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Minimally invasive aortic valve replacement through a transverse sternotomy: a word of caution
B Bridgewater1, R S Steyn, S Ray
1Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK.
Objectives:
To compare aortic valve replacement (AVR) using a minimally invasive approach through a transverse sternotomy with the established approach of median sternotomy.
Design:
Retrospective, case-control study.
Patients:
Fourteen high risk patients (median age 78, Parsonnet score of 18%) who underwent AVR performed through a minimally invasive transverse sternotomy were compared with a historical group of patients matched for age, sex, and Parsonnet score who underwent AVR performed through a median sternotomy by the same surgeon.
Outcome Measures:
Cross clamp time, total bypass time, intensive care stay, postoperative in-hospital stay, morbidity, and mortality.
Results:
There were two deaths in the minimally invasive group and none in the control group (NS). The cross clamp and total bypass times were longer in the minimally invasive group (67 and 92 minutes v 46 and 66 minutes, p < 0.001). There was a higher incidence of re-exploration for bleeding (14% v 0%) and paravalvar leaks (21% v 0%) in the minimally invasive group but these differences were not significant. The minimally invasive group had a longer postoperative in-hospital stay (p = 0.025). The incidence of mortality or major morbidity was 43% (six of 14) in the minimally invasive group and 7% (one of 14) in the matched pairs (p = 0.013).
Conclusions:
AVR can be performed through a transverse sternotomy but the operation takes longer and there is an unacceptably high incidence of morbidity and mortality.
Insights
Minimally invasive aortic valve replacement (AVR) via transverse sternotomy is longer and has higher morbidity and mortality than median sternotomy. This approach is not recommended due to unacceptable patient outcomes.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Minimally Invasive Procedures
Background:
- Aortic valve replacement (AVR) is a critical procedure for managing aortic valve disease.
- Median sternotomy is the traditional surgical approach for AVR.
- Minimally invasive techniques are increasingly explored to improve surgical outcomes.
Purpose of the Study:
- To compare the outcomes of AVR performed via minimally invasive transverse sternotomy versus the conventional median sternotomy.
- To evaluate differences in operative times, recovery, morbidity, and mortality between the two approaches.
Main Methods:
- Retrospective, case-control study comparing 14 high-risk patients undergoing AVR via transverse sternotomy with matched historical controls.
- Matched on age, sex, and Parsonnet score.
- Outcome measures included cross-clamp time, bypass time, ICU stay, hospital stay, morbidity, and mortality.
Main Results:
- The minimally invasive group experienced longer cross-clamp (67 vs. 46 min) and bypass times (92 vs. 66 min).
- Higher rates of re-exploration for bleeding (14% vs. 0%) and paravalvular leaks (21% vs. 0%) were observed in the minimally invasive group.
- Mortality or major morbidity was significantly higher in the minimally invasive group (43% vs. 7%, p=0.013).
Conclusions:
- AVR through a transverse sternotomy is technically feasible but associated with prolonged operative times.
- The minimally invasive transverse sternotomy approach resulted in an unacceptably high incidence of morbidity and mortality.
- Current evidence suggests median sternotomy remains the preferred approach for AVR in high-risk patients.