Partial Upper Sternotomy Versus Full Sternotomy For Mitral Valve Surgery: A Propensity Score Matched Analysis
Cenk U. Oezpeker, Daniel Hoefer, Fabian Barbieri, Nikolaos Bonaros, Michael Grimm, Ludwig Mueller.
Medical University of Innsbruck, Innsbruck, Austria.
Background: Minimally invasive mitral valve surgery (MIMVS) through anterolateral mini-thoracotomy (MT) has become the standard therapy for isolated mitral valve disease in experienced centers. Multiple valve disease or other anatomical and certain clinical conditions, however, make this access not suitable for some patients and conventional full sternotomy (FS) is the mostly preferred alternative approach. For those patients partial upper sternotomy (PS) can be used as a less invasive access. Whereas FS has been widely investigated, there are not enough insights to the PS approach for mitral valve surgery (MVS). Therefore we compared the data of both accesses. Methods: This retrospective analysis includes data on 1639 patients, who underwent either isolated or combined primary MVS at our department from May 2011 to August 2017. Out of these, 1191 patients were excluded from this analysis due to MT access (n=663) and due to concomitant coronary artery bypass surgery but also because of re-do cases, concomitant aortic surgery or urgent/salvage MVS (n=528). Finally 99 patients who had been judged suitable for PS. In addition, 349 patients with FS for primary MVS were included in our study. To reduce the possibility of selection bias a 1:1 propensity-score matchmaking was performed which resulted in 98 pairs. Results: During a median follow-up time of 1491 days (478-2186; PS 1103 [331- 1806 days], FS 2180 days [841-3054]) all-cause mortality was 15.90% (70 of 439 patients). In the propensitiy score paired model, PS showed statistically significant superior survival compared to FS at 30 days (p=0.044, hazard ratio (HR) 7.525, 95 % confidence interval (CI) 1.06-53.56. Furthermore, 90- and 365 days survival after surgery showed a similiar trend, but without reaching statistical significance (p=0.096 and p=0.077). As secondary endpoints number of second pump runs and hospital length of stay were significantly less (p=0.016, p<0.001) in PS patients. Conclusion: The less invasive PS approach for MVS seems to have short- and long-term survival benefits. In patients who are not candidates for MT PS seem a favorable approach although prospective randomized-controlled trials are necessary for confirmation.
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