Evolution of Minimally Invasive Surgical Aortic Valve Replacement at a Veterans Affairs Medical Center

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> The majority of minimally invasive surgical aortic valve replacements (MIAVRs) are performed at high-volume cardiac surgery centers. However, outcomes at lower volume federal facilities are not yet reported in the literature and not captured in the national Society of Thoracic Surgeons (STS) database. Our study objective was to describe the evolution of MIAVR at a Veterans Affairs Medical Center (VAMC). </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> A single-center retrospective cohort study was performed of 114 patients who underwent MIAVR for isolated aortic valvular disease between January 2011 and August 2018. Preoperative STS risk factors were determined and perioperative outcomes were analyzed. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> By 2016, 100% of isolated surgical aortic valve replacements were performed as MIAVRs at our VAMC. Introduction of automatic knot-fastening devices, single-shot del Nido cardioplegia, and rapid deployment valves decreased aortic cross-clamp (AXC) times from a median of 96 (interquartile range [IQR]: 84 to 103) to 53 minutes (38 to 61, P &lt; 0.001, Kruskal–Wallis). Thirty-day mortality was 0.9%. Median length of hospital stay was 9 days (7 to 13). Postoperative atrial fibrillation occurred in 54% of patients, stroke occurred in 1.8% of patients, and 7.1% of patients required permanent pacemakers. Transition to rapid deployment valves decreased postoperative mean pressure gradient from median 14 mmHg (10 to 17) to 7 mmHg (4.7 to 10, P &lt; 0.001, Mann–Whitney). At median 1.5-year follow-up echocardiogram, mean gradient was 10.8 mmHg with mild paravalvular leak rate of 1.8%. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Facilitating technologies decreased operative times during MIAVR adoption at our VAMC. For patients with isolated aortic valve pathology, MIAVR can be performed with low morbidity and mortality at lower volume federal institutions, with outcomes comparable to those reported from higher volume centers. </jats:p></jats:sec>

The role of Cor‐Knot in the future of cardiac surgery: A systematic review

“…Cor‐Knot also reduced the total operation time in the two studies that measured this outcome 9,30 . CPBT was significantly reduced in five out of six studies when compared to manually tied knots 6,9,10,12,31 . These measures were statistically significant in open surgery as well as MIVS 10,30 .…”

“…9,30 CPBT was significantly reduced in five out of six studies when compared to manually tied knots. 6,9,10,12,31 These measures were statistically significant in open surgery as well as MIVS. 10,30 The results obtained from literature pertaining to Cor-Knot in aortic valve surgery are summarized in Table 2.…”

“…Current literature discusses the many proven and postulated advantages of using Cor‐Knot in valve surgery. These include the reduction of cardiopulmonary bypass time (CPBT), aortic cross clamp time (AXT), and total operation time; the provision of enhanced consistency in knot strength; and the facilitation of access to deeper structures whilst performing MIVS 6,9‐14 . However, no evidence exists to date to support the translation of these advantages into improved patient outcomes.…”

“…These include the reduction of cardiopulmonary bypass time (CPBT), aortic cross clamp time (AXT), and total operation time; the provision of enhanced consistency in knot strength; and the facilitation of access to deeper structures whilst performing MIVS. 6,[9][10][11][12][13][14] However, no evidence exists to date to support the translation of these advantages into improved patient outcomes. Taken together with its significant cost, a difficult question arises: do the intraoperative advantages afforded by Cor-Knot justify its financial burden in the absence of evidence to support improved patient outcomes?…”

Conventional Versus Minimally Invasive Aortic Valve Replacement Surgery: A Systematic Review, Meta-Analysis, and Meta-Regression

“…1 Since its introduction in the 1990s, minimally invasive AVR (MIAVR) has emerged as an alternative treatment with partial upper hemisternotomy (UHS) and right anterior thoracotomy (RAT) as the most frequent approaches. [2][3][4] However, there is still conflicting evidence of the superiority of one procedure over the other, and there is still ongoing debate about the benefits of minimally invasive surgical interventions.…”