title: Should less-invasive aortic valve replacement be avoided in patients with pulmonary dysfunction?
abstract: OBJECTIVE
  In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate.
  
  
  METHODS
  From January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs.
  
  
  RESULTS
  Patients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P = .001) and postoperative (7.1 vs 6.1 days, P < .0001) lengths of stay than those without chronic lung disease. At normal values of FEV1%, little difference was observed in either of these times for J-incision versus full sternotomy; however, at progressively lower FEV1%, these times lengthened, with increasing benefit for J-incision. Among propensity-matched patients, other postoperative complications were similar. Early survival (93% vs 89% at 1 year, P = .07) was possibly higher in matched patients with J-incision, but late survival was similar (P = .9). Patients with FEV1% less than 50 who underwent J-incision had the greatest survival advantage, which persisted for 5 years.
  
  
  CONCLUSIONS
  In patients with preoperative respiratory dysfunction, a less-invasive partial upper J-incision for aortic valve replacement can lead to more favorable outcomes than a full sternotomy, including shorter intensive care unit and postoperative lengths of stay and better early survival, which are amplified with decreasing pulmonary function.
authors: Department of Thoracic and Cardiovascular Surgery and Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
authors: Turki B
authors: TB
authors: Albacker
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Eugene H
authors: EH
authors: Blackstone
authors: Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Sarah J
authors: SJ
authors: Williams
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: A Marc
authors: AM
authors: Gillinov
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Jose L
authors: JL
authors: Navia
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Eric E
authors: EE
authors: Roselli
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Suresh
authors: S
authors: Keshavamurthy
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Gösta B
authors: GB
authors: Pettersson
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Tomislav
authors: T
authors: Mihaljevic
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Douglas R
authors: DR
authors: Johnston
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Joseph F
authors: JF
authors: Sabik
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Bruce W
authors: BW
authors: Lytle
authors: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: svenssl@ccf.org.
authors: Lars G
authors: LG
authors: Svensson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D002908:Chronic Disease; D005260:Female; D005541:Forced Expiratory Volume; D006349:Heart Valve Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D016015:Logistic Models; D008168:Lung / Q000503:physiopathology*; D008171:Lung Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D057216:Propensity Score; D012042:Registries; D012307:Risk Factors; D056346:Sternotomy / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
keywords: 11; 28; 35; AVR; CABG; CLD; FEV1; FEV1%; ICU; aortic valve replacement; chronic lung disease; coronary artery bypass grafting; forced expiratory volume in 1 second; forced expiratory volume in 1 second, percent of predicted; intensive care unit