The Role of Microbes in Surgical Decision Making for Infective Endocarditis: Mitral Valve Repair or Replacement?

BACKGROUND: The benefits of mitral repair versus replacement for endocarditis are inconclusive. This study compares outcomes of patients with infective endocarditis undergoing mitral valve repair versus replacement and investigates the impact of microbial etiology. METHODS: All 251 patients undergoing mitral valve surgery for active endocarditis between 2010 and 2023 were enrolled, 180 (71.7%) replacement and 71 (28.3%) repair. To adjust for imbalances, inverse probability of treatment weighting was applied and 187 patients were obtained. RESULTS: The analysis between groups, following the application of inverse probability of treatment weighting, showed no statistically significant differences across all considered outcomes. Early and late death was observed respectively in 6 (8.5%) and 11 (15.5%) patients in the repair group versus 24 (13.3%) and 45 (25.0%) in the replacement group without statistical significance (p = 0.221 and p = 0.446). Relapse occurred in six patients (8.5%) in the repair group after a median time of 4.0 months and in six (3.3%) in the replacement after 6.9 months (p = 0.071). CONCLUSIONS: Surgical strategy in mitral endocarditis has no effect on major postoperative complications, mortality, or medium/long-term survival. Staphylococcus aureus and Coagulase-negative Staphylococci represent a risk for early mortality and relapse. However, mitral valve repair for endocarditis can be pursued when it ensures the complete eradication of all infected tissue, particularly in cases caused by Streptococcus infection, in young patients, and after a minimum of 18 days of antibiotic therapy.

Surgical Treatment of Active Endocarditis Pre- and Post-COVID-19 Pandemic Onset.

BACKGROUND: Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. The impact of COVID-19 on the diagnosis and outcome of the surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics, and outcomes of surgically treated IE before and after the COVID-19 pandemic. METHODS: This study retrospectively analyzed the data of 535 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided into two groups depending on the date of their operation: before (n = 393) and after (n = 142) COVID-19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Weighted univariate logistic regressions were reported for outcomes; weights were derived from IPTW. Interrupted time series analysis (ITSA) according to Linden's method was used to evaluate the changes in the manifestation of IE after 11 March 2020. RESULTS: Patients from the post-COVID-19 cohort (after 11 March 2020) had a greater number of comorbidities such as diabetes (29.6% vs. 16.3% p = 0.001), hypertension (71.1% vs. 59.5% p = 0.015), and preoperative kidney injury requiring dialysis (9.2% vs. 2.5% p = 0.002), but the median additive and logistic EuroSCORE were not statistically different. In the post-COVID-19 group, we observed a greater prevalence of Staphylococcus aureus-related endocarditis (24.5% vs. 15.4% p = 0.026), a consequent reduction in Staphylococcus non aureus-related endocarditis (12.2% vs. 20.1% p = 0.048), and a decrease in aortic valve replacements (43.0% vs. 53.9%), while the number of mitral valve replacements and repair was greater (21.1% vs. 15.0% and 6.3% vs. 4.3%, respectively). No differences were found in the two groups concerning early death, death, or relapse at 1 year after surgery. Data obtained by multivariable analysis identified preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality via stratifying by time periods in analysis. CONCLUSIONS: The incidence of surgically treated IE significantly increases after the COVID-19 pandemic with a higher incidence of mitral valve involvement with respect to the aortic valve. Although a delay in surgical timing occurred during the COVID-19 pandemic, data in terms of mortality and outcomes were largely unaffected.

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement.

BACKGROUND: Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length. METHODS: All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time. RESULTS: The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2-3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14-5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05-1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89-7.68, p = 0.080). CONCLUSIONS: Shortening the operative times resulted in marked improvements of the patients' outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.

Renin-Angiotensin-Aldosterone System Inhibitors, Statins, and Beta-Blockers in Diabetic Patients With Critical Limb Ischemia and Foot Lesions.

