Comparing Minimal Access And Sternotomy Approaches To Surgical Aortic Valve Replacement In Octogenarians In The Tavi Era.
Mukesh Karuppannan, Grzegorz Laskawski, David Rose, Antony Walker, Amal Bose, Carmelo Raimondo, Mohamad Nidal Bittar, Joseph Zacharias.
Lancashire Cardiac Centre,Blackpool Victoria Hospital, Blackpool, United Kingdom.
BACKGROUND: As more people survive into their ninth decade, there is an increasing prevalence of aortic valve disease requiring intervention. This study sought to identify the early and long term outcomes of minimally invasive surgical aortic valve replacement (MIS) in this selected patient group during the period of a TAVI option and compare it to the conventional sternotomy approach
METHODS: : A retrospective review of prospectively collected data from all patients aged 80-99 who underwent surgical aortic valve replacement (sternotomy / hemisternotomy /minithoracotomy) between January 2011 and December 2021 were analysed. Patients who underwent redo operations, concomitant aortic replacement or multi valve procedures were excluded. Primary outcomes were 30-day mortality and morbidity and secondary outcome was one & 5-year survival.
RESULTS: Out of the 355 patients (mean age 83.0 ± 2.7 years, Females 50.8%) who underwent surgical aortic valve replacement, 63 (18%) were done through minimal access approach (Hemisternotomy in 55.5% and right anterior mini-thoracotomy in 45.5%). The mean logistic EuroSCORE was 12.6 ± 9.7. The median length of post operative ICU stay was 1 day (IQR-0) in both the groups however the median post operative hospital stay was lesser in the MIS group( 7 vs 9 days).The morbidity among both the groups were similar except that there were no instances of pacemaker implantation or wound infection/mediastinitis in the MIS group with 1.5% incidence of reopening for bleeding/tamponade (vs 5.8% in Sternotomy group). The 30 day and 1 year survival were similar between the groups (97% and 89% MIS vs 98.2% and 91.4% sternotomy group ) and the 5 year survival of the MIS group was 73% compared to the sternotomy group (64.3%).
CONCLUSIONS: This study confirms surgical AVR by minimal access approach is safe in selected octogenarians with excellent outcomes comparable to the conventional sternotomy approach.There is a very acceptable mortality rate in the years after this procedure.In our experience the anterior right mini-thoracotomy approach is better tolerated by octogenarians but needs further evaluation. 
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