title: Full sternotomy versus right anterior minithoracotomy for isolated aortic valve replacement in octogenarians: a propensity-matched study †.
abstract: OBJECTIVE
  Surgical aortic valve replacement (AVR) is increasingly performed in elderly patients with good perioperative outcomes and long-term survival, resulting in significant health-related quality-of-life benefits. This study aimed to evaluate the outcome of patients aged ≥ 80 years undergoing isolated AVR through a right anterior minithoracotomy (RAMT) and compare it with a full sternotomy (FS).
  
  
  METHODS
  Two hundred and eighty-three elderly patients aged 80 years or more underwent isolated AVR between February 2001 and September 2013. With propensity score matching (1 : 1), the outcomes of patients having minimally invasive surgery (RAMT) were compared with those in whom the FS approach had been employed (100 vs 100 patients). TAVRs and partial sternotomy cases were excluded from the analysis.
  
  
  RESULTS
  There were two conversions in the RAMT group. Operative times did not significantly differ in the two groups. Patients in the RAMT group received a larger-sized prosthesis (P < 0.001) and were more likely to receive sutureless valves (P < 0.001). Shorter time for extubation (P < 0.001) and shorter hospital length of stay (P = 0.005) were observed in the RAMT group. Zero vs 4 (4.0%) (P = 0.043) patients had postoperative stroke and 2 (2.0%) vs zero (P = 0.16) had a transient ischaemic attack in the RAMT versus FS group, respectively. We registered the same rate of permanent pacemaker implant (P = 0.47) and that of new-onset atrial fibrillation (P = 0.28) for both groups. Six patients died, with no significant difference for in-hospital mortality (P = 0.68). No variable had a statistically significant predictive value for in-hospital mortality. RAMT patients were more likely to be discharged home directly or via rehabilitation (P = 0.031). FS, along with four other factors, independently predicted longer hospital stay. Though the median follow-up duration was longer in the FS group (59 vs 24 months, P < 0.001), the two groups had similar survival rates at 5 years (80 vs 81%, P = 0.37). Ten factors were associated with long-term survival by Cox regression analysis, and RAMT had no statistical impact (P = 0.38).
  
  
  CONCLUSIONS
  Minimally invasive AVR through right anterior minithoracotomy can be safely performed in patients aged ≥80 years with acceptable morbidity and mortality rates. It is an expeditious and effective alternative to full sternotomy AVR and might be associated with lower postoperative stroke incidence, earlier extubation and shorter hospital stay.
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy drgilmanov@hotmail.it.
authors.forename: Daniyar
authors.initials: D
authors.lastname: Gilmanov
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Pier Andrea
authors.initials: PA
authors.lastname: Farneti
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ferrarini
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Santarelli
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Murzi
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Miceli
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Solinas
authors.affiliation: Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Gabriele Monasterio Foundation, Massa, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Glauber
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D061646:Operative Time; D011183:Postoperative Complications / Q000401:mortality; D057216:Propensity Score; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D056346:Sternotomy / Q000009:adverse effects / Q000401:mortality; D013908:Thoracotomy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic valve replacement; Biological heart valve prosthesis; Minimally invasive surgery; Outcomes; Statistics, propensity matching