11. Comparison Between Minimally Invasive and Standard Surgical Aortic Valve Replacement: A Multi-Center Propensity Matched Study
Domenico Paparella1, Pietro Giorgio Malvindi1, Marco Moscarelli2, Giuseppe Santarpino3, Piero Guida4, Khalil Fatthouch5, Luigi Martinelli6, Alberto Albertini7, Giuseppe Speziale2
1Santa Maria Hospital GVM Care & Research, Bari, Italy; 2Anthea Hospital GVM Care & Research, Bari, Italy; 3Città di Lecce Hospital GVM Care & Research, Lecce, Italy; 4Fondazione Maugeri IRCCS, Cassano Murge (BA), Italy; 5Maria Eleonora Hospital GVM Care & Research, Palermo, Italy; 6ICLAS - Istituto Clinico Ligure di Alta Specialità GVM Care & Research, Rapallo (GE), Italy; 7Maria Cecilia Hospital GVM Care & Research, Cotignola (RA), Italy
Invited Discussant: *Theodor J. M. Fischlein
Objective: Surgical aortic valve replacement can be performed via full sternotomy (AVR) or minimally invasive approach (Mini-AVR). Despite long-lasting experience, Mini-AVR is not routinely adopted because challenges are not universally considered adequately balanced by clear clinical advantages. We compare contemporary outcomes of mini-AVR and conventional-AVR in a large multi-institutional national cohort.
Methods: Evaluated were 5801 patients undergone mini-AVR (2851) or AVR (2950) in 10 different centers in the period 2011-2017. Shared institutional clinical and administrative databases were utilized. Patients undergone redo operations (397 patients) in both approaches as well as patients receiving any other concomitant procedure were excluded. Standard aortic prostheses were utilized in all cases. Trend of minimally invasive approach is increasing over the years. The primary outcome is the incidence of 30-day mortality following mini-AVR and AVR. Secondary outcomes are the occurrence of major complications following both procedures. Propensity matched comparisons was performed based on multivariable logistic regression model.
Results: In the overall population AVR patients had increased surgical risk based on the EuroSCORE (additive Euroscore 7±3 vs. 6±2, p=<0.001) and 30-day mortality was higher (2.3% and 1.5% in AVR and mini-AVR respectively, p=0.048). Propensity score identified 2257 patients per group with similar baseline profile (EuroSCORE 6±2). In the matched groups Mini-AVR patients, despite longer CPB (81±32 vs. 76±28 minutes; p=0.004) and cross clamp (64±24 vs. 59±21 minutes; p=<0.001) times, had lower 30-day mortality (1.2% vs. 2.0%, p=0.036), reduced low cardiac output (0.8% vs. 1.4%, p=0.046) and reduced postoperative length of stay (9±8 vs. 10±7 days, p=0.004). Blood transfusion (36.4% vs. 30.8%, p=<0.001) and postoperative atrial fibrillation (26.0% vs. 21.5%, p=<0.001) were higher in Mini-AVR.
Conclusions: In a large multi-institutional recent matched cohort, minimally invasive surgical replacement of the aortic valve is associated with reduced 30-day mortality and shorter postoperative length of stay compared to standard sternotomy.