A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients.
OBJECTIVE
Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy.


METHODS
Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed.


RESULTS
Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups.


CONCLUSIONS
Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA michael.bowdish@med.usc.edu.
Michael E
ME
Bowdish
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Dawn S
DS
Hui
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
John D
JD
Cleveland
Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Wendy J
WJ
Mack
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Raina
R
Sinha
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Rupesh
R
Ranjan
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Robbin G
RG
Cohen
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Craig J
CJ
Baker
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Mark J
MJ
Cunningham
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Mark L
ML
Barr
Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Vaughn A
VA
Starnes
D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D001705:Bioprosthesis; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D003422:Critical Care; D004812:Epidemiologic Methods; D005260:Female; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D056346:Sternotomy / Q000379:methods* / Q000401:mortality; D013906:Thoracoscopy / Q000379:methods / Q000401:mortality; D013908:Thoracotomy / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome
Aortic valve; Minimally invasive surgery; Valve replacement