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OBJECTIVE: The small incisions of minimally invasive surgery have the proposed benefit of less trauma, pain, and improved cosmetic outcome; all of which correspond to faster postoperative recovery. Opponents claim smaller incisions lead to poor exposure, making the operation longer, more difficult and dangerous. Here, we report our experience performing minimally invasive aortic valve replacements (AVRs), via minimally invasive anterior thoracotomy or mini-sternotomy approach, compared to conventional sternotomy.
METHODS: All data were collected from the Robert Wood Johnson University Hospital Cardiac Surgery Database. A total of 189 AVRs were completed from January 2012-December 2013 using one of three techniques: 1) Mini-thoracotomy 2) Mini-sternotomy 3) Conventional sternotomy. Preoperative comorbidities and aortic valve dysfunction were compared, along with operative morbidity and mortality, length of hospitalization, and postoperative complications.
RESULTS: Of the 189 cases, 82(43.4%) were mini-thoracotomy, 44(23.3%) mini-sternotomy, and 63(33.3%) conventional sternotomy. Analysis of postoperative complications revealed that the mini-thoracotomy approach, compared to the mini-sternotomy and conventional sternotomy, had a lower incidence of prolonged ventilator support [2.4% vs. 11.4% and 11.1%, respectively(p = 0.054)]. Further, the mini-thoracotomy approach, compared to the mini-sternotomy and conventional sternotomy, required a shorter ICU stay [38.3 vs. 62.8 and 92.7 hours, respectively(p<0.05)] and shorter postoperative length of stay [6.5 vs. 9.4 and 9.3 days, respectively(p<0.05)], resulting in an overall shorter hospitalization [8.8 vs. 12.8 and 14.7 days, respectively(p<0.05)]. Incidence of stroke [1.2% vs. 2.3% and 1.6%, respectively(p=1.0)], reoperation for bleeding [4.8% vs. 6.8% and 4.8%, respectively(p=0.84)], renal failure [6.1% vs. 9.1% and 6.4%, respectively(p=0.82)], and atrial fibrillation [21.9% vs. 34.1% and 23.8%, respectively(p=0.34)], were lower in the mini-thoracotomy group compared to the mini-sternotomy and conventional sternotomy; however, these differences were not statistically significant. Overall, minimally invasive techniques demonstrated a trend towards better survival [mini-thoracotomy 2.4%, mini-sternotomy 2.3%, and conventional sternotomy 4.8%(p=0.77)].
CONCLUSIONS: Minimally invasive AVR is a safe and effective alternative to conventional sternotomy. The mini-thoracotomy approach showed a decrease in postoperative ventilation time, a decrease in length of ICU stay, and a decrease in overall duration of hospitalization. Finally, postoperative morbidity and mortality trended towards being lower following mini-thoracotomy when compared to mini-sternotomy and conventional sternotomy.