immediately apply manual pressure. CT angiogram showed proximal right subclavian artery injury with active contrast extravasation and resultant large haematoma in the neck. The patient underwent urgent exploration of the injured vessel through a J-shaped ministernotomy, and primary repair of the artery was performed. The patient recovered from the procedure without any complications. He continued to stay in the hospital for a few days, afterwards, he underwent the initially planned CABG surgery. He was discharged home on day 5 after surgery without further concerns.
Collapse
Affiliation(s)
- Myat Soe Thet
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Jimmy Kyaw Tun
- Department of Interventional Radiology, The Royal London Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Ana Lopez-Marco
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| |
Collapse
|
7
|
Woldendorp K, Doyle MP, Bannon PG, Misfeld M, Yan TD, Santarpino G, Berretta P, Di Eusanio M, Meuris B, Cerillo AG, Stefàno P, Marchionni N, Olive JK, Nguyen TC, Solinas M, Bianchi G. Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis. Ann Cardiothorac Surg 2020; 9:347-363. [PMID: 33102174 DOI: 10.21037/acs-2020-surd-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. Methods Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. Results Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. Conclusions Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.
Collapse
Affiliation(s)
- Kei Woldendorp
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mathew P Doyle
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Misfeld
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Tristan D Yan
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Adventist Hospital, Sydney, Australia
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.,Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany.,Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Pierluigi Stefàno
- Unit of Cardiac Surgery, Careggi University Hospital, Florence, Italy.,University of Florence School of Medicine, Florence, Italy
| | - Niccolò Marchionni
- University of Florence School of Medicine, Florence, Italy.,Unit of Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Heart and Vascular Institute, Houston, Texas, USA
| | - Marco Solinas
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| |
Collapse
|