Postoperative quality of life and pain after upper hemisternotomy and conventional median sternotomy for aortic valve replacement: results of a randomized clinical trial

Abstract

OBJECTIVES Surgical aortic valve replacement through conventional sternotomy yields excellent results. Minimally invasive techniques are deemed equally safe and serve as a viable and less traumatic alternative. However, it is unclear how both surgical techniques affect patient reported outcomes. The objective of this trial is to compare postoperative cardiac-related quality of life and postoperative pain after upper hemisternotomy and conventional surgical aortic valve replacement. METHODS In this single centre, open-label, investigator-initiated randomized clinical trial, patients were randomized to upper hemisternotomy or conventional full median sternotomy. Patients unable to undergo randomization were monitored prospectively (registry group). Primary outcome was cardiac specific quality of life, measured with the Kansas City Cardiomyopathy Questionnaire up to one year postoperatively. RESULTS Patients undergoing upper hemisternotomy had a significantly higher physical limitation domain score across all post-operative time points than patients undergoing conventional surgical aortic valve replacement (estimated mean difference 2.12 points; p = 0.014). Patients undergoing upper hemisternotomy were more likely to have a pain score <30 the first two days postoperatively than patients undergoing conventional surgical aortic valve replacement (Odds Ratio 2.63; p = 0.007). This was associated with reduced opioid analgesic intake. Postoperative surgical outcome did not differ between both groups. CONCLUSIONS Surgical aortic valve replacement through both conventional sternotomy and upper hemisternotomy resulted in clinically similar and important improvements in quality of life, with a small advantage for upper hemisternotomy, while there was no compromise in safety.