Decision Making for Severe Aortic Stenosis in Era of Universal TAVR Risk Approval: Which Low/Intermediate Risk Patients Should We Preferentially Recommend Surgery?
Martin Andreas1, Günther Laufer1, Paolo Berretta2, Marco Solinas3, Giuseppe Santarpino4, Utz Kappert5, Thierry Folliguet6, Antonio Miceli7, Martin Misfeld8, Carlo Savini9, Elisa Mikus10, Emmanuel Villa11, Kevin Phan12, Theodor Fischlein13, Bart Meuris14, Gianluca Martinelli15, Kevin Teoh16, Carmelo Mignosa17, Malak Shrestha18, Thierry P. Carrel19, Tristan Yan20, Marco Di Eusanio21.
1Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria, 2Cardiac Surgery Unit - Ospedali Riuniti, Ancona, Italy, 3Pasquinucci Heart Hospital, Massa, Italy, 4Città di Lecce Hospital, GVM care&research, Lecce, Italy, 5Department of Cardiac Surgery, Dresden Heart Center, Dresden, Germany, 6Henri Mondor Hospital, University of Paris, Paris, France, 7Istituto Clinico Sant'Ambrogio, Clinical & Research Hospitals IRCCS Gruppo San Donato, Milano, Italy, 8University of Leipzig, Leipzig, Germany, 9Cardiac Surgery Department, Sant’Orsola Malpighi Hospital, University of Bologna, Bologna, Italy, 10Maria Cecilia Hospital GVM Care & Research, Cotignola, Italy, 11Poliambulanza Foundation Hospital, Brescia, Italy, 12The Collaborative Research (CORE) Group, Sydney, Australia, 13Cardiovascular Center, Paracelsus Medical University, Vienna, Austria, 14Gasthuisberg, Cardiale Heelkunde, Leuven, Belgium, 15Cardiovascular Department, Clinica San Gaudenzio, Novara, Italy, 16Southlake Regional Health Centre, Ontario, ON, Canada, 17ISMETT/UPMC, Palermo, Italy, 18Hannover Medical School, Hannover, Germany, 19Hospital Universitaire de Berne, Berne, Switzerland, 20Macquarie University, Sydney, Australia, Sydney, Australia, 21Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ospedali Riuniti,, Ancona, Italy.
Background. Rapid-deployment aortic valves are increasingly implanted via minimally invasive procedures, namely mini-sternotomy (MS) or anterior right thoracotomy (ART). Recently, a single-center study questioned the safety of the ART procedure compared to MS. We therefore analyzed procedural details and outcomes of both accesses with data of the international registry for sutureless and rapid-deployment aortic valves (SURD-IR).Methods. Eighteen centers participate in the SURD-IR registry and contributed 3651 patients. All isolated aortic valve replacements excluding reoperations operated via a minimally access were included. Risk profiles, operative and outcome variables were analyzed. Results. 1111 patients underwent MS (37% male; 76±7 years) and 627 patients underwent the ART procedure (39% male; 76±7 years). Patients undergoing MS had a higher BMI (27.7±5.1 vs. 27.0±4.5;p=0.006), and were more likely to present with atrial fibrillation (14% vs. 7%;p<0.001), pulmonary hypertension (25% vs. 19%;p=0.01) and renal insufficiency (45% vs. 36%;p=0.001). However, logistic EuroScore was comparable (9.1±6.6 vs 8.6±6.1;p=0.18). Cross-clamp and bypass time were increased in the ART group (59±24 vs. 45±18 min and 91±33 vs. 73±26 min;p<0.001). While in-hospital mortality was comparable (1.8% vs. 0.7%;p=0.83), MS patients had a higher stroke rate (3.1% vs. 1.1%;p=0.02) and a prolonged ICU and hospital stay [ 2 (1-3) vs 1(1-2) days and 10 (8-15) vs. 8 (7-12) days;p<0.001) (table 1). Conclusions. Both groups had an excellent surgical outcome. Patients undergoing MS had a higher risk profile, which may be related to the observed stroke rate. Hospital stay was shorter for the ART procedure, and no increased risk was observed for this access.
Table 1. In-hospital outcomes. LEGEND: AV: atrio-ventricular. ART: anterior right thoracotomy. ICU: intensive care unit. IQR: interquartile range. MS: ministernotomy. PM: pacemaker 
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