Ministernotomy Aortic Valve Replacement vs the Full Sternotomy Approach: Comparing the Need for Blood Transfusion and Clinical Outcomes
Najah Adreak1, Defen Peng2, Yinshan Zhao2, Bruce McManus3, Anson Cheung1
1Division of Cardiothoracic Surgery, University of British Columbia, Vancover, BC, Canada, 2ICV Health, University of British Columbia, Vancover, BC, Canada, 3Department of Pathology and Laboratory Medicine, University of British Columbia, Vancover, BC, Canada
BACKGROUND:Advantages of mini-sternotomy aortic valve replacement (MSAVR) including improved cosmesis, reduction in postoperative pain, blood loss, shorter length of hospital stays (LOS) and better wound healing. However, MSAVR is not widely adopted by surgeons, and clinical outcomes of MSAVR have not been widely reported in Canada. We study the outcomes of MSAVR in our institution in British Columbia (BC) comparing to full sternotomy aortic valve replacement (FSAVR).
METHODS: Retrospective analysis of Cardiac Service BC database to evaluate all isolated aortic valve replacement performed in our institution from Jan 2007 to Dec 2016. Nine hundred and ten patients were identified (776 FSAVR and 134 MSAVR) with a median follow-up period of 6.2 years. Standard statistical analysis was conducted.
RESULTS: Baseline variables were similar with a mean age of 70 years, and 40% were females. 77.5% of MSAVR patients were in NYHA III/IV vs 49.3% (p=<0.001) and had a greater incidence of renal dysfunction (12.7% vs 8.8%, p=0.15). The freedom from blood product transfusion in the MSAVR group was significantly higher than FSAVR (65.7% vs 49.6 % respectively, p= <0.001). The CBP and AXT times were approximately 9 and 6 minutes shorter in the MSAVR group than FSAVR, respectively (mean CBP 75.4 ± 14.7 vs 84.3 ± 30.0, p=0.014, and mean AXT 58.5 ± 12.2 vs 64.7 ± 24.7, p=0.08, respectively). There were no significant differences in the incidence of new-onset of atrial arrhythmias, stroke, new dialysis or prolonged ventilation. There was no significant difference in 30-day (p=0.79) and long-term mortality between groups (p=0.70). The overall 30-day mortality rate was 0.5, while the long-term survival rate was 75.6 %. LOS in the hospital was shorter in the MSAVR group (mean 7.8 ± 6.2 vs 8.6 ± 7.2, p=0.006).
CONCLUSIONS: Mini sternotomy is an effective alternative to the standard approach for aortic valve replacement. It is proven to be a safe and effective treatment for aortic stenosis. It decreases the blood transfusion and hospital stay with equivalent 30-day mortality and long-term survival rate. It should be considered as part of the armamentarium of cardiac surgeons in the modern era.
Table 1. Summary of blood product transfusion (PRBC/plasma/platelets) by surgical type