Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement.

BACKGROUND: Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement. METHODS: From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs. RESULTS: In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group. CONCLUSIONS: In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.

Comparison of Anterolateral Minithoracotomy Versus Partial Upper Hemisternotomy in Aortic Valve Replacement.

BACKGROUND: In aortic valve replacement, a comparison between the anterolateral minithoracotomy and the partial upper hemisternotomy approach has not been reported to date. METHODS: From 2006 to 2012, isolated aortic valve replacement was performed in 1,118 consecutive patients. Aortic valve replacement was performed through a anterolateral minithoracotomy in 166 patients (14.9%) and through a partial upper hemisternotomy in 245 patients (21.9%). A propensity score-matched analysis was performed in 160 matched pairs. RESULTS: Conversion to median sternotomy was significantly higher in the anterolateral group (n = 22, 13.1%) than in the hemisternotomy group (n = 7, 4.4%) (p = 0.004). A second cross-clamp was significantly more often necessary in the anterolateral group (n = 14, 8.8%) than in the hemisternotomy group (n =2, 1.3%) (p = 0.003). The median cross-clamp time was significantly longer in the anterolateral group, 93 minutes (range, 43 to 231 minutes) than in the hemisternotomy group, 75 minutes (range, 46 to 137 minutes) (p < 0.0001). The median perfusion time was significantly longer in the anterolateral group, 137 minutes (range, 81 to 456 minutes) than in the hemisternotomy group, 113 minutes (range, 66 to 257 minutes) (p < 0.0001). Significantly more groin adverse events occurred in the anterolateral group (n = 17, 10.8%) than in the hemisternotomy group (n = 0, 0%) (p < 0.0001). No significant difference in 90-day mortality was seen in the anterolateral group (n = 6, 3.8%) than in the hemisternotomy group (n = 2, 1.3%) (p = 0.16). CONCLUSIONS: The anterolateral minithoracotomy is associated with more perioperative adverse events. The partial upper hemisternotomy is an excellent surgical technique for minimally invasive aortic valve replacement in the daily routine for every staff surgeon.