Minimally Invasive Approach for Aortic Valve Replacement Reintervention versus a Full-Sternotomy Approach. A Propensity Match Clinical Experience

Objective: Re-Operation (REDO) aortic valve surgery (AVR) can represent a surgical challenge and is generally associated to a high risk of complications and mortality. Minimally invasive approaches, as reported by few experiences, are safe and feasible for REDO. Aim of the study is to compare minimally invasive REDO strategies versus Full-Sternotomy.

Methods: From 2009 to 2016, a total of 308 patients underwent isolated AVR-REDO for aortic valve/prostheses degeneration: ninety-five underwent REDO through upper “J-shaped” mini-sternotomy (MIC-group) and 213 through conventional Full-Sternotomy (FULL-group). Acute endocarditis patients were excluded. After a Propensity Matching two groups of 81 patients were obtained. First Major Composite Endpoint (MCE) consisted in rate of re-exploration for bleeding, pericardial effusion, pleural effusion, major infections, deep sternal wound infections. Secondary endpoints were transfusion rate and Fresh Frozen Plasma/Platelet transfusion (FFP/PLT) rate.

Results: After the Propensity Match analysis no differences between groups were reported. A trend toward lower mortality rate was reported in the mini-sternotomy group (MIC: 4.9% vs FULL: 7.4%, p = 0.746). Cross Clamp Time was comparable between the two groups. In MIC was reported a low duration of Cardio-Pulmonary Bypass (MIC: 75.5 ± 29.5 minute vs FULL 85.5 ± 38.2, p = 0.054), as well as a reduced incidence of post-operative revision for bleeding (MIC: 6.2% vs FULL: 16%,p = 0.078), pleural effusion(MIC: 4.9% vs FULL: 8.6%, p = 0.534) and Infections(MIC: 2.5% vs FULL: 6.2%,p = 0.443). Moreover we found out in MIC-group a lower incidence of MCE-events (MIC: 13.6% vs FULL: 27.2%, p = 0.050). At the Binary Logistic Regression the Full-Sternotomy was depicted as predictor for MCE (OR: 2.5, 95% CI: 1.5–5.6, p = 0.025). In MIC-group was reported a shorter ICU stay (MIC: 3.1 ± 3.9 vs FULL: 4.1 ± 6.5, p = 0.263) and In-Hospital Stay duration (MIC:10.8 ± 11.4 minute vs FULL:11.4 ± 8.7, p = 0.700). Furthermore in FULL-group was reported an higher incidence of blood transfusion (MIC: 49.7% vs FULL: 66.6%, p = 0.038) and use of FFP/PLT (MIC: 16% vs. FULL: 22%, p = 0.425).

Conclusion: MI-ReAVR is a safe and feasible strategy for these subset of patients and allows a faster recovery and the improvement of early post-operative outcomes, reducing several post-operative complications when compared with Full-sternotomy.