Medical therapy for secondary prevention is known to be under-used in patients with peripheral artery disease (PAD). Few data are available on the subgroup with critical limb ischemia (CLI). Prescription of cardiovascular preventive therapies was recorded at discharge in a large, prospective cohort of patients admitted for treatment of CLI and foot lesions, stratified for coronary artery disease (CAD) diagnosis. All patients were followed up for at least 1 year. The primary endpoint was major adverse cardiovascular events (MACE). 618 patients were observed for a median follow-up of 981 days. Renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, beta-blockers, and antithrombotic drugs were prescribed in 52%, 80%, 51%, and 99% of patients, respectively. However, only 43% of patients received optimal medical therapy (OMT), defined as the combination of RAAS inhibitor plus statin plus at least one antithrombotic drug. It was observed that the prescription of OMT was not affected by the presence of a CAD diagnosis. On the other hand, it was noticed that the renal function affected the prescription of OMT. OMT was independently associated with MACE (HR 0.688, 95%CI 0.475-0.995, P = .047) and, after propensity matching, also with all-cause mortality (HR 0.626, 95%CI 0.409-0.958, P = .031). Beta-blockers prescription was not associated with any outcome. In conclusion, patients with critical limb ischemia are under-treated with cardiovascular preventive therapies, irrespective of a CAD diagnosis. This has consequences on their prognosis.

Surgical aortic valve replacement for low-gradient aortic stenosis.

AIMS: Low-gradient aortic stenosis is a challenging entity that needs accurate preoperative evaluation. For this high-risk patient population, ad hoc predictive scores are not available and profile risk is currently revealed by the EuroSCOREs. Aims of this study are to verify the suitability of the ES II as predictor of mortality in low-gradient aortic stenosis and to analyse the role of surgery as a treatment. METHODS: From June 2013 to August 2019, 414 patients underwent surgical aortic valve replacement for low-gradient aortic stenosis. Mean age was 75.78 ±â€Š6.77 years and 190 were women. The prognostic value of Logistic EuroSCORE and EuroSCORE II were compared by receiver-operating characteristics (ROC) curve analysis. RESULTS: In-hospital, 30-day and 1-year mortality rates were respectively 3.4, 2.9 and 4.8% (14, 12 and 20 patients over 414). In-hospital mortality risk calculated by the Additive EuroSCORE was 7.2 ±â€Š2.7%, by the Logistic EuroSCORE was 9 ±â€Š5.2% and by the ES II was 4.13 ±â€Š2.56%. The prognostic values of the EuroSCORE II and of the EuroSCORE were analysed in a ROC curve analysis for the prediction of in-hospital mortality [area under the curve (AUC): 0.62 vs. 0.58], 30-day mortality (AUC: 0.63 vs. 0.64) and 1-year mortality (AUC: 0.79 vs. 0.65). Both scores did not show significant differences with the only exception of 1-year mortality, for which EuroSCORE II had a better predictive ability than the Logistic EuroSCORE (P < 0.05). CONCLUSION: In low-gradient aortic stenosis undergoing surgery, the EuroSCORE II is a strong predictor of 1-year mortality.

Impact of comorbidities on older patients undergoing open heart surgery.

BACKGROUND: The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery. METHODS: Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019. RESULTS: In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death. CONCLUSION: Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Impairment of mitophagy and autophagy accompanies calcific aortic valve stenosis favouring cell death and the severity of disease.

AIMS: In the last 15 years, some observations tried to shed light on the dysregulation of the cellular self-digestion process in calcific aortic valve stenosis (CAVS), but the results obtained remain still controversial. This work is aimed to definitively establish the trend of autophagy in patients affected by CAVS, to analyse the putative involvement of other determinants, which impact on the mitochondrial quality control mechanisms and to explore possible avenues for pharmacological interventions in the treatment of CAVS. METHODS AND RESULTS: This observational study, performed exclusively in ex vivo human samples (cells and serum), by using biochemical approaches and correlations with clinical data, describes new biological features of the calcified valve in terms of mitochondrial dysfunctions. In detail, we unveiled a significant deficiency in mitochondrial respiration and in ATP production coupled to increase production of lactates. In addition, mitochondrial population in the pathologic group is aged with significant alterations in biogenesis and mitophagy pathways. We are also reporting an updated view about autophagy accompanying the calcification process and advanced stages of the disease. We provided evidence for a rapamycin-based therapeutic strategy to revert the calcified phenotype to the wild type one. CONCLUSION: Our data suggest that the CAVS phenotype is featured by defects in mitochondrial quality control mechanisms and that autophagy is not activated enough to counteract cell death and sustain cell functions. Thus, boosting autophagy and mitophagy from short- to long-term reverts quite all pathological phenotypes.

