International Society For Minimally Invasive Cardiothoracic Surgery

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Is A Minimally Invasive Approach Safe And Feasible For Aortic Valve Replacement In Obese Patients?
Fabrizio Rosati, Camila Mayorga Palacios, Darrin M. Payne, Andrew G. Hamilton, Dimitri Petsikas, Gianluigi Bisleri.
Division of Cardiac Surgery, Kingston Health Science Centre, Queen's University, Kingston, ON, Canada.

OBJECTIVE: Minimally invasive techniques for aortic valve surgery have been widely adopted and they can be safely performed with excellent results. However, concerns have been raised about risks and benefits related to the use of a minimally invasive access in morbidly obese patients. We sought to investigate perioperative and short-term outcomes in obese patients undergoing minimally invasive aortic valve replacement(mini-AVR). METHODS: From February 2017 to November 2018, 15 consecutive overweight patients (BMI>25Kg/m2)underwent elective mini-AVR by means of ministernotomy at the fourth intercostal space. Mean age was 64.99.4years, mean BMI was 33.07.4Kg/m2 and mean EuroScore II was 2.190.01. Of those patients, 66.7%(10/15) were obese(BMI>30Kg/m2). Endpoints were 30-days mortality and incidence of perioperative complications as bleeding requiring revision, conversion to sternotomy, transfusions, cerebrovascular accidents, cardiac arrhythmia as well as survival at follow-up time. RESULTS: Mini-AVR was successfully performed in all patients through mini-sternotomy and no paravalvular leaks/regurgitation occurred. All patients received a biological valve: 12 stented and 3 stentless valves were implanted respectively. Mean aortic cross-clamp/cardiopulmonary bypass time were 119.829.8minutes and 92.915.7minutes respectively. Only one patient required conversion to sternotomy for bleeding due to an accidental tear of the pulmonary artery while no other patients required surgical revision for bleeding. Transfusion of more than 2 units of blood were necessary in 20% of patients(3/15) while two patients(16%) required prolonged mechanical ventilation(>48h) and also experienced acute kidney injury requiring temporary hemofiltration. The incidence of post-operative atrial fibrillation was 33.3% (5/15)and the mean hospital stay was 8.810.8days(range 4-45days). Perioperative mortality was 0% and no cerebrovascular accidents or wound infection occurred with excellent cosmetic results(Figure 1). At 3 months mean follow-up(90.562.1 days), death occurred in one patient(6.7%) without cardiac correlation or valve related complication. CONCLUSIONS: Mini-sternotomy is a safe and effective approach for minimally invasive aortic valve surgery also in obese patients and it is not associated with increased risk for peri-operative morbidity or mortality. Further investigations are warranted on a large series of patients with a focus also on the potential impact of different types of biological valves (such as sutureless) in this specific subset of patients.
LEGENDFigure 1 - Cosmetic result in morbidly obese patient after mini-AVR.

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