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Aortic Valve Replacement via Right Minithoracotomy Versus Median Sternotomy: A Propensity Score Analysis

Glower, Donald D. MD; Desai, Bhargavi S. BS; Hughes, G. Chad MD; Milano, Carmelo A. MD; Gaca, Jeffrey G. MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2014 - Volume 9 - Issue 2 - p 75–81
doi: 10.1097/IMI.0000000000000062
Original Articles

Objective The aim of this study was to define the relative role of a right minithoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR).

Methods A retrospective analysis was performed of all 1348 patients undergoing isolated, open AVR at a single institution during a 14-year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n = 20), all redo patients (n = 209) were excluded, leaving 1139 patients available for analysis. Patients converting from RT to ST approach (n = 15) were analyzed separately.

Results Relative to ST (n = 672), the RT patients (n = 452) were older with more stenosis but with more recent operation year, lower rate of congestive heart failure, higher ejection fraction, lower rate of endocarditis, and lower rate of renal disease than the ST AVR patients (all P < 0.0001). Right minithoracotomy AVR was associated with longer cardiopulmonary bypass times [157 (25) vs 131 (38), P = 0.0004] and clamp times [103 (20) vs 85 (27), P < 0.0001] but less transfusion (1.4 vs 3.4 U, P = 0.0003), less chest tube output (405 vs 950 mL, P < 0.0001), fewer reoperations for bleeding (0.4% vs 4%, P < 0.0001), shorter length of stay (6 vs 8 days, P = 0.03), and lower rate of atrial fibrillation (15% vs 20%, P = 0.03). Stroke, operative mortality, and survival were not significantly different between the groups.

Conclusions Given the biases of retrospective propensity-adjusted analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients, with advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times.

From the Department of Surgery, Duke University Medical Center, Durham, NC USA.

Accepted for publication December 30, 2013.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 12–15, 2013, Prague, Czech Republic.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Donald D. Glower, MD, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710 USA. E-mail:

©2014 by the International Society for Minimally Invasive Cardiothoracic Surgery