Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study.

OBJECTIVE: The study objective was to compare the 30-day outcomes of a standardized aortic valve repair technique (REPAIR group) associating root remodeling with an expansible aortic ring annuloplasty versus mechanical composite valve and graft (CVG group) replacement in treating aortic root aneurysms. METHODS: A total of 261 consecutive patients with aortic root aneurysm were enrolled in this multicentric prospective cohort (131 in the CVG group, 130 in the REPAIR group) in 20 centers. The main end point is a composite criterion including mortality; reoperation; thromboembolic, hemorrhagic, or infectious events; and heart failure. Secondary end points were major adverse valve-related events. Crude and propensity score adjusted estimates are provided. RESULTS: The mean age was 56.1 years, and the valve was bicuspid in 115 patients (44.7%). The median (interquartile range) preoperative aortic insufficiency grade was 2.0 (1.0-3.0) in the REPAIR group and 3.0 (2.0-3.0) in the CVG group (P = .0002). Thirty-day mortality was 3.8% (n = 5) in both groups (P = 1.00). Despite a learning curve and longer crossclamp times for valve repair (147.7 vs 99.8 minutes, P < .0001), the 2 groups did not differ significantly for the main criterion (odds ratio, 1.31; 95% confidence interval, 0.72-2.40; P = .38) or 30-day mortality (odds ratio, 0.99; 95% confidence interval, 0.28-3053; P = .99), with a trend toward more frequent major adverse valve-related events in the CVG group (odds ratio, 2.52; 95% confidence interval, 0.86-7.40; P = .09). At discharge, 121 patients (96.8%) in the REPAIR group had grade 0 or 1 aortic insufficiency. CONCLUSIONS: A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

Benefits and complications of total sternotomy and ministernotomy in cardiac surgery.

Ministernotomy (MS) is a well-known procedure developed in the past ten years along with the rise of minimally invasive cardiac surgery. Upper, mid, or inferior partial sternotomies allow coronary surgery, as well as aortic and mitral valve approaches. Contrary to anterior thoracotomy, access to the great vessels is sometimes easy, which renders central cannulation possible. In opposition to total sternotomy (TS), MS could procure better postoperative stability that would aide in reduction of wound infections. Nevertheless, upper MS can be responsible for the lesion of the internal thoracic arteries (ITAs). Moreover, little evidence exists regarding blood sparing in MS approaches. MS presents the problem of hiding a part of the cardiac structures. For example, in the case of aortic surgery by way of upper sternotomy for example, left venting is risky or even impossible. However, partial inferior sternotomy can be interesting for aortic valve surgery in patients with in situ right ITA passing in front of the aorta, protecting the grafts during dissection. In coronary surgery, inferior T sternotomy and C sternotomy allow perfect access to the coronary network. Some authors also have described inferior "T" sternotomy for various congenital lesions. If mini-invasive cardiac surgery can offer reduced postoperative morbidity and faster rehabilitation, the advantages of MS upon TS--except for cosmetic aspects--remain to be defined. Thus, this approach should be reserved for selected patients and lesions.