Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country

Abstract

Background: Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra-and postoperative clinical outcomes and address health resource utilization after MIAVR. Results: A total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; p = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; p = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; p = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; p = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); p < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); p = 0.048). Total operative mortality of 4.46% was recorded (n = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach (p < 0.0001). Conclusions: With a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.

Tunneled right atrial two-stage cannulation in aortic surgery via ministernotomy

“…We have read with great interest the article of Sanad et al [1] entitled Minimally invasive aortic valve replacement with central cannulation: a cost-benefit analysis in a developing country. First of all, we congratulate the authors for their important contribution to the literature.…”

A simpler minimal

“…In the real world, a dedicated CT scan means technological skills, time and financial resources and they might not be found at once in every center who wants to start a MiAVR program; on the contrary this surgical approach has to be direct and simplified, made suitable for everyone. 4 In our opinion, MiAVR has to reproduce the gold-standard conventional procedure in terms of safety, effectiveness and especially operative times through a more respectful approach; the noninvasive CT-scan assessment might be helpful, especially in the beginning of the experience.…”

A Simpler Minimal

“…We have treated more than 1200 patients with a total central cannulation MiAVR approach (2,3) and in our opinion this message is misleading: the non-invasive anatomical assessment might be useful in the beginning of the experience to rule out difficult cases, especially the ones who have got a longmini-thoracotomy to aortic annulus distance; moreover, the surgical access site selection does not require a CT scan, the third being the right intercostal space (rarely if not, the surgeon can easily change it to the second from the same skin incision). In the real world, a dedicated CT scan means technological skills, time and financial resources and they might not be found at once in every Center who wants to start a MiAVR program; on the contrary this surgical approach has to be direct and simplified, made suitable for everyone (4). The video assistance, the peripheral cannulation and the transcutaneous clamping allow to avoid any need of costal spreading and occasional rib injuries: the camera should be the surgeon's eyes and the mini-thoracotomy only the access to bring the valve in.…”