Alternative incision sutureless aortic valve replacement: propensity matched comparison between partial sternotomy and right anterior minithoracotomy.

BACKGROUND: Sutureless aortic valve prostheses have the potential to augment the adoption of alternative incision approaches for aortic valve replacement (AVR). Still, we lack the evidence on which surgical approach is best associated with sutureless AVR. METHODS: Data on 483 patients undergoing sutureless small incision AVR between 2010-2014 in two European institutions (207 with ministernotomy [MS] and 276 via right anterior minithoracotomy [RAMT]) have been retrospectively analyzed. After propensity score matching, 160 pairs of patients have been selected. RESULTS: No significant difference for in-hospital mortality was observed between MS and RAMT (P=0.12). Both perfusion and aortic cross-clamping times were longer in RAMT group (P<0.0005). Lower incidence of third degree atrioventricular block requiring pacemaker implantation (P=0.04), shorter ventilation times (P<0.0005) and less requirement for pleural drainage/thoracentesis (P=0.007) have been registered in the RAMT group. Follow-up was shorter for RAMT group (14.6 vs. 21.7 months, P<0.0005). Survival by Kaplan-Meier was comparable both for unmatched (P=0.79) and matched (P=0.90) cohorts. Cox regression analysis showed no statistically significant difference for mid-term survival between the two approaches (P=0.95 for intercohort comparison [MS vs. RAMT]). Mid-term survival by Cox multivariable proportional hazards regression model was associated with two independent predictors: preoperative left ventricular ejection fraction (P=0.021) and prolonged (>24 h) assisted ventilation (P=0.001). CONCLUSIONS: Small incision sutureless AVR through both partial sternotomy and right anterior minithoracotomy provides excellent clinical outcomes. Right anterior minithoracotomy, though associated with longer operative times compared to partial sternotomy, may result in less perioperative morbidity, with no difference in early and mid-term survival.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients.

BACKGROUND: To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period. METHODS: From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT. RESULTS: The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %. CONCLUSIONS: Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Minimally invasive mitral valve repair through right minithoracotomy in the setting of degenerative mitral regurgitation: early outcomes and long-term follow-up.

BACKGROUND: Mitral valve (MV) repair is the gold standard for the treatment of degenerative MV regurgitation. Recently, minimally invasive mitral valve surgery (MIMVS) has shown excellent postoperative outcomes compared with conventional surgery. The aim of our study is to report early and long-term outcomes of patients undergoing MIMVS through right mini-thoracotomy (RT) over an eight year period. METHODS: From September 2003 to December 2011, a total of 1,604 consecutive patients underwent MIMVS through RT. RESULTS: The mean age was 62±13 years, 295 (42%) patients were female and 16 (2.3%) had previous cardiac operations. MV repair was successfully performed in 670 patients, with a rate of success of 95.3%. Repair techniques included annuloplasty (89%), leaflet resection (n=54.2%), neochordae implantation (12.1%), and sliding plasty (10.5%). Overall in-hospital mortality was 0.1%. Incidence of stroke was 1.3%. At eight-year follow-up, overall survival was 90.1%, freedom from reoperation 93%, and freedom from recurrent mitral regurgitation was 90%. CONCLUSIONS: MIMV repair through right minithoracotomy is a safe and reproducible procedure associated with high rate of MV repair, and excellent early postoperative and long-term results.

Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study.

OBJECTIVE: Minimally invasive aortic valve surgery by way of a right anterior minithoracotomy has shown excellent results in terms of mortality, morbidities, and patient satisfaction. The aim of the present study was to compare minimally invasive aortic valve surgery by way of a right anterior minithoracotomy with conventional full sternotomy on early outcomes and midterm survival. METHODS: A retrospective, observational, cohort study was undertaken of prospectively collected data from 637 consecutive patients undergoing isolated aortic valve surgery from January 2005 to July 2010. Of the 637 patients, 192 (30%) underwent minimally invasive aortic valve surgery by way of a right anterior minithoracotomy. Of these, 138 patients (right anterior minithoracotomy group) were matched to a control group (full sternotomy group) using propensity score analysis. RESULTS: The baseline characteristics were similar in both groups. The overall in-hospital mortality was 0.7% (2/276), with no difference between the 2 groups. Minimally invasive aortic valve surgery by way of a right anterior minithoracotomy was associated with a lower incidence of postoperative atrial fibrillation (25 [18.1%] vs 41 [29.7%]; P = .003) and blood transfusions (26 [18.8%] vs 47 [34.1%]; P = .0006). In addition, patients in the right anterior minithoracotomy group had a shorter mechanical ventilation time (median, 6 vs 8 hours; P = .004) and postoperative length of stay (median, 5 vs 6 days; P = .02). The occurrence of stroke, renal failure, reexploration for bleeding, and wound infection was similar in both groups. At a median follow-up of 30 months (range, 17-54 months), survival was 96% ± 2% vs 88% ± 4% (P = .3). CONCLUSIONS: Right anterior minithoracotomy in patients undergoing isolated aortic valve surgery is associated with a lower incidence of postoperative atrial fibrillation and blood transfusion and shorter ventilation time and hospital length of stay. Prospective randomized trials are needed to confirm our data.

Evaluation of platelet count after isolated biological aortic valve replacement with Freedom Solo bioprosthesis.

OBJECTIVE: The risk of thrombocytopenia in patients undergoing aortic valve replacement (AVR) with the Freedom Solo (FS) bioprosthesis is controversial. The aim of our study was to evaluate the postoperative evolution of platelet count and function after AVR in patients undergoing isolated biological AVR with FS. METHODS: Between May 2005 and June 2010, 322 patients underwent isolated biological AVR. Of these, 116 patients received FS and were compared with 206 patients who received biological valves. Platelet count, mean platelet volume (MPV), and platelet distribution width (PDW) were evaluated at baseline (T0), first (T1), second (T2), and fifth (T3) postoperative days, respectively. RESULTS: Overall in-hospital mortality was 1.5% with no difference between the two groups. Thirty-seven (11.5%) patients developed thrombocytopenia. FS implantation was associated with a higher incidence of thrombocytopenia compared with the control group (24.1% vs 4.4%, p<0.0001). Patients in the FS group showed a lower platelet count than the control group at T1 (99.4±38×10(3) µl(-1) vs 122.5±41.6×10(3) µl(-1), p<0.001), T2 (79.7±36.3×10(3) µl(-1) vs 122.5±43.3×10(3) µl(-1), p<0.001) and T3 (86.6±57.4×10(3) µl(-1) vs 158.4±55.8×10(3) µl(-1), p<0.001). Moreover, the FS group also had a higher MPV (11.6±0.9 fl vs 11±1 fl, p<0.001) and higher PDW (15.1±2.3 fl vs 13.9±2.1 fl, p<0.001) at T3. In a multivariable analysis, FS (p<0.0001), body surface area (p<0.0001), cardiopulmonary bypass time (p=0.003), and lower preoperative platelet counts (p=0.006) were independent predictors of thrombocytopenia. CONCLUSIONS: The FS valve might increase the risk of thrombocytopenia and platelet activation, in the absence of adverse clinical events. Prospective randomized studies on platelet function need to confirm our data.