Impact Of Pleural Integrity Preservation On Clinical Outcomes After Minimally Invasive Aortic Valve Surgery.
Beatrice Bacchi1, Francesco Cabrucci1, Aleksander Dokollari2, Massimo Bonacchi1.
1Careggi University Hospital, Florence, Italy, 2Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, USA.
Background: While benefits of mini-invasive aortic valve surgery compared to standard sternotomy have been widely described, the impact of pleural integrity preservation based on the type of mini-invasive approach is still widely discussed. This study aims to define the role of pleural integrity preservation on post-operative and long-term outcomes after mini-invasive aortic valve replacement (AVR). Methods: Data from consecutive patients who underwent AVR with ministernotomy (MS) between 1999-2019 were retrospectively collected. A second cohort of patients that received AVR through right minithoracotomy (MT) was used as a control group. Patients undergoing MS had their pleura preserved (PPI-MS) while patients receiving right MT were considered non-PPI (non-PPI-MT). A propensity-matched analysis was used to compare the two groups (PPI-MS vs non-PPI-MT). Primary outcome was incidence analysis of short- and long-term outcomes. Results: A total of 2,419 patients that underwent AVR were included in the analysis. After propensity-matching, 986 patients were included in each group (PPI-MS vs non-PPI-MT). Mean follow-up was 120.7 months. Post-operative outcomes evidenced a longer intensive care unit stay (hours) (12.4 vs 16.5, RR= 1.62 p= 0.037, respectively) and hospital length of stay (days) (and 5.4 vs 8.7, RR= 1.74 p= 0.028, respectively) in non-PPI-MT patients (Table 1). The rate of respiratory complications including, incidence of pneumothorax or subcutaneous emphysema, significant pulmonary atelectasis, and pleural effusions events requiring thoracentesis was higher in non-PPI-MT. Peri-operative, short- and long-term mortality were significantly higher in the non-IPS-MT group. (Figure 1) Conclusions: Pleural integrity preservation after MS is associated with a reduced incidence of post-operative complications and improved overall survival compared to non-pleural preservation with right MT. Therefore, a tailored patient-procedure approach can positively impact short- and long-term outcomes, especially in patients with associated pulmonary comorbidities.
LEGEND:
Figure 1: Survival curves by Kaplan-Meier - comparison between matched MS and MT Groups.Blue line and numbers refer to the MS group and red one to the MT group.p=0.0001 by Mantel-Cox log-rank.MS: ministernotomy; MT: mini-thoracotomy.
| RR [95% CI] | P-value | |
| Pneumothorax/subcutaneous emphysema requiring chest tube | 1.88 [1.73-2.04] | < 0.001 |
| Significative pulmonary atelectasis | 2.18 [2.04-2.32] | < 0.001 |
| Pleural effusion requiring thoracentesis | 1.42 [1.27-1.60] | < 0.001 |
| ICU stay [hours](SD) | 1.62 [1.34-2.03] | 0.037 |
| Hospital stay [days](SD) | 1.74 [1.02-2.49] | 0.028 |
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