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Ministernotomy Is Superior To The Right Anterior Minithoracotomy For Aortic Valve Surgery Regarding The Early And Long-term Outcomes
Massimo Bonacchi, MD1, Aleksander Dokollari, MD2, Orlando Parise, MSc3, Edvin Prifti, MD4, Gianluigi Bisleri, MD5, Giulia Chiuselli, MD1, Sandro Gelsominno, MD6.
1Cardiac Surgery, Department of Experimental and Clinical Medicine - University of Florence, Firenze, Italy, 2Cardiac Surgery, St. Michael's Hospital, University of Toronto, Canada, Canada, ON, Canada, 3CARIM, Maastricht University Medical Center, The Netherlands, Maastricht, Netherlands, 4Division of Cardiac Surgery, University Hospital Center of Tirana, Albania, Tirana, Albania, 5Kingston General Hospital, Queen University, Kingston, ON, Canada, 63Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands.
BACKGROUND: Ministernotomy (MS) and right anterior minithoracotomy (MT) are the two main techniques applied for minimally invasive aortic valve replacement (AVR). The goal of this study is to compare the early and long-term outcomes of both techniques.METHODS: 2419 patients undergoing isolated minimally invasive AVR between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the MS group (n=1,352) and the MT group (n= 1,067).
RESULTS: Following propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the MT versus MS group (184.6±45.2 vs 241.3±68.6, RR= 2.54 p=0.005 and 0.09 vs 0.23, RR= 1.45 p= 0.013, respectively). The 30-days mortality, excluding cardiac death, was lower in the MS vs MT group (0.012. vs 0.028, RR=1.41, p=0.011, respectively); the intensive care unit (ICU) length of stay (12.4 vs 16.5, RR= 1.62, p=0.037, respectively) and hospital length of stay (5.4 vs 8.7, RR= 1.74 p=0.028, respectively) were significantly longer in the MT group. The MT surgical approach resulted in being the strongest independent predictor for early mortality (OR= 3.6, 95% CI= 2.1-5.7, p=0.026).
The actuarial survival by Kaplan - Meier analysis at 1, 3, 5, 10, and 20-years was significantly better in the MS versus MT (p=0.0001). Actuarial freedom from re-operation at 5-years was 97.3±4.4% in MS versus 95.8±5.2% in MT, p=0.087.
CONCLUSIONS: Minimally invasive AVR using MS is associated with reduced operative time, ICU and hospital length of stay, lower postoperative morbidities and incisional pain and improves early and log-term mortality.LEGEND: Survival curves by Kaplan-Meier - comparison between matched MS and MT Groups.Blue line and numbers refer to the mini sternotomy (MS) group and red one to the mini-thoracotomy (MT) group.p=0.0001 by Mantel-Cox log-rank. MS= ministernotomy; MT:minithoracotomy. 
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