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Right Mini-thoracotomy versus Median Sternotomy for Mitral Surgery in Patients with Chronic Renal Impairment, a Propensity Matched Study
Paul C. Tang, Mark W. Onaitis, Jeffrey G. Gaca, Carmelo A. Milano, Donald D. Glower.
Duke University Medical Center, Durham, NC, USA.

OBJECTIVE: Compared to conventional median sternotomy (MS), a right mini-thoracotomy(RT) approach to mitral surgery is associated with lower postoperative rise in creatinine and decreased incidence of acute renal failure. Therefore we retrospectively examined propensity matched patients with chronic renal impairment to compare the mortality and morbidity between the MS and RT techniques.
METHODS: We performed a retrospective review of the Duke cardiothoracic surgery database from 1986 to 2010 and identified patients who underwent mitral valve surgery. Patients who had procedures that were not usually performed through a RT approach (e.g. aortic valve or aortic surgery) were excluded. Of the 2306 patients fullfilling the above criteria, we identified 445 patients with preoperative creatinines of 1.3mg/dL or greater. Using 1:1 propensity score matching based on comorbidities, operative year and surgeon, we obtained 90 matched patients per group for outcomes analysis.
RESULTS: There was no difference in median year of operation between the two groups (2001 vs 2003, P=0.180). Mortality was 20% lower for the RT group (P=0.009) using Mantel-Cox statistics. This greater survival in the RT group occurred within the first year and was maintained on long term follow up (see figure). A RT approach was associated with a Cox proportional hazard for mortality of 0.507 (P=0.007). Incidence of complications with a RT approach was lower for new onset atrial fibrillation (21% vs 79%, P=0.046), acute renal failure (9% vs 28%, P=0.001), initiation of dialysis (6% vs 13%, p=0.074), and tracheostomy (2% vs 9%, P=0.05). Operative parameters for RT versus MS groups are duration of aortic cross clamp (68 vs 90 mins, P=0.037) and cardiopulmonary bypass (179 vs 171 mins, P=0.233). RT had lower chest tube output (490 vs 1369 mls, P<0.001) and packed red blood cell transfusions (3.4 vs 5 units, P=0.025).
CONCLUSIONS: A RT approach compared with MS was associated with lower postoperative mortality and morbidity in patients with impaired renal function. RT is preferred in this high risk population with mitral valve disease.



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