Traditional Sternotomy versus Minimally Invasive Aortic Valve Replacement in Patients Stratified by Ejection Fraction

Abstract

Objective

Low ejection fraction (EF < 40%) portends adverse outcomes in patients undergoing valvular heart surgery. The role of traditional median sternotomy aortic valve replacement (SAVR) compared with minimally invasive aortic valve replacement (MIAVR) in this cohort remains incompletely understood.

Methods

A multi-institutional retrospective review of 1503 patients who underwent SAVR (n = 815) and MIAVR via right anterior thoracotomy (n = 688) from 2011 to 2014 was performed. Patients were stratified into two groups: EF of less than 40% and EF of 40% or more. In each EF group, SAVR and MIAVR patients were propensity matched by age, sex, body mass index, race, diabetes, hypertension, dyslipidemia, dialysis, cerebrovascular disease, cardiovascular disease, cerebro-vascular accident, peripheral vascular disease, last creatinine level, EF, previous MI and cardiogenic shock, and the Society for Thoracic Surgeons (STS) score.

Results

Among patients with an EF of 40% or more (377 pairs), patients who underwent MIAVR compared with SAVR had decreased intensive care unit hours (56.8% vs 84.6%, P < 0.001), postoperative length of stay (7.1 vs 7.9 days, P = 0.04), incidence of atrial fibrillation (18.8% vs 38.7%, P < 0.001), bleeding (0.8% vs 3.2%, P = 0.04), and a trend toward decreased 30-day mortality (0.3% vs 1.3%, P = 0.22). The STS scores were largely equivalent in patients undergoing MIAVR compared with SAVR (2.4% vs 2.6%, P = 0.09). In patients with an EF of less than 40% (35 pairs), there was no difference in intensive care unit hours (69% vs 72.6%, P = 0.80), postoperative length of stay (10.3 vs 7.2 days, P = 0.13), 30-day mortality (3.8% vs 0.8%, P = 0.50), or the STS score (3.3% vs 3.2%, P = 0.68).

Conclusions

Minimally invasive aortic valve replacement in patients with preserved EF was associated with improved short-term outcomes compared with SAVR. In patients with left ventricular dysfunction, short-term outcomes between MIAVR and SAVR are largely equivalent.

Keywords

Aortic valve disease Aortic valve replacement Minimally invasive surgery Left ventricular dysfunction

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References

Pai

R.G.

, Varadarajan

, Razzouk

Survival benefit of aortic valve replacement in patients with severe aortic stenosis with low ejection fraction and low gradient with normal ejection fraction. Ann Thorac Surg. 2008; 86: 1781–1789.

Connolly

H.M.

, Oh

J.K.

, Orszulak

T.A.

Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators. Circulation. 1997; 95: 2395–2400.

Parikh

, Goodman

A.L.

, Barr

Outcomes of surgical aortic valve replacement for severe aortic stenosis: incorporation of left ventricular systolic function and stroke volume index. J Thorac Cardiovasc Surg. 2015; 149: 1558–1566.

Chaliki

H.P.

, Mohty

, Avierinos

J.F.

Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation. 2002; 106: 2687–2693.

Vaquette

, Corbineau

, Laurent

Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: predictors of operative risk, left ventricular function recovery, and long term outcome. Heart. 2005; 91: 1324–1329.

Flores-Marín

, Gómez-Doblas

J.J.

, Caballero-Borrego

Long-term predictors of mortality and functional recovery after aortic valve replacement for severe aortic stenosis with left ventricular dysfunction. Rev Esp Cardiol. 2010; 63: 36–45.

Rao

P.N.

, Kumar

A.S.

Aortic valve replacement through right thoracotomy. Tex Heart Inst J. 1993; 20: 307–308.

Cosgrove

III , Sabik

J.F.

Minimally invasive approach for aortic valve operations. Ann Thorac Surg. 1996; 62: 596–597.

Cohn

L.H.

, Adams

D.H.

, Couper

G.S.

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997; 226: 421–428.

10.

Benetti

F.J.

, Mariani

M.A.

, Rizzardi

J.L.

, Benetti

Minimally invasive aortic valve replacement. J Thorac Cardiovasc Surg. 1997; 113: 806–807.

11.

Malaisrie

S.C.

, Barnhart

G.R.

, Farivar

R.S.

Current era minimally invasive aortic valve replacement: techniques and practice. J Thorac Cardiovasc Surg. 2014; 147: 6–14.

12.

Bakir

, Casselman

F.P.

, Wellens

Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients. Ann Thorac Surg. 2006; 81: 1599–1604.

13.

Brown

M.L.

, McKellar

S.H.

, Sundt

T.M.

, Schaff

H.V.

Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009; 137: 670–679.

14.

Glauber

, Miceli

, Gilmanov

Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg. 2013; 145: 1222–1226.