Sutureless versus transcatheter aortic valve replacement: A multicenter analysis of "real-world" data.

BACKGROUND: Recent data suggested that transcatheter aortic valve replacement (TAVR) may be indicated also for low-risk patients. However, robust evidence is still lacking, particularly regarding valve performance at follow-up that confers a limitation to its use in young patients. Moreover, a literature gap exists in terms of 'real-world' data analysis. The aim of this study is to compare the cost-effectiveness of sutureless aortic valve replacement (SuAVR) versus transfemoral TAVR. METHODS: Prospectively collected data were retrieved from a centralized database of nine cardiac surgery centers between 2010 and 2018. Follow-up was completed in June 2019. A propensity score matching (PSM) analysis was performed. RESULTS: Patients in the TAVR group (n=1002) were older and with more comorbidities than SuAVR patients (n=443). The PSM analysis generated 172 pairs. No differences were recorded between groups in 30-day mortality [SuAVR vs TAVR: n=7 (4%) vs n=5 (2.9%); p=0.7] and need for pacemaker implant [n=10 (5.8%) vs n=20 (11.6%); p=0.1], but costs were lower in the SuAVR group (20486.6±4188€ vs 24181.5±3632€; p<0.01). Mean follow-up was 1304±660 days. SuAVR patients had a significantly higher probability of survival than TAVR patients (no. of fatal events: 22 vs 74; p<0.014). Median follow-up was 2231 days and 2394 days in the SuAVR and TAVR group, respectively. CONCLUSION: The treatment of aortic valve stenosis with surgical sutureless or transcatheter prostheses is safe and effective. By comparing the two approaches, patients who can undergo surgery after heart team evaluation show longer lasting results and a more favorable cost ratio.

A naturally occurring mutation in ATP synthase subunit c is associated with increased damage following hypoxia/reoxygenation in STEMI patients.

Preclinical models of ischemia/reperfusion injury (RI) demonstrate the deleterious effects of permeability transition pore complex (PTPC) opening in the first minutes upon revascularization of the occluded vessel. The ATP synthase c subunit (Csub) influences PTPC activity in cells, thus impacting tissue injury. A conserved glycine-rich domain in Csub is classified as critical because, when mutated, it modifies ATP synthase properties, protein interaction with the mitochondrial calcium (Ca2+) uniporter complex, and the conductance of the PTPC. Here, we document the role of a naturally occurring mutation in the Csub-encoding ATP5G1 gene at the G87 position found in two ST-segment elevation myocardial infarction (STEMI) patients and how PTPC opening is related to RI in patients affected by the same disease. We report a link between the expression of ATP5G1G87E and the response to hypoxia/reoxygenation of human cardiomyocytes, which worsen when compared to those expressing the wild-type protein, and a positive correlation between PTPC and RI.

Use of a negative pressure wound therapy system over closed incisions option in preventing post-sternotomy wound complications.

