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Updated: Jun 18, 2025
Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Impact of Pleural Integrity Preservation After Minimally Invasive Aortic Valve Surgery
Beatrice Bacchi1, Francesco Cabrucci1, Bruno Chiarello1
1Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University of Florence, Italy.
Objective:
While the benefits of minimally invasive aortic valve surgery compared with standard sternotomy have been widely described, the impact of preservation of pleural integrity (PPI) in minimally invasive surgery is still widely discussed. This study aims to define the role of PPI on postoperative and long-term outcomes after minimally invasive aortic valve replacement (MIAVR).
Methods:
All 2,430 consecutive patients undergoing MIAVR (ministernotomy or right anterior minithoracotomy) between 1997 and 2022 were included in the study. Patients were divided into 2 groups: patients with and without PPI. PPI was considered the maintenance of the pleura closed without the need for a chest tube insertion at the end of the surgical procedure. A propensity-matched analysis was used to compare the PPI and not-PPI groups.
Results:
After propensity matching, 848 patients were included in each group (PPI and not-PPI). The mean age was 70.21 versus 71.42 years, and the mean Society of Thoracic Surgeons predicted risk of mortality was 0.31% versus 0.30% in not-PPI versus PPI, respectively. The mean follow-up time was 147.4 months. Postoperatively, not-PPI versus PPI patients had a longer intensive care unit stay (9.7 vs 17.3 h, P < 0.001) and hospital length of stay (5.2 vs 8.9 days, P < 0.001). The rate of respiratory complications including the incidence of pneumothorax or subcutaneous emphysema, pulmonary atelectasis, and pleural effusion events requiring thoracentesis/drainage was significantly higher in not-PPI versus PPI. The 30-day all-cause mortality was higher in not-PPI versus PPI (0.029 vs 0.010, P = 0.003). Perioperative, short-term, and long-term all-cause mortality was significantly higher in the not-PPI group.
Conclusions:
PPI after MIAVR is associated with reduced incidence of postoperative complications, reduced lengths of stay, and improved overall survival compared with not-PPI. Therefore, a MIAVR tailored patient-procedure approach to maintaining the pleura integrity positively impacts short-term and long-term outcomes.
Insights
Preserving pleural integrity (PPI) during minimally invasive aortic valve replacement (MIAVR) reduces complications and hospital stays. This approach improves both short-term and long-term survival rates for patients undergoing MIAVR.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Minimally Invasive Procedures
Background:
- Minimally invasive aortic valve replacement (MIAVR) offers benefits over traditional sternotomy.
- The impact of preserving pleural integrity (PPI) during MIAVR remains debated.
- This study investigates the role of PPI in MIAVR outcomes.
Purpose of the Study:
- To define the role of pleural integrity preservation (PPI) on postoperative and long-term outcomes after minimally invasive aortic valve replacement (MIAVR).
Main Methods:
- Included 2,430 patients undergoing MIAVR (1997-2022).
- Compared patients with and without PPI (defined as no chest tube insertion).
- Utilized propensity-matched analysis for 848 patients in each group.
Main Results:
- Patients without PPI had longer ICU and hospital stays (17.3h vs 9.7h and 8.9 days vs 5.2 days, respectively).
- Respiratory complications (pneumothorax, atelectasis, pleural effusion) were significantly higher in the not-PPI group.
- The not-PPI group showed higher 30-day, perioperative, short-term, and long-term all-cause mortality.
Conclusions:
- Preserving pleural integrity (PPI) in MIAVR is linked to fewer postoperative complications.
- PPI is associated with reduced hospital lengths of stay.
- Maintaining pleural integrity during MIAVR improves both short-term and long-term patient survival.
