International Society For Minimally Invasive Cardiothoracic Surgery

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Impact Of Postoperative Annular Diameter On Mid-term Outcomes After Minimally-invasive Aortic Valve Repair
Johannes Petersen, Theresa Holst, Sarah Krohm, Niklas Neumann, Hermann Reichenspurner, Evaldas Girdauskas.
University Heart Center Hamburg, Hamburg, Germany.

Ventriculo-aortic junction (VAJ) diameter has been reported to predict the outcome after aortic valve repair (AVRep). We aimed to compare the postoperative and follow-up results of AVRep surgery performed in minimally-invasive vs. standard sternotomy setting.
All patients undergoing elective aortic valve repair at our institution from January 2016 until September 2018 were prospectively included. Eighty-seven patients (58 %) underwent AVRep via partial-upper sternotomy (MICS-group) while the remaining 42 % patients underwent median sternotomy (Sternotomy-group). Transthoracic echocardiography was performed at discharge, at 6 months, 1 year and 2 years after surgery. Systematic echocardiographic measurements of annular (VAJ) diameter in mid-systole were performed before and after aortic valve repair. Primary endpoint was achievement of postoperative VAJ ≤ 25 and freedom from AR ≥ 2 and secondary endpoints were freedom from redo aortic valve surgery and prosthetic aortic valve replacement.
A total of 150 consecutive patients (mean age 47 14 years, 75% male) underwent aortic valve repair during the study period. In-hospital mortality was similar in both groups (MICS-group: 1.2 % vs. Sternotomy-group: 1.6 %; p = 1.000). Overall survival at follow-up was 98 % in the MICS-group and 95 % in the sternotomy group; p = 0.650. Mean preoperative VAJ diameter (MICS-group: 26.8 4.4 mm (18.8 - 34.7 mm); Sternotomy-group: 27.2 4.1 mm (18.2 - 37.6 mm)) was significantly reduced after surgery in both groups (MICS-group: 23.8 2.9 mm (17.9 - 31.9 mm); Sternotomy-group: 23.9 2.8 mm (18.1 - 31.2 mm); p<0.001). Postoperative VAJ ≤ 25 mm could be similarly often achieved in standard sternotomy vs. partial-upper sternotomy (i.e., 67 % vs. 77%, p=0.224). In patients with postoperative VAJ ≤ 25 mm freedom of AR ≥ 2 (MICS-group: 93.9 % vs. Sternotomy-group: 100 %; p = 0.100), aortic valve redo surgery and prosthetic valve replacement (MICS-group: 98.5 % vs. Sternotomy-group: 100 %; p = 0.484) at follow-up were similar excellent. If postoperative VAJ is > 25 mm freedom of AR ≥ 2 (MICS-group: 70.0 % vs. Sternotomy-group: 85.7 %; p = 0.071) and aortic valve redo surgery (MICS-group: 80.0 % vs. Sternotomy-group: 95.2 %; p = 0.026) were significantly lower in both groups, especially in the MICS-group, respectively. Freedom of prosthetic valve replacement (MICS-group: 95.2 % vs. Sternotomy-group: 95.2 %; p = 0.564) was similar in both groups if postoperative VAJ was > 25 mm. Multivariate cox regression analysis revealed postoperative VAJ > 25 mm to be a risk factor for recurrence of AR ≥ 2 and redo aortic valve surgery in both groups.
Aortic valve repair via partial upper sternotomy is safe, reproducible and results in comparable postoperative outcomes as compared to median sternotomy if appropriate VAJ stabilization can be achieved. Postoperative VAJ > 25 mm is a risk factor for failure after aortic valve repair procedures independent of the surgical access.

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