Benefits of rapid deployment aortic valve replacement with a mini upper sternotomy

Abstract

Background: Surgical aortic valve replacement (AVR) is currently deemed the gold standard of care for patients with severe aortic stenosis. Currently, most AVRs are safely performed through a full median sternotomy approach. With an increasingly elderly and high-risk patient population, major advances in valve technology and surgical technique have been introduced to reduce perioperative risk and post-operative complications associated with the full sternotomy approach, in order to ensure surgical AVR remains the gold standard. For example, minimally invasive approaches (most commonly via mini sternotomy) have been developed to improve patient outcomes. The advent of rapid deployment valve technology has also been shown to improve morbidity and mortality by reducing cardiopulmonary bypass and aortic cross-clamp times, as well as facilitating the use of minimal access approaches. Rapid deployment valves were introduced into our department at the Royal Infirmary of Edinburgh in 2014. The aim of this study is to investigate if utilising the combination of rapid deployment valves and a mini sternotomy minimally invasive approach resulted in improved outcomes in various patient subgroups. Methods: Over a 3-year period, we identified 714 patients who underwent isolated AVR in our centre. They were divided into two groups: 61 patients (8.5%) were identified who received rapid deployment AVR via J-shaped mini upper sternotomy (MIRDAVR group), whilst 653 patients (91.5%) were identified who received either a full sternotomy (using a conventional prosthesis or rapid deployment valve) or minimally invasive approach using a conventional valve (CONVAVR group). We retrospectively analysed data from our cardiac surgery database, including pre-operative demographics, intraoperative times and postoperative outcomes. Outcomes were also compared in two different subgroups: octogenarians and high-risk patients.

Propensity-score matched comparison between minimally invasive and conventional aortic valve replacement

“…This observation stems from the fact that the caudal part of the sternum and the underlying pericardial sac remain intact during the primary, minimally invasive procedure, which allows for surgical entry into a seemingly virgin chest during reoperation. The expanding use of rapid deployment aortic valve prosthesis will likely enhance the adoption of minimally invasive strategies, as it simplifies the placement of a prosthesis and reduces all procedural times ( 6 ).…”

“…The latter likely stem from partial preservation of anterior thoracic wall integrity and are manifested by earlier resumption of daily activities, reduction of pain, and lower transfusion requirements ( 5 ). In comparison with conventional AVR, minimally invasive procedures reduce operative trauma, while not exposing the patient to transcatheter aortic valve implantation-related risks of paravalvular leak, increased rate of pacemaker implantations, and vascular complications ( 6 ). Notwithstanding the potential benefits of mini-AVR, these have not been uniformly shown in all studies evaluating the impact of less invasive procedures ( 7 , 8 ).…”

Contemporary trends in the surgical management of aortic valve disease

“…We are witnessing a paradigm shift as the proportion of patients treated with TAVI is increasing worldwide and increas- ingly lower risk patients are being recruited (12,13,14). Surgery, however, remains the standard of care, as it offers reproducible long-term results and is much less likely to be associated with paravalvular leaks, new onset third degree AV block and vascular access related complications; all of which burden TAVI (15). The two technologies should be complementary and not competing, as they should target different patient populations (13).…”

Efficacy of Intraventricular Sponge Placement to Capture Debris in Aortic Valve Replacement

“…Surgical aortic valve replacement (SAVR) has been the gold standard treatment for severe aortic stenosis for the past several decades and remains one of the most commonly performed operations for the practicing adult cardiac surgeon. 1 Despite SAVR being a relatively standard operation, it is not without significant risk to the patient. This risk is attributed in part to the innate invasiveness of the procedure and the comorbidities common within the patient population.…”