Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients.
OBJECTIVE
The proportion of minimally invasive approaches is rising in cardiac surgery, in part driven by increasing patient demand. This study aimed to perform a risk-adjusted comparison of mortality, rate of stroke and perioperative morbidity of aortic valve replacement (AVR) conducted through either partial mini-sternotomy or conventional sternotomy.


METHODS
Between July 2009 and July 2012, data from 984 consecutive patients undergoing isolated AVR were prospectively recorded. In 44.3% (n = 436), the less invasive partial mini-sternotomy was used. Propensity score matching was performed based on 15 preoperative risk factors to correct for selection bias. In-hospital mortality, stroke rate as well as other major complications in the minimally invasive group and conventional sternotomy group were compared in 404 matched patient pairs (total 808).


RESULTS
In-hospital mortality and rate of postoperative intra-aortic balloon pump use were identical for propensity-matched patients, 1.0% (4 in each group). The rate of stroke [OR (95% confidence interval (CI)): 0.80 (0.22-2.98)], perioperative myocardial infarction [OR (95% CI): 2.00 (0.18-22.06)], low-output syndrome [OR (95% CI): 0.90 (0.37-2.22)], new onset of dialysis [OR (95% CI): 1.25 (0.49-3.17)] and re-exploration for bleeding [OR (95% CI): 0.88 (0.50-1.56)] were similar. Likewise, resource utilization (operation time, duration of stay in the intensive care unit and in-hospital stay) and valve selection (type and size) was not affected by the surgical approach either.


CONCLUSIONS
AVR can be safely conducted through a partial mini-sternotomy. This approach is not associated with an increased rate of complications. However, wide CIs reflect the still prevailing statistical uncertainty in estimates, not excluding patient-relevant differences between approaches. Large trials, which also address end points, such as postoperative pain, duration of postoperative recovery and quality of life, are needed to clarify the role of minimally invasive AVR.
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany qtgkk994@yahoo.co.jp.
Nobuyuki
N
Furukawa
Faculty of Medicine, Centre for Health and Society, Heinrich Heine University, Düsseldorf, Germany.
Oliver
O
Kuss
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Anas
A
Aboud
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Michael
M
Schönbrodt
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Andre
A
Renner
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Kavous
K
Hakim Meibodi
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Tobias
T
Becker
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Amin
A
Zittermann
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Jan F
JF
Gummert
Department of Cardiothoracic Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany.
Jochen
J
Börgermann
D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D000082882:Bicuspid Aortic Valve Disease; D005260:Female; D006330:Heart Defects, Congenital / Q000453:epidemiology / Q000601:surgery*; D006349:Heart Valve Diseases / Q000453:epidemiology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D057216:Propensity Score; D012189:Retrospective Studies; D012307:Risk Factors; D056346:Sternotomy / Q000009:adverse effects / Q000379:methods / Q000401:mortality
Aortic valve replacement; Minimally invasive cardiac surgery; Propensity score analysis