title: Less invasive versus conventional heart valve surgery in patients with severe heart failure.
abstract: OBJECTIVE
  Patients with severe heart failure might benefit from reduced operative trauma, but rarely undergo less-invasive valve surgery. The present study compared the outcomes of less-invasive heart valve surgery with those of complete sternotomy in such patients.
  
  
  METHODS
  From January 1995 to July 2010, 871 patients in New York Heart Association class III or IV underwent valve surgery (aortic or mitral, or both). A less-invasive approach was used in 205. Propensity score matching yielded 185 matched pairs for outcomes comparison adjusted for patient characteristics and 139 pairs adjusted further for individual surgeon.
  
  
  RESULTS
  Without considering surgeons, myocardial ischemic times (59 ± 27 vs 64 ± 26 minutes, P = .04), cardiopulmonary bypass times (75 ± 35 vs 86 ± 34 minutes, P < .0001), and intensive care unit stays (median, 24 vs 43 hours; P = .007) were shorter for less-invasive surgery. Hospital morbidity, mortality (1.6% [3 of 185] vs 2.7% [5 of 185]; P = .5), and long-term survival (53% and 48% at 12 years; P = .3) were similar. After considering the surgeon, these benefits were not apparent; rather, efficiency, safety, and effectiveness were equivalent to those of complete sternotomy. Thus, myocardial ischemic (63 ± 30 vs 62 ± 25 minutes, P = .8) and cardiopulmonary bypass (80 ± 40 vs 81 ± 31 minutes, P = .5) times were similar, as were intensive care unit stay (median, 28 vs 30 hours; P = .09), postoperative complications, in-hospital mortality (2.2% [3 of 139] vs 3.6% [5 of 139]; P = .5), and long-term survival (57% and 53% at 12 years; P = .5).
  
  
  CONCLUSIONS
  In selected patients with severe heart failure, less-invasive valve surgery is a viable option, yielding at least equivalent efficiency, safety, and effectiveness to complete sternotomy. However, achieving these outcomes requires surgeons experienced in less-invasive surgery.
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates. Electronic address: mihaljt@ccf.org.
authors.forename: Tomislav
authors.initials: T
authors.lastname: Mihaljevic
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates.
authors.forename: Mislav
authors.initials: M
authors.lastname: Planinc
authors.affiliation: Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Williams
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Medicine Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates.
authors.forename: Randall C
authors.initials: RC
authors.lastname: Starling
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Smedira
authors.affiliation: Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, and Abu Dhabi, United Arab Emirates; Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D002315:Cardiopulmonary Bypass; D006333:Heart Failure / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006349:Heart Valve Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery*; D018579:Patient Selection; D057216:Propensity Score; D012307:Risk Factors; D012720:Severity of Illness Index; D056346:Sternotomy / Q000009:adverse effects / Q000401:mortality; D013908:Thoracotomy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome