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Using the Endoclamp for Cardiac Surgery improves Patient Outcomes: A Propensity Matched Comparison with Sternotomy Patients.
Vivek Srivastava, Abdul Nasir, David Rose, Laura Howell, P. Saravanan, Andrew Knowles, Joseph Zacharias.
Victoria Hospital, Blackpool, United Kingdom.

Background: Cardiac surgery with right anterior mini-thoracotomy and use of an Endoclamp (ThruPORT approach) is now an established procedure in many developed centres. However given its added costs, it is difficult to justify in a nationalised health service. Our objective for the present study was to evaluate if the ThruPORT approach has advantages over conventional median sternotomy approach by comparing propensity-matched cohorts.
Methods: ThruPORT patients between June 2007 and September 2013 were identified from the departmental database. Using propensity matching (MatchIt software package), a comparable group was identified for similar cardiac surgery by median sternotomy approach over the same period. Outcomes for the two groups were compared using a two sample t-test or Mann-Whitney U test for continuous variables and chi-square test for categorical variables.
Results: There were 134 patients in each group with the ThruPORT group consisting of 57 (42.5%) females and the sternotomy group having 54 (40.3%) females. Mean age was 60.1 years for the ThruPORT approach and 62.4 years in the sternotomy group (p=0.15). Comorbidities and other preoperative characteristics including ventricular function and operative priority were not different between the two groups. There were 3 deaths (2.2%) in each group. Mean postoperative stay was 8.4 ± 5.9 days in the ThruPORT group while in the sternotomy group, it was 10.3 ± 8.3 days (p=0.032). Despite more redo surgery in the ThruPORT group, blood loss, incidence of reopening and blood usage were higher in the sternotomy group (p<0.001). Other outcomes were not statistically different between the two groups (Table 1).
Conclusions: The present study demonstrates that minimally invasive surgery using the Endoclamp is associated with a shorter postoperative stay and reduced blood loss translating into less blood usage. Despite the possibility of a learning curve, other complication rates were not significantly different between the two groups even though the ThruPORT cohort had longer CPB and cross-clamp times.
Table 1: Comparison of ThruPORT and Median Sternotomy Cohorts
ThruPORT (n=134)Median sternotomy (n=134)Significance (p value)
Preoperative Characteristics
Age at surgery (years) median (IQR)
mean
63.0 (51.0 to 70.0)
62.4 ± 12.8
64.5 (55.0 to 72.0)
60.1 ± 14.2
0.182
0.15
Female gender57 (42.5%)54 (40.3%)0.804
Diabetes10 (7.5%)8 (5.9%)0.808
Renal dysfunction1 (0.7%)2 (1.5%)1.000
h/o Neurological disease12 (9%)15 (11.1%)0.873
LV function good
moderate
poor
117 (87.3%)
14 (10.4%)
3 (2.2%)
119 (88.8%) 12 (9%)
3 (2.2%)
0.948
Operative priority elective
urgent
emergency
125 (93.3%)
9 (6.7%)
0
124 (92.5%)
9 (6.7%)
1 (0.7%)
1.000
Redo surgery13 (9.7%)9 (6.7%)0.505
mean additive EuroSCORE I5.05 ± 2.65.19 ± 2.360.652
Intraoperative characteristics
mean CPB time (min.)191.32 ± 50131.2 ± 51<0.001
mean cross-clamp time (min.)123.73 ± 49.192.8 ± 37.2<0.001
Postoperative Outcomes
Deaths3 (2.2%)3 (2.2%)1.000
Pulmonary complications11 (8.2%)14 (10.7%)0.534
New haemofiltration1 (0.7%)3 (2.2%)0.135
Neurological complications4 (2.9%)5 (3.7%)0.899
reoperation for bleeding1 (0.7%)5 (3.7%)0.213
Blood loss (1st 12 hrs) - median (IQR)220 ml (160.0 to 320.0)390 ml (260.0 to 645.0)<0.001
Donor blood used1 (0.8%)20 (14.9%)<0.001
median CSU stay days110.504
Postop stay days mean
median (IQR)
8.4 ± 5.9
7 (5.0 to 9.0)
10.3 ± 8.3
8 (6.0 to 12.0)
0.032
0.007


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