Trans-right Axillary Aortic Valve Replacement : Propensity Score-matched Analysis
Masayoshi Tokoro, Toshiaki Ito, Atsuo Maekawa, Sadanari Sawaki, Junji Yanagisawa, Takahiro Ozeki, Mamoru Orii, Toshiyuki Saiga.
Japanese Red Cross Nagoya Daiich Hospital, Nagoya City, Aich Pref., Japan.
OBJECTIVE: Minimally invasive aortic valve replacement (MIAVR) is usually performed through partial sternotomy, or thoracotomy in the anterior chest wall. In 2012, we began performing MIAVR through a right axillary longitudinal incision for over 100 patients. This trans-right axillary aortic valve replacement (TAX-AVR) was apparently advantageous in terms of its cosmetic outcome. The aim of this study is to compare the safety and less invasiveness of TAX-AVR with those of conventional AVR(C-AVR).
METHODS: Surgery: The patient was set in partial left lateral position and cardio-pulmonary bypass was established through the right groin. A small thoracotomy was made through the right axillary skin incision. The ascending aorta was cross clamped. Endoscopic assist was used, and all sutures were tied using a knot-pusher. Comparison with C-AVR: Between January 2007 and November 2016, 388 patients underwent isolated AVR at our institution. Of them, 123 underwent TAX-AVR, 226 C-AVR, and 39 parasternal AVR. From C-AVR, emergency cases and patients with severely calcified aorta were excluded, and 192 cases were enrolled as control group. Propensity matching between TAX-AVR and C-AVR patients generated 119 matched pairs. Early outcomes were compared in these 238 patients. Primary endpoints were major adverse cardiac and cerebral events(MACCE). Secondary endpoint was postoperative hospitalization.
RESULTS: After matching, there were no longer any significant differences in background. One patient was converted to sternotomy from TAX-AVR due to uncontrollable bleeding from aortic root. There were no differences in hospital death (0,1), MACCE (4,6) (TAX-AVR, C-AVR, respectively). ICU stay and postoperative hospitalization were shorter in TAX-AVR group (TAX- vs C-AVR:1.0 (1.0-1.0)days vs ±1.0 (2.0-1.0)days, p<0.001 and 9 (10-8)days vs 13 (16-10) days, p<0.001, respectively). There was no significant difference in prosthetic valve size (TAX- vs C-AVR:21 (23-21)mm vs 21 (25-21)mm). Aorta cross-clamp time was significantly longer in TAX-AVR (TAX- vs C-AVR:93 (111-80)min vs 90 (104-77)min, p=0.043) but operation time was shorter in TAX-AVR group (TAX- vs C-AVR:206 (242-180)min vs 235 (265-205)min, p<0.001). Continuous variables were expressed as median(third quartile-first quartile).
CONCLUSIONS: TAX-AVR was as safe as C-AVR in selected patients. TAX-AVR was less invasive approach for AVR.
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