Post-sternotomy surgical site infections may be serious complications responsible for increased morbidity, mortality and length of hospital stay. A variety of wound-healing strategies can be used over closed surgical incisions, including negative pressure wound therapy (NPWT). The aim of the study is to assess sternal wound complications after heart surgery using NPWT in patients at risk for surgical site complication. Considered risk factors affecting wound healing were type 2 diabetes, Body Mass Index (BMI) >30, chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF) and myocardial revascularization by double mammary artery harvesting. With these premises, 90 patients were selected: 30 patients received traditional gauze dressings, 30 advanced dressings (hydrocolloid and carboxymethyl cellulose) and 30 patients NPWT. Thirty-four patients (37.7%) had two risk factors, 41 patients (45.5%) were affected by three risk factors and 15 patients (16.6%) by four risk factors. The NPWT group had lower rates of diabetes and CRF and only one patient presented four risk factors. With regard to surgical times and types of surgical procedure, no significant differences were observed within the three groups. The patients who received NPWT over closed incision experimented a significantly lower rate of deep sternal complication over traditional gauze and hydrocolloid and carboxymethyl cellulose dressings.

Patient with unicuspid aortic valve and ascending aorta aneurysm treated with ozaki procedure and ascending aorta replacement

Abstract Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.

Pacemaker need after sutureless aortic valve replacement: the role of the learning curve.

AIM: Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. METHODS: Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73-82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. RESULTS: The univariate logistic regression showed previous aortic valve surgery [P = 0.028; odds ratio (OR) 3.248], dialysis (P = 0.036; OR 6.435), renal insufficiency (P = 0.021; OR 2.75), EuroSCORE II (P = 0.016; OR 1.051) and year of operation (P < 0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. CONCLUSION: The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.

Patient with Unicuspid Aortic Valve and Ascending Aorta Aneurysm Treated with Ozaki Procedure and Ascending Aorta Replacement.

Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.

Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

BACKGROUND: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. METHODS: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. RESULTS: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. CONCLUSIONS: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.

Aortic valve endocarditis complicated by proximal false aneurysm.

BACKGROUND: Aortic valve endocarditis remains a life-threatening condition, especially in cases of periannular complications. Aorto-ventricular discontinuity associated with proximal false aneurysm represents a severe picture caused by extensive tissue disruption and is usually associated with prosthetic valve infection. Complex surgical repair is required in these cases and continues to be associated with high mortality and morbidity rates. METHODS: We retrieved information for 32 patients undergoing operation for infective aortic valve/prosthetic valve endocarditis complicated by pseudoaneurysm arising from aorto-ventricular discontinuity. Patients were relatively young, mostly male and most of them had a prior cardiac operation. Aortic root replacement with valve graft conduit was performed in all cases; it was associated with other procedures in seven patients: CABG (n=2), MV surgery (n=3), MV surgery + CABG (n=1) and pulmonary valve replacement (n=1). We reported and analysed patient outcomes at early and mid-term follow-up. RESULTS: Pre-discharge mortality was 22% (n=7). The postoperative course was complicated in 24 (75%) cases. Eighteen patients (56%) sustained low cardiac output resulting in multiple organ failure syndrome and death in five cases. One patient (3%) experienced a major neurologic deficit with a permanent cerebral stroke. Acute kidney injury complicated the course in 12 cases (37%), continuous renal replacement therapy was necessary in four patients (12%). Overall survival and freedom from endocarditis and reoperation at 5-year was 59% and 89%, respectively. CONCLUSIONS: Patients with complicated aortic valve endocarditis presented generally in a poor preoperative state. Surgical treatment poses a non-negligible risk of postoperative mortality and morbidity but provides an acceptable survival rate and a satisfactory recovery at mid-term.

Clinical experience with dalbavancin for the treatment of deep sternal wound infection.

