Efficacy of Aortic Valve Replacement through Full Sternotomy and Minimal Invasion (Ministernotomy)

Abstract

Background: new minimally invasive sternotomy (mini-sternotomy) procedures have improved the treatment outcome and reduced the incidence of perioperative complications leading to improved patient satisfaction and a reduced cost of aortic valve replacement in comparison to the conventional median sternotomy (full sternotomy). The aim of this study is to compare and gain new insights into operative and early postoperative outcomes, long-term postoperative results, and 5-year survival rates after aortic valve replacement through a ministernotomy and full sternotomy. Methods: This is a retrospective study of patients who underwent an isolated replacement of the aortic valve via a full sternotomy or ministernotomy from 2011 to 2016. From 2011 to 2016, 426 cardiac interventions were performed, 70 of which (16.4%) were of the ministernotomy and 356 (83.6%) of the full sternotomy. Through propensity score matching, 70 patients who underwent the ministernotomy (ministernotomy group) were compared with 70 patients who underwent the full sternotomy (control group). Results: in the propensity matching cohort, no statistical difference in operative time was noted (p = 0.856). The ministernotomy had longer cross clamp (88.7 ± 20.7 vs. 80.3 ± 24.6 min, p = 0.007) and bypass (144.0 ± 29.9 vs. 132.9 ± 44.9 min, p = 0.049) times, less ventilation time (9.7 ± 1.7 vs. 11.7 ± 1.4 h, p < 0.001), shorter hospital stay (18.3 ± 1.9 vs. 21.9 ± 1.9 days, p = 0.012), less 24-h chest tube drainage (256.2 ± 28.6 vs. 407.3 ± 40.37 mL, p < 0.001), fewer corrections of coagulopathy (p < 0.001), fewer patients receiving catecholamine (5.71 vs. 30.0%, p < 0.001) and better cosmetic results (p < 0.001). Moreover, the number of patients without complaints at 1 year after the operation was significantly greater in the ministernotomy group (p = 0.002), and no significant differences in the 5-year survival between the groups were observed. In the overall cohort, the ministernotomy had longer cross clamp times (88.7 ± 20.7 vs. 79.9 ± 24.8 min, p < 0.001), longer operative times (263.5 ± 62.0 vs. 246.7 ± 74.2 min, p = 0.037) and bypass times (144.0 ± 29.9 vs. 132.7 ± 44.5 min, p = 0.026), lower incidence of 30-day mortality (1(1.4) vs. 13(3.7), p = 0.022), shorter hospital stays post-surgery p = 0.025, less 24-h chest tube drainage, p < 0.001, and fewer corrections of coagulopathy (p < 0.001). Conclusions: the ministernotomy has a number of advantages compared with the full sternotomy and thus could be a better approach for aortic valve replacement.

Partial upper sternotomy for aortic valve replacement provides similar mid-term outcomes as the full sternotomy

“…The learning curve in RDPV-implantation could negatively influence final cross-clamp times. Considerably shorter bypass and cross-clamp time compared to other studies (12,20,21) has been reached by using of monofilament 3/0 running suture by implantation of stented biological prostheses (22). Furthermore, the implantation of the ATS 3f Enable ® (also defined as RDPV) in the minimally invasive group did not really reduce the time of implantation compared to our results, as a multicentric study in (20).…”

“…Furthermore, the implantation of the ATS 3f Enable ® (also defined as RDPV) in the minimally invasive group did not really reduce the time of implantation compared to our results, as a multicentric study in (20). The quality of life after minimally invasive aortic valve replacement has been previously classified in a questionnaire (8-QOL, EQ-5D), based on the subjective evaluation of patients with potential for substantial bias (12,27,28). The frequency of readmissions in the early and mid-term period after surgery can be better reflected in the problems faced by the patients.…”

“…The resulting longer surgical time could also have an adverse effect on certain subgroups of high-risk patients (10,11). However, the majority of the published mid-and long-term results focus on survival only (12), omitting the other aspects of the postoperative phase such as long-term morbidity expressed by the hospital readmission rate in patients undergoing aortic valve surgery. The advantages of the minimally invasive approach early on in the postoperative phase should be reflected in the midterm results as well.…”

Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion

“…We report a case of subclavian artery repair through a J-shaped ministernotomy. Ministernotomy approach, compared with traditional median sternotomy, tends to have a shorter hospital stay, less 24-hour chest tube drainage, less coagulopathy and better cosmetic results 14. In the past, a malpositioned haemodialysis catheter in the brachiocephalic artery has been successfully removed and the artery was repaired using a limited upper sternotomy approach, as well 15.…”

Minimal Invasive Aortic Valve Replacement by Upper Ministernotomy Approach in Comparison to The Conventional Full Median Sternotomy Approach

“…It is important to note that blood loss through the chest tube is not the best clinical endpoint. However, because the fluid collected in chest tubes may be a combination of blood and other fluids and may not be consistently measured (10) . A more clinically useful endpoint would be the rate of blood transfusion according structured protocols such as those proposed in the recent clinical guidelines from the Society of Thoracic Surgeons and The Society of Cardiovascular Anaesthesiologists (11) .…”