Trans-right axillary aortic valve replacement: propensity-matched comparison with standard sternotomy approach

We developed trans-right axillary aortic valve replacement (TAX-AVR) as a more cosmetically superior approach to minimally invasive AVR. We herein retrospectively compared the safety and invasiveness between TAX-AVR and conventional AVR (C-AVR).

TAX-AVR was performed under femorofemoral cardiopulmonary bypass. Creation of a small right axillary vertical skin incision was followed by anterolateral intercostal thoracotomy. AVR was performed using long-shafted minimally invasive instruments, a knot pusher and endoscopic assistance. From January 2007 to June 2016, 112 patients underwent TAX-AVR and 183 controls underwent first-time, isolated non-emergency C-AVR. The factors used to calculate the European System for Cardiac Operative Risk Evaluation score and Society of Thoracic Surgeons score were adopted for propensity matching. Early mortality and major adverse cardiac and cerebral events were compared. The procedural time, postoperative intensive care unit stay and hospital stay were compared as markers of invasiveness.

Propensity matching generated 108 matched pairs with similar backgrounds. Thirty-day mortality occurred in 0 and 1 patient in the TAX-AVR and C-AVR groups, respectively. The major adverse cardiac and cerebral events rates were not significantly different between the groups. The average aortic clamp time was longer (100 vs 94 min), but the intensive care unit stay (1.2 vs 1.8 days) and hospital stay (10.0 vs 12.5 days) were shorter in the TAX-AVR group. Postoperative blood loss, transfusion and atrial fibrillation were lower in the TAX-AVR group. The average prosthesis size was 22 mm in both groups.

TAX-AVR is as safe as C-AVR and less invasive in terms of a shorter recovery period.