OBJECTIVES: Deep sternal wound infection (DSWI) is a complication of major heart surgery with high morbidity as well as prolonged antimicrobial treatment and hospital length of stay (LoS). Dalbavancin is a new lipoglycopeptide antibiotic active against Gram-positive micro-organisms, including methicillin-resistant Staphylococcus aureus (MRSA), with a long half-life. This small case series assessed the feasibility of dalbavancin for the treatment of DSWI. METHODS: This was retrospective, observational, cohort study of patients treated with dalbavancin for DSWI over a 2-year period (March 2016 to April 2018) in two cardiac surgery departments in Italy. All patients with DSWI underwent surgical accurate debridement. Dalbavancin was administered during the hospital stay or in an outpatient facility. RESULTS: Among 15 patients enrolled in the study, MRSA was isolated in 7 (47%), methicillin-resistant Staphylococcus epidermidis in 6 (40%) and other coagulase-negative staphylococci in 2 (13%). Dalbavancin was administered by two infusions in 9 patients (60%), whereas 5 patients (33%) received a median of four doses. Fourteen patients received a first dose of 1000mg followed by 500mg, whereas one patient received two doses of 1500mg each. All patients were defined as clinically cured. The median hospital LoS was 13 days (interquartile range, 8-18 days). At 6 months after discharge, 14 patients (93%) showed no relapse of DSWI, whereas 1 patient recurred with a diagnosis of DSWI caused by another pathogen (Candida sp.). CONCLUSION: Dalbavancin may be an alternative option for DSWI caused by Gram-positive bacteria when first-line treatments are contraindicated or as salvage treatment.

Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference?

BACKGROUND: This study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others. METHODS: All patients who underwent AVR were enrolled. The choice of the approach was left to surgeon's preference. Data were retrospectively collected, and the major baseline characteristics (including age, sex, body mass index, creatinine clearance, preoperative condition, cardiovascular risk factors, functional status, and left ventricular ejection fraction, etc.) and intraoperative variables were recorded. To adjust for differences in baseline characteristics between the study groups, a propensity score matching was performed. Linear and logistic regression analyses were performed. RESULTS: Partial upper hemisternotomy was performed in 820 patients (43%), right anterior minithoracotomy in 488 (26%), and median sternotomy in 599 (31%). After propensity score matching, three groups of 377 patients were obtained. Cardiopulmonary bypass and cross-clamp times were shorter in the right anterior minithoracotomy group than in the median sternotomy and partial upper hemisternotomy groups (p < 0.001). No significant differences in in-hospital mortality were observed (p = 0.9). Renal failure (odds ratio, 5.4; 95% confidence interval, 2.3 to 11.4; p < 0.0001), extracardiac arteriopathy (odds ratio, 2.9; 95% confidence interval, 1.1 to 6.7; p = 0.017), and left ventricular ejection fraction (odds ratio, 0.96; 95% confidence interval, 0.93 to 0.99; p = 0.009) emerged as independent predictors of in-hospital mortality. CONCLUSIONS: Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.

Right anterior mini-thoracotomy vs. conventional sternotomy for aortic valve replacement: a propensity-matched comparison.

BACKGROUND: Right anterior mini-thoracotomy (MIAVR) is a promising technique for aortic valve replacement. We aimed at comparing its outcomes with those obtained in a propensity-matched group of patients undergoing sternotomy at our two high-volume centers. METHODS: Main clinical and operative data of patients undergoing aortic valve replacement between January 2010 and May 2016 were retrospectively collected. A total of 678 patients were treated with a standard full sternotomy approach, while MIAVR was performed in 502. Propensity score matching identified 363 patients per each group. RESULTS: In-hospital mortality was not significantly different between the propensity-matched groups (1.7% in MIAVR patients vs. 2.2% in conventional sternotomy patients; P=0.79). No significant difference in the incidence of major post-operative complications was observed. Post-operative ventilation times (median 7, range 5-12 hours in MIAVR patients vs. median 7, range 5-12 in conventional sternotomy patients; P=0.72) were not significantly different between the two groups. Cardiopulmonary bypass time (61.0±21.0 vs. 65.9±24.7 min in conventional sternotomy group; P<0.01) and aortic cross-clamping time (48.3±16.7 vs. 53.2±19.6 min in full sternotomy group; P<0.01) were shorter in MIAVR group. EuroSCORE (OR 1.52, 95% CI, 1.12-2.06; P<0.01) was found to be the only independent predictor of intra-hospital mortality in the whole propensity-matched population. CONCLUSIONS: Our experience shows that mini-access isolated aortic valve surgery is a reproducible, safe and effective procedure with similar outcomes and no longer operative times compared to conventional sternotomy.