Limited versus full sternotomy for aortic valve replacement

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.

Limited versus full sternotomy for aortic valve replacement

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.

Warfarin-induced skin necrosis and heparin-induced thrombocytopenia following mitral valve replacement for marantic endocarditis

Hemostatic physiology involves a complex interlinking of blood and endothelial factors. Its pharmacological manipulation invariably impacts at multiple molecular sites. Herein is reported an unusual case of coexistent warfarin-induced skin necrosis and heparin-induced thrombocytopenia following mitral valve replacement for thromboembolic phenomena associated with marantic endocarditis and bronchial adenocarcinoma. Thrombophilia in the face of endocarditis should be treated with a suspicion of underlying cancer.

Childhood asthma predisposes to spontaneous pneumomediastinum

Spontaneous pneumomediastinum is a rare condition for which potentially life threatening differential diagnoses must be excluded. A case is presented of a young man with a history of severe childhood asthma, who was successfully treated conservatively.

A case-control analysis of readmissions to the cardiac surgical intensive care unit

OBJECTIVE

To identify predictors of requirement for readmission to the intensive care unit (ICU) for patients undergoing cardiac surgery.

METHODS

The setting was a 17-bedded ICU in a tertiary level institute for specialist adult cardiorespiratory disease. The case notes and ICU charts of 65 ICU readmissions and 65 controls, matched for day of initial ICU discharge, were analysed. Patient variables assessed included preoperative risk stratification, ICU admission APACHE III score and intensive therapy interventions, complications and indication for readmission if readmitted.

RESULTS

Twenty of 65 patients (31%) readmitted to the cardiac ICU died, compared with no mortality among the control group. Significant univariate determinants of ICU readmission (odds ratio, 95% confidence interval) included worse angina (1.38, 0.99-1.91) and dyspnoea (1.70, 1.10-2.61) classes and corresponding non-elective surgery (2.04, 1.31-3.19), higher Parsonnet score (1.06, 1.01-1.11) or EuroSCORE (1.14, 1.01-1.28), APACHE III score (1.03, 1.00-1.05), body mass index>27 (4.25, 1.43-12.63), non-usage of beta-blockers (1.53, 1.03-2.26), emergency resternotomy (5.00, 1.10-22.79), and lower haemoglobin (0.75, 0.58-0.96), higher required inspiratory oxygen (1.05, 1.02-1.08), and higher respiratory rate upon ICU discharge (1.09, 1.01-1.18). Renal failure, respiratory failure and cardiac arrest were the most common indications for ICU readmission. Thirty-five of 65 patients readmitted to the ICU required ventilation for a mean of 7.1 days. The mean ICU readmission duration for all 65 cases was 5.7 days.

CONCLUSIONS

Readmission of cardiac surgical patients to the ICU is associated with high morbidity and mortality, and substantial resource consumption. Parsonnet or EuroSCORE risk stratification models in combination with obesity, operative urgency, resternotomy and respiratory indices at time of intended ICU discharge are strongly associated with readmission to ICU.

Aorto-atrial fistula after operated type A dissection

The development of a fistula between the aorta and right atrium is a rare complication of ascending aortic dissection and has a high mortality if not diagnosed and surgically treated. Clinical diagnosis is best supported by specialised imaging. In addition it may present technically very challenging problems. We report the first case which follows aortic root replacement for an acute type A dissection. Aorto-right atrial fistula (AoRAF) rarely complicates ascending aortic dissection. We report the first case to follow corrective surgery for aortic dissection.

Videothoracoscopic drainage of mediastinal abscess: an alternative to thoracotomy

A late-presenting high esophageal perforation that resulted in a massive mediastinal abscess and bronchopleural fistula in an elderly moribund patient unfit for radical surgery was successfully drained using a videothoracoscopic technique.

Thymic carcinoma--analysis of nineteen clinicopathological studies

BACKGROUND

Primary thymic carcinomas are rare tumours with nonuniform management protocols and poor prognosis due to delayed diagnosis and highly malignant behaviour. This review summarises the major clinicopathological studies to assess more fully the prognostic importance of tumour histology and staging as well as treatment benefit.

METHODS

A Medline search from 1966 to date was carried out and relevant references gleaned from these. Nineteen clinicopathological studies form the core of this review. Demographic data and clinical features were examined in all studies. Correlation of outcome with histology was possible in fifteen of the studies and with tumour staging in thirteen.

