title: Traditional Sternotomy Versus Minimally Invasive Aortic Valve Replacement in Patients Stratified by Ejection Fraction.
abstract: OBJECTIVE
  Low ejection fraction (EF < 40%) portends adverse outcomes in patients undergoing valvular heart surgery. The role of traditional median sternotomy aortic valve replacement (SAVR) compared with minimally invasive aortic valve replacement (MIAVR) in this cohort remains incompletely understood.
  
  
  METHODS
  A multi-institutional retrospective review of 1503 patients who underwent SAVR (n = 815) and MIAVR via right anterior thoracotomy (n = 688) from 2011 to 2014 was performed. Patients were stratified into two groups: EF of less than 40% and EF of 40% or more. In each EF group, SAVR and MIAVR patients were propensity matched by age, sex, body mass index, race, diabetes, hypertension, dyslipidemia, dialysis, cerebrovascular disease, cardiovascular disease, cerebrovascular accident, peripheral vascular disease, last creatinine level, EF, previous MI and cardiogenic shock, and the Society for Thoracic Surgeons (STS) score.
  
  
  RESULTS
  Among patients with an EF of 40% or more (377 pairs), patients who underwent MIAVR compared with SAVR had decreased intensive care unit hours (56.8% vs 84.6%, P < 0.001), postoperative length of stay (7.1 vs 7.9 days, P = 0.04), incidence of atrial fibrillation (18.8% vs 38.7%, P < 0.001), bleeding (0.8% vs 3.2%, P = 0.04), and a trend toward decreased 30-day mortality (0.3% vs 1.3%, P = 0.22). The STS scores were largely equivalent in patients undergoing MIAVR compared with SAVR (2.4% vs 2.6%, P = 0.09). In patients with an EF of less than 40% (35 pairs), there was no difference in intensive care unit hours (69% vs 72.6%, P = 0.80), postoperative length of stay (10.3 vs 7.2 days, P = 0.13), 30-day mortality (3.8% vs 0.8%, P = 0.50), or the STS score (3.3% vs 3.2%, P = 0.68).
  
  
  CONCLUSIONS
  Minimally invasive aortic valve replacement in patients with preserved EF was associated with improved short-term outcomes compared with SAVR. In patients with left ventricular dysfunction, short-term outcomes between MIAVR and SAVR are largely equivalent.
authors.affiliation: From the *Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA; †Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA USA; ‡Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA; §Department Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Memorial Hermann Hospital, Houston, TX USA; and ∥Department of Cardiac Surgery, Mount Sinai Medical Center, Miami Beach, FL USA.
authors.forename: Tom C
authors.initials: TC
authors.lastname: Nguyen
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.forename: Justin Q
authors.initials: JQ
authors.lastname: Pham
authors.forename: Yelin
authors.initials: Y
authors.lastname: Zhao
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Terwelp
authors.forename: Prakash
authors.initials: P
authors.lastname: Balan
authors.forename: Daniel
authors.initials: D
authors.lastname: Ocazionez
authors.forename: Catalin
authors.initials: C
authors.lastname: Loghin
authors.forename: Richard W
authors.initials: RW
authors.lastname: Smalling
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Estrera
authors.forename: Joseph
authors.initials: J
authors.lastname: Lamelas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006352:Heart Ventricles / Q000503:physiopathology*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D012189:Retrospective Studies; D056346:Sternotomy / Q000009:adverse effects / Q000379:methods*; D013318:Stroke Volume; D016896:Treatment Outcome