Partial versus Complete Sternotomy for Aortic Valve Replacement—Multicenter Study

Abstract

Background The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort.

Methods A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy.

Results Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy.

Conclusion In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Keywords

root - aortic valve surgery - minimally invasive surgery - outcomes - surgery/incision

Note

The study results were presented at the 52nd Annual Meeting of the German Society for Thoracic, Cardiac, and Vascular Surgery (DGTHG) in Hamburg, Germany, February 11–14, 2023. The abstract has been awarded the Hans Georg Borst Award for highest ranking in the review process.

Authors' Contribution

Conception and design of the study were performed by N.G., F.S., R.F., H.D., H.H., P.M., M.S., T.F., D.F., and U.F. Acquisition, analysis, and interpretation of data by N.G., T.S., F.P., K.H., H.J., J.S., C.S., T.Z., Y.E., and S.H. Drafting the manuscript by N.G., T.S., F.P., K.H., H.H., P.M., and U.F. Critical revision of the manuscript by H.J., J.S., C.S., T.Z., Y.E., F.S., R.F., H.D., M.S., S.H., T.F., and D.F. All authors approved the final manuscript version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Publikationsverlauf

Eingereicht: 22. November 2023

Angenommen: 27. Februar 2024

Artikel online veröffentlicht:
16. April 2024

• References

• 1 Reichenspurner H, Gulielmos V, Daniel WG, Schüler S. Minimally invasive coronary-artery bypass surgery. N Engl J Med 1997; 336 (01) 67-68
• 2 Carpentier A, Loulmet D, Carpentier A. et al. Open heart operation under videosurgery and minithoracotomy. First case (mitral valvuloplasty) operated with success]. C R Acad Sci III 1996; 319 (03) 219-223
• 3 Tam RK, Almeida AA. Minimally invasive aortic valve replacement via partial sternotomy. Ann Thorac Surg 1998; 65 (01) 275-276
• 4 Knuuti J, Wijns W, Saraste A. et al; ESC Scientific Document Group. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41 (03) 407-477
• 5 Vahanian A, Beyersdorf F, Praz F. et al. ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2021; •••: 2021
• 6 Beckmann A, Meyer R, Lewandowski J, Markewitz A, Blaßfeld D, Böning A. German Heart Surgery Report 2022: the annual updated registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2023; 71 (05) 340-355
• 7 Merk DR, Lehmann S, Holzhey DM. et al. Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison. Eur J Cardiothorac Surg 2015; 47 (01) 11-17 , discussion 17
• 8 Paparella D, Malvindi PG, Santarpino G. et al. Full sternotomy and minimal access approaches for surgical aortic valve replacement: a multicentre propensity-matched study. Eur J Cardiothorac Surg 2020; 57 (04) 709-716
• 9 Bonacchi M, Prifti E, Giunti G, Frati G, Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg 2002; 73 (02) 460-465 , discussion 465–466
• 10 Doll N, Borger MA, Hain J. et al. Minimal access aortic valve replacement: effects on morbidity and resource utilization. Ann Thorac Surg 2002; 74 (04) S1318-S1322
• 11 Furukawa N, Kuss O, Aboud A. et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients. Eur J Cardiothorac Surg 2014; 46 (02) 221-226 , discussion 226–227
• 12 Tabata M, Umakanthan R, Cohn LH. et al. Early and late outcomes of 1000 minimally invasive aortic valve operations. Eur J Cardiothorac Surg 2008; 33 (04) 537-541
• 13 Russo MJ, Thourani VH, Cohen DJ. et al. Minimally invasive versus full sternotomy for isolated aortic valve replacement in low-risk patients. Ann Thorac Surg 2021
• 14 Kirmani BH, Jones SG, Malaisrie SC, Chung DA, Williams RJ. Limited versus full sternotomy for aortic valve replacement. Cochrane Database Syst Rev 2017; 4 (04) CD011793
• 15 Zaouter C, Oses P, Assatourian S, Labrousse L, Rémy A, Ouattara A. Reduced length of hospital stay for cardiac surgery-implementing an optimized perioperative pathway: prospective evaluation of an enhanced recovery after surgery program designed for mini-invasive aortic valve replacement. J Cardiothorac Vasc Anesth 2019; 33 (11) 3010-3019
• 16 Di Eusanio M, Berretta P, Alfonsi J. et al. [Surgical treatment of aortic valve disease: early results of a 360° minimally invasive approach]. G Ital Cardiol (Rome) 2019; 20 (09) 523-528
• 17 Torres A, Niederman MS, Chastre J. et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50 (03) 50
• 18 Yu PJ, Cassiere HA, Fishbein J, Esposito RA, Hartman AR. Outcomes of patients with prolonged intensive care unit length of stay after cardiac surgery. J Cardiothorac Vasc Anesth 2016; 30 (06) 1550-1554
• 19 Imazio M, Brucato A, Rovere ME. et al. Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. Am J Cardiol 2011; 108 (08) 1183-1187
• 20 Boyle Jr EM, Gillinov AM, Cohn WE, Ley SJ, Fischlein T, Perrault LP. Retained blood syndrome after cardiac surgery: a new look at an old problem. Innovations (Phila) 2015; 10 (05) 296-303
• 21 Shehada SE, Elhmidi Y, Mourad F. et al. Minimal access versus conventional aortic valve replacement: a meta-analysis of propensity-matched studies. Interact Cardiovasc Thorac Surg 2017; 25 (04) 624-632
• 22 Rewa O, Bagshaw SM. Acute kidney injury-epidemiology, outcomes and economics. Nat Rev Nephrol 2014; 10 (04) 193-207
• 23 Shehada SE, Öztürk Ö, Wottke M, Lange R. Propensity score analysis of outcomes following minimal access versus conventional aortic valve replacement. Eur J Cardiothorac Surg 2016; 49 (02) 464-469 , discussion 469–470