RESULTS

Thymic carcinomas occur most commonly in the fifth to sixth decades of life, usually presenting with symptoms of space occupation or invasion. Paraneoplastic syndromes are rarely associated, except with the well differentiated thymic carcinoma. Of 140 thymic carcinomas, 40 were squamous cell, 19 were spindle cell and 16 were lymphoepithelioma-like. Completely resected stage I and II tumours demonstrated the best survival.

CONCLUSIONS

Complete surgical resection is taken to be the desired treatment, but the continued high mortality and relapse rates and the variable benefit of adjuvant therapies challenge this strategy.

Relocation of the internal mammary artery graft in a case of coronary-subclavian steal

Reverse flow in the internal mammary artery coronary graft in the presence of subclavian stenosis is rare. We describe a 67-year-old man who 7 years after coronary artery surgery was admitted with left subclavian artery stenosis and retrograde flow in the pedicled left internal mammary artery graft. Subsequent redo triple coronary artery bypass grafts included regrafting the left internal mammary artery graft to a new vein conduit.

G(i) activator region of alpha(2A)-adrenergic receptors: distinct basic residues mediate G(i) versus G(s) activation

The structural determinants of G protein coupling versus activation by G protein-coupled receptors are not well understood. We examine the role of two distinct basic regions in the carboxyl terminal portion of the third intracellular loop of the alpha(2A)-adrenergic receptor to dissect these aspects of function. Changing three arginines to alanines by mutagenesis and stable expression in Chinese hamster ovary-K1 cells impaired the alpha(2)-adrenergic receptor G(s)-mediated stimulation of cyclic AMP (cAMP) accumulation, whereas G(i)-mediated inhibition was normal. When two (B2) or three (B3) basic residues closer to transmembrane span 6 were mutated to alanine, normal ligand binding was observed, but G(i)-mediated inhibition of cAMP accumulation showed 20-fold and 50-fold decreases in agonist potency for the B2 and B3 mutants, respectively. Surprisingly, a normal G(s) response was seen for the B2 mutant, and the B3 mutant showed only a 6-fold decrease in agonist potency. Mutation of both the three alanines and B3 residues to alanines showed a 200-fold decrease in agonist potency for G(i)-mediated inhibition of cAMP accumulation, whereas the G(s) response was nearly completely eliminated. The three basic residues (which include the BB of the BBXXF motif) play a role as G(i) activators rather than in receptor-G protein coupling, because high-affinity agonist binding is intact. Thus, we have identified three basic residues required for activation of G(i) but not required for receptor-G protein coupling. Also, distinct basic residues are required for optimal G(i) and G(s) responses, defining a microspecificity determinant within the carboxyl terminal portion of the third intracellular loop of the alpha(2a) adrenergic receptor.

Delayed presentation of foreign body reaction secondary to retained pacing wires

Temporary pacing wires are often left behind, assumed not to cause problems. We present 2 cases of delayed presentation of anterior mediastinal foreign body reaction secondary to retained pacing wires after coronary operations performed more than 5 years previously.

Two closely related kappa variable region pseudogenes pose an evolutionary paradox

Two pseudogenes belonging to the Igk-V1 variable region group have been isolated from BALB/c mice. The genes share greater than 96.5% identity of nucleotide sequence in a 1800 base pair (bp) region surrounding the coding region, but deletions of 221 bp and 84 bp have removed essential sequences from the two genes. As the deletions are different in the two pseudogenes, they must have occurred independently in each gene during or subsequent to the duplication event which gave rise to the genes from a common ancestral gene. Polymerase chain reaction analysis was used to identify the pseudogenes in inbred strains of mice. BALB/c (Igkc) and AKR (Igka), prototype strains representative of the predominant kappa haplotypes, possess both pseudogenes but no intact copy. Only one of the pseudogenes was present in SJL (Igka). Strains C58, c.C58 (Igkd) and NZB (Igkb) possessed an intact version of the gene. This distribution of haplotypes is consistent with a close linkage of the pseudogenes with other Igk-V1 genes on chromosome 6. The translated amino acid sequence of the pseudogenes indicates that prior to their acquiring deletions they encoded typical Igk-V1 variable regions except for an unusual FR2 region, in which the conserved proline at position 44 is replaced by leucine and the normally hydrophobic position 36 was occupied by histidine. Possible mechanisms to explain the occurrence of deletions in both of the pseudogenes in the recent evolution of BALB/c are discussed. One explanation would be that the two genes were already nonfunctional at the time of the duplication so that the subsequent deletions represent neutral events which became fixed in the inbred strains by a process of genetic drift. Alternatively, if the genes were functional at the time of duplication, their rapid loss due to deletion events suggests that negative selection may have acted to eliminate the genes from the V-region repertoire.