Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients

Welp, Henryk; Herlemann, I.; Martens, Sven; Deschka, Heinz

doi:10.1093/icvts/ivy083

Cited by 24 publications

(35 citation statements)

References 27 publications

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“…As part of a drive to improve shortterm outcomes associated with surgical procedures, there has been an increasing number of patients undergoing aortic valve replacement via minimally invasive approaches; the most common access incisions are a partial upper hemisternotomy and a right anterior thoracotomy. These approaches have demonstrated benefits of reduced incidence of post-operative atrial fibrillation, shorter hospital and ICU LOS and a reduced blood transfusion requirement compared with conventional full sternotomy, with no significant difference in mortality or perioperative stroke (16)(17)(18). Despite these benefits, minimally invasive approaches have longer cross-clamp and CPB times and are technically more demanding.…”

Section: Discussionmentioning

confidence: 99%

Sutureless valve and rapid deployment valves: a systematic review and meta-analysis of comparative studies

Flynn

Williams

Chakos

et al. 2020

Ann Cardiothorac Surg

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Background: The treatment of aortic valve disease is the most common valvular surgery in industrialized nations, with 3-9% of the population over the age of eighty having at least moderate aortic stenosis. As transcatheter aortic valve replacement (TAVR) has become more established, newer surgical prostheses have been developed with a variety of anchoring systems that do not rely solely on sutures to hold the valve in an appropriate position. The Edwards Intuity valve is a bovine pericardial prosthesis that is modelled on the widely implanted Perimount MagnaEase aortic prosthesis. The Perceval valve is a bovine pericardial valve attached to a self-expanding nitinol stent, which uses the radial force exerted on the patient's aortic annulus and aortic root by the stent portion to hold the valve in position. This meta-analysis compares the outcomes of comparative studies of these two valve systems. Methods: This systematic review and meta-analysis compares the outcomes of rapid deployment valves (RDV) and sutureless valves (SURD) and was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and guidance. The search strategy interrogated six electronic databases. Outcomes measured included all-cause mortality at latest follow up, stroke, cross-clamp and cardiopulmonary bypass (CPB) times, pacemaker implantation rates, paravalvular leak and post-operative transvalvular gradient. Results: The search strategy identified 407 unique papers for initial assessment with seven studies qualifying for inclusion in the analysis. The outcomes of 4,076 patients (1,650 RDV, 2,426 SURD) were included. There was no difference in mortality, stroke or moderate or worse paravalvular regurgitation between the two groups. SURD had significantly shorter CPB time by 15.7 minutes [95% confidence interval (CI): 4.2-27.1; P=0.007] and a shorter cross-clamp time by 11.3 minutes (95% CI: 6.3-16.3; P<0.001) compared to RDV. RDV had a lower post-operative transvalvular gradient by 2.5 mmHg (95% CI: 1.2-3.8; P<0.001) and a lower rate of mild paravalvular regurgitation (OR 2.51; 95% CI: 1.435-4.768; P=0.004). Conclusions: Both valve types have an adequate safety profile and are comparable to conventional sutured prostheses. There was a significant reduction in cross-clamp and CPB times associated with SURD. This may be of benefit for patients requiring multiple concomitant procedures and increases the utility of minimally invasive valve replacement. However, SURD was associated with higher post-operative transvalvular gradients and a higher incidence of paravalvular regurgitation.

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Section: Discussionmentioning

confidence: 99%

Sutureless valve and rapid deployment valves: a systematic review and meta-analysis of comparative studies

Flynn

Williams

Chakos

et al. 2020

Ann Cardiothorac Surg

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“…Thus, on the one hand, the reduction of wound extension with a mini‐invasive approach seems to be a logical answer of the problem. On the other hand, there are reservations particularly for high‐risk patients, as inadequate exposure can complicate or make a procedure unfeasible 20‐22 . The relationship between BMI and survival after AVR is controversial.…”

Section: Discussionmentioning

confidence: 99%

“…On the contrary, Rahmanian et al 12 reported that obesity is an independent predictor of longer hospital mortality, wound infection occurrence, and more frequent postoperative bleeding. A general consensus exists on the role of obesity as a possible indicator of poor quality of life and life expectancy 2‐25 …”

Section: Discussionmentioning

confidence: 99%

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Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

et al. 2020

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Background: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. Methods: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra-and postoperative data were retrospectively collected. Results: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. Conclusions: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.

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“…Main findings of this studies are represented by lower rates of transfusions in patients undergoing MIAVR, as well as shorter ICU stay and hospital length of stay, if compared to conventional surgery, without prolonged surgical time, CPB and cross-clamp time (3,(24)(25)(26)(27)(28). Furthermore, these studies report a reduced rate of pulmonary complications in patients treated with minimally invasive approaches (24)(25)(26)(27)(28).…”

Section: Commentmentioning

confidence: 74%

Minimally invasive aortic valve surgery

Bacco¹,

Miceli²,

Glauber³

2021

J Thorac Dis

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Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intraand post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.

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Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients

Cited by 24 publications

References 27 publications

Sutureless valve and rapid deployment valves: a systematic review and meta-analysis of comparative studies

Sutureless valve and rapid deployment valves: a systematic review and meta-analysis of comparative studies

Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

Minimally invasive aortic valve surgery

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