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A combined approach to furtherly reduce the invasiveness of aortic valve replacement through ministernotomy
Pier G. Bruno, Piero Farina, Alessandro Di Cesare, Natalia Pavone, Andrea Mazza, Massimo Massetti.
Gemelli Hospital, Rome, Italy.
OBJECTIVE: Straight upper ministernotomy is an appealing technique for minimally invasive aortic valve replacement (MIAVR): the operative procedure is virtually the same as in full sternotomy and an immediate convertion is possible in case of complications. In order to reduce operative times and incision size (up to 3cm of skin incision), without affecting exposure and myocardial protection, we evaluated the results of the combined use of rapid deployment prosthesis (RDV), percutaneous cardioplegia delivery (PCD) and percutaneous left heart venting (PLHV).
METHODS: using propensity score matching, we restrospectively identified three cohorts of patients submitted to isolated MIAVR at our center over a three-year period: MIAVR with conventional prosthesis (group A, 108 patients), MIAVR with RDV (group B, 108 patients) and MIAVR with RDV, PCD and PLHV (group C, 53 patients). Incision size, intraoperative times (total operative, cardiopulmonary bypass (CPB) and cross-clamping) and postoperative in-hospital outcomes (use of inotropes, time at extubation, ICU length of stay, need for blood transfusion, revision for bleeding, postoperative atrial fibrillation) were compared in the three groups.
RESULTS: patients in group C showed significantly shorter intraoperative times and a shorter skin incision when compared to groups A e B (total operative time 198.0 ± 44.4min vs 244.1 ± 43.4min vs 214.4 ± 24.2min respectively, p value <0.001; CPB time 78.7 ± 10.4min vs 100.1 ± 25.1min vs 80.9 ± 18.5min respectively, p value <0.001; cross-clamping time 54.2 ± 11.1min vs 72.1 ± 16.0min vs 54.3 ± 11.5min respectively, p value <0.001; skin incision length 3.6 ± 0.4cm vs 5.8 ± 0.6cm vs 6.0 ± 0.6cm respectively, p value <0.001) (Figure 1). Postoperative in-hospital outcomes showed no significant difference.
CONCLUSIONS: The combined use of RDV, PCD and PLHV allows a significant reduction of the incision length and of the intraoperative times. The in-hospital outcomes are similar to MIAVR with conventional prosthesis and intrathoracic left heart venting and cardioplegia delivery, confirming that the use PCD and PLHV is safe and effective. 
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