15.

Korach

, Shemin

R.J.

, Hunter

C.T.

, Bao

, Shapira

O.M.

Minimally invasive versus conventional aortic valve replacement: a 10-year experience. J Cardiovasc Surg (Torino). 2010; 51: 417–421.

16.

Attia

R.Q.

, Hickey

G.L.

, Grant

S.W.

Minimally invasive versus conventional aortic valve replacement: a propensity-matched study from the UK national data. Innovations. 2016; 11: 15–23.

17.

Bonacchi

, Prifti

, Giunti

, Frati

, Sani

Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg. 2002; 73: 460–466.

18.

Bowdish

M.E.

, Hui

D.S.

, Cleveland

J.D.

A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients. Eur J Cardiothorac Surg. 2016; 49: 456–463.

19.

Gilmanov

, Bevilacqua

, Murzi

Minimally invasive and conventional aortic valve replacement: a propensity score analysis. Ann Thorac Surg. 2013; 96: 837–843.

20.

Lim

J.Y.

, Deo

S.V.

, Altarabsheh

S.E.

Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg. 2015; 30: 125–134.

21.

Murtuza

, Pepper

J.R.

, Stanbridge

R.D.

Minimal access aortic valve replacement: is it worth it?

Ann Thorac Surg. 2008; 85: 1121–1131.

22.

Neely

R.C.

, Boskovski

M.T.

, Gosev

Minimally invasive aortic valve replacement versus aortic valve replacement through full sternotomy: the Brigham and Women's Hospital experience. Ann Cardiothorac Surg. 2015; 4: 38–48.

23.

Phan

, Xie

, Di Eusanio

, Yan

T.D.

A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg. 2014; 98: 1499–1511.

24.

Sharony

, Grossi

E.A.

, Saunders

P.C.

Minimally invasive aortic valve surgery in the elderly: a case-control study. Circulation. 2003; 108(Suppl 1): II43–II47.

25.

Candaele

, Herijgers

, Demeyere

, Flameng

, Evers

Chest pain after partial upper versus complete sternotomy for aortic valve surgery. Acta Cardiol. 2003; 58: 17–21.

26.

Genereux

, Cohen

D.J.

, Williams

M.R.

Bleeding complications after surgical aortic valve replacement compared with transcatheter aortic valve replacement: insights from the PARTNER I Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol. 2014; 63: 1100–1109.

27.

Lindman

B.R.

, Pibarot

, Arnold

S.V.

Transcatheter versus surgical aortic valve replacement in patients with diabetes and severe aortic stenosis at high risk for surgery: an analysis of the PARTNER Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol. 2014; 63: 1090–1099.

28.

Tabata

, Aranki

S.F.

, Fox

J.A.

, Couper

G.S.

, Cohn

L.H.

, Shekar

P.S.

Minimally invasive aortic valve replacement in left ventricular dysfunction. Asian Cardiovasc Thorac Ann. 2007; 15: 225–228.

29.

Downs

E.A.

, Johnston

L.E.

, LaPar

D.J.

Minimally invasive mitral valve surgery provides excellent outcomes without increased cost: a multi-institutional analysis. Ann Thorac Surg. 2016; 102: 14–21.

30.

Connolly

H.M.

, Oh

J.K.

, Schaff

H.V.

Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction: result of aortic valve replacement in 52 patients. Circulation. 2000; 101: 1940–1946.

31.

Monin

J.L.

, Monchi

, Gest

, Duval-Moulin

A.M.

, Dubois-Rande

J.L.

, Gueret

Aortic stenosis with severe left ventricular dysfunction and low transvalvular pressure gradients: risk stratification by low-dose dobutamine echocardiography. J Am Coll Cardiol. 2001; 37: 2101–2107.

32.

Pereira

J.J.

, Lauer

M.S.

, Bashir

Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol. 2002; 39: 1356–1363.

33.

Sharma

U.C.

, Barenbrug

, Pokharel

, Dassen

W.R.

, Pinto

Y.M.

, Maessen

J.G.

Systematic review of the outcome of aortic valve replacement in patients with aortic stenosis. Ann Thorac Surg. 2004; 78: 90–95.

34.

Tribouilloy

, Levy

, Rusinaru

Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol. 2009; 53: 1865–1873.

35.

Barreto-Filho

J.A.

, Wang

, Dodson

J.A.

Trends in aortic valve replacement for elderly patients in the United States, 1999–2011. JAMA. 2013; 310: 2078–2085.

36.

Dunning

, Gao

, Chambers

Aortic valve surgery: marked increases in volume and significant decreases in mechanical valve use—an analysis of 41,227 patients over 5 years from the Society for Cardiothoracic Surgery in Great Britain and Ireland National database. J Thorac Cardiovasc Surg. 2011; 142: 776–782.