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

Nguyen, Tom C. MD; Thourani, Vinod H. MD; Pham, Justin Q. MD; Zhao, Yelin MS; Terwelp, Matthew D. MD; Balan, Prakash MD; Ocazionez, Daniel MD; Loghin, Catalin MD; Smalling, Richard W. MD; Estrera, Anthony L. MD; Lamelas, Joseph MD

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: January/February 2017 - Volume 12 - Issue 1 - p 33–40
doi: 10.1097/IMI.0000000000000338
Original Articles

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, cerebrovascular 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.

From the *Department of Cardiothoracic Surgery, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA; †Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA USA; ‡Division of Cardiology, Department of Internal Medicine, Memorial Hermann Hospital, University of Texas Medical School at Houston, Heart and Vascular Institute, Houston, TX USA; §Department Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Memorial Hermann Hospital, Houston, TX USA; and ∥Department of Cardiac Surgery, Mount Sinai Medical Center, Miami Beach, FL USA.

Accepted for publication December 7, 2016.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 15–18, 2016, Montreal, QC, Canada.

Disclosures: Vinod H. Thourani, MD, is a consultant for Edwards Lifesciences Corp, Irvine, CA USA, Medtronic, Inc, Minneapolis, MN USA, and St. Jude Medical, Inc, St. Paul, MN USA. Richard W. Smalling, MD, is a consultant for Edwards Lifesciences Corp, Irvine, CA USA. Joseph Lamelas, MD, is a consultant for Medtronic, Inc, Minneapolis, MN USA, St. Jude Medical, St. Paul, MN USA, and ON-Q Halyard Health, Inc, Alpharetta, GA USA. Tom C. Nguyen, MD, Justin Q. Pham, MD, Yelin Zhao, MS, Matthew D. Terwelp, MD, Prakash Balan, MD, Daniel Ocazionez, MD, Catalin Loghin, MD, and Anthony L. Estrera, MD, declare no conflicts of interest.

Address correspondence and reprint requests to Tom C. Nguyen, MD, Department of Cardiothoracic Surgery, University of Texas, Memorial Hermann, 6400 Fannin St, Suite 2850, Houston, TX 77030 USA. E-mail: tom.c.nguyen@gmail.com.

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery