Minimally‐invasive parasternal aortic valve replacement–A slow learning curve towards improved outcomes

Abstract

Background We report our starting experience with parasternal minimally‐invasive aortic valve replacement. Methods From 7/14 to 8/18, 192 received classic aortic valve surgery using a 5 cm parasternal incision and percutaneous groin cannulation. Patients were selected based on anatomic feasibility judged by preoperative computed tomography‐scan. Except for porcelain aorta, left‐sided aortic location, or endocarditic abscess, there were no exclusions. Results Patients were divided into two groups (first and second half of experience). Demographics were equal. Patients’ mean ejection fraction was 59%, with preoperative stroke (12%), severe chronic obstructive pulmonary disorder (11%), and endocarditis (2%). All cases were elective or urgent. The Euroscore II was 3.37 ± 3.31 in the first and 3.68 ± 3.97 in the second group (n.s.). Biological prostheses were implanted in 90%. Operating times in the first group were just under 3 hours, with bypass times of 129 ± 32 minutes and clamp times of 77 ± 20 minutes. In the second group, these times changed only minimally. There were three conversions to sternotomy in the first, but only one in the second group. Similarly, three patients died in the first and one in the second group. There were fewer complications in the second group regarding revision for bleeding (7 vs 1%), stroke (4 vs 0%) dialysis (3 vs 1%), and pericardial effusions (3 vs 1%). The O/E ratio dropped from 0.93 to 0.28. Conclusions Parasternal minimally‐invasive aortic valve replacement is a feasible technique associated with a slow learning curve but the potential to achieve improved outcomes. Considering the transcatheter alternatives, the relative risk reduction may be worth investigating in future trials.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center

“…Various studies have shown that RAMT AVR is associated with a low rate of postoperative complications and favorable midterm survival 19,23,24,36–46 . Our center established a minimally invasive surgical program dedicated to the sternum‐sparing RAMT approach in 2016.…”

“…Operative setup for the right anterior minithoracotomy (RAMT) approach. (B) Exposure of the aortic valve through a RAMT Various studies have shown that RAMT AVR is associated with a low rate of postoperative complications and favorable midterm survival 19,23,24,[36][37][38][39][40][41][42][43][44][45][46]. Our center established a minimally invasive…”

Cardiac Surgery 2021 Reviewed

“…5C, D ). 34 47 48 Thus, individual decision-making, taking local expertise, and prognosis for the individual patient into account seem to be the most promising way for optimal patient care.…”

Cardiac Surgery 2020 Reviewed

“…We presented our experience of the first almost 200 patients with parasternal minithoracotomy for aortic valve replacement. 52 We used conventional prostheses with classic suturing and tying (clamp times 78 þ 24 minutes). We demonstrated in this Fig.…”

“…(B) Comparison of the treatment effect of early surgical aortic valve replacement compared with conservative management in relation to the degree of chronic kidney disease 47 (reproduced with permission). (C) Photograph (left) of the surgical access and the ratio of observed to expected mortality (right panel, first and second half of experience) in a complete series of patients having undergone parasternal aortic valve replacement at a single institution 52 (reproduced with permission). 20,000 patients from 14 studies, the authors report a survival advantage for mechanical valves in a propensity-matched comparison.…”