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OUTCOME OF ISOLATED, OPEN AORTIC VALVE REPLACEMENT VIA RIGHT MINI-THORACOTOMY VERSUS MEDIAN STERNOTOMY IN 1371 PATIENTS
Donald Glower, Bhargavi Desai, G. Chad Hughes, Carmelo A. Milano, Jeffrey G. Gaca.
Duke Univ Med Ctr, Durham, NC, USA.

OBJECTIVE: To define the relative role, advantages and disadvantages of a right mini-thoracotomy (RT) versus standard median sternotomy (ST) for open aortic valve replacement (AVR).
METHODS: A retrospective analysis was performed of all 1371 patients undergoing isolated, open aortic valve replacement at single institution over a 14 year period. Because relatively few patients were technically suitable for redo AVR with the RT approach (n=21), all redo patients (n=211) were excluded, leaving 1160 patients available for analysis. Patients were selected for RT versus ST approach by patient or surgeon choice.
RESULTS: Relative to ST (N=700), patients undergoing RT AVR (N=460) were older (67±13 v 63±14, p<0.0001) with more stenosis (88% v 76%, p<0.0001) and less regurgitation (31% v 42%, p<0.0001) but with more recent operation year (2008 v 2003, p<0.0001), less CHF (NYHA Class II v III, p<0.0001), higher EF (55±9 v 52±13, p<0.0001), less endocarditis (2% v 9%, p<0.0001), and less renal disease (8% v 18%, p<0.001) than ST AVR patients. Conversion to ST occurred in 16(1.36 %) of RT patients. RT AVR was associated with longer cardiopulmonary bypass times (156±25 v 134±40, p<0.0001) and clamp times (101±21 v 86±28, p<0.0001), but less transfusion (1.4 v 3.7U, p<0.0001), less chest tube output (404 v 992ml, p<0.0001), less reoperation for bleeding (0.4% v 4%, p<0.0001), shorter length of stay (6 v 8 dy, p<0.0001), less sternal infection (0% v 2%, p=0.001), and less atrial fibrillation (14% v 21%, p<0.01). Operative mortality, stroke, and pneumonia and long term multivariable survival were not significantly different between groups. With experience, one surgeon ultimately performed 446/463 (96 %) of selected, isolated, first time AVR using RT approach.
CONCLUSIONS: Given the biases of a retrospective analysis, these data suggest that RT AVR is a safe alternative to ST AVR in selected patients. RT AVR may have advantages of avoiding sternotomy with associated bleeding, transfusion, and delayed wound healing, at the expense of longer pump and clamp times. These results suggest that the RT platform may have value in TAVR and sutureless AVR.


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