International Society For Minimally Invasive Cardiothoracic Surgery

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Transcatheter Vs. Mini-sternotomy For Native Aortic Valve Replacement In Patients With Prior Cabg: A Propensity-matched Study.
Oleg Orlov1, Vishal Shah1, Cinthia Orlov1, Diamantis Tsilimigras1, Roseline Atchori1, Vivian Tran1, Meghan Buckley2, Scott Goldman1, Konstadinos Plestis1.
1Lankenau Medical Center, Philadelphia, PA, USA, 2Lankenau Institute for Medical Resarch, Wynnewood, PA, USA.

Background: Surgical treatment of aortic valve dysfunction after prior CABG poses unique technical challenges. We sought to compare early and midterm outcomes of transcatheter aortic valve replacement (TAVR) to redo mini-sternotomy aortic valve replacement (Mini-RAVR) in a contemporary cohort of patients. Methods: Out of 177 patients who developed native aortic valve dysfunction after CABG, 124 (70%) patients underwent TAVR and 53 (30%) patients underwent Mini-RAVR between 2006 and 2017. The median age was 80 years and 78 years for TAVR and Mini-RAVR respectively (p =0.002). There were no differences in gender (86% vs. 81% males, p=0.372), ejection fraction (58% vs. 55%, p=0.367), urgent procedures (13% vs. 9%, p=0.618), creatinine (1.2 vs. 1.1 mg/dL, p=0.062), COPD (23% vs. 19%, p=0.691), and diabetes (44% vs. 38%, p=0.507) in TAVR vs Mini-RAVR respectively. TAVR had higher incidence of chronic heart failure (90% vs. 74%, p=0.009) and STS Risk Score (median 6% vs. 3%, p<0.001). Propensity-matching identified 42 pairs (Table 1). Results: Thirty-day mortality was 0% for TAVR and 2.4% (1 patient) for Mini-RAVR (p=1.0). No postoperative strokes or new-onset renal failure were identified in either group. There were five (12%) mild postoperative paravalvular leaks and two (5%) permanent pacemaker placements in TAVR vs. none in Mini-RAVR (p>0.05). The length of stay was shorter in TAVR (4 vs. 7 days, p<0.001); however, ICU stay (2.2 vs. 2.2 days) and prolonged mechanical ventilation (>24 hours) (2.4% vs. 7.3%, p=0.36) were similar in both groups (p>0.05). The cumulative 1, 2, and 4-year survival rates in TAVR and Mini-RAVR were 100%, 88%, 70.8% and 93%, 93%, 93%, respectively (p=0.03) (Figure 1). Multivariable analysis demonstrated that older age (HR=1.11, CI=1.01-1.23, p=0.04) and procedure type (TAVR) (HR=6.05, CI=1.31-27.87, p=0.02) were predictors of midterm mortality. Conclusions: TAVR and Mini-RAVR after prior CABG offer similar early outcomes with no differences in major adverse events. Although short-term survival is comparable, mini-RAVR has a significantly longer midterm survival.

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