Paparella Domenico, Malvindi Pietro Giorgio, Santarpino Giuseppe, Moscarelli Marco, Guida Piero, Fattouch Khalil, Margari Vito, Martinelli Luigi, Albertini Alberto, Speziale Giuseppe
Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy.
Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy.
Eur J Cardiothorac Surg. 2020 Apr 1;57(4):709-716. doi: 10.1093/ejcts/ezz286.
Surgical aortic valve replacement (AVR) can be performed via a full sternotomy or a minimal access approach (mini-AVR). Despite long-term experience with the procedure, mini-AVR is not routinely adopted. Our goal was to compare contemporary outcomes of mini-AVR and conventional AVR in a large multi-institutional national cohort.
A total of 5801 patients from 10 different centres who had a mini-AVR (2851) or AVR (2950) from 2011 to 2017 were evaluated retrospectively. Standard aortic prostheses were used in all cases. The use of the minimally invasive approach has increased over the years. The primary outcome is the incidence of 30-day deaths following mini-AVR and AVR. Secondary outcomes are the occurrence of major complications following both procedures. Propensity-matched comparisons were performed based on the multivariable logistic regression model.
In the overall population patients who had AVR had an increased surgical risk based on the EuroSCORE, and the 30-day mortality rate was higher (1.5% and 2.3% in mini-AVR and AVR, respectively; P = 0.048). Propensity scores identified 2257 patients per group with similar baseline profiles. In the matched groups, patients who had mini-AVR, despite longer cardiopulmonary bypass (81 ± 32 vs 76 ± 28 min; P = 0.004) and cross-clamp (64 ± 24 vs 59 ± 21 min; P ≤ 0.001) times, had lower 30-day mortality rates (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 transfusions (36.4% vs 30.8%; P ≤ 0.001) and atrial fibrillation (26.0% vs 21.5%, P ≤ 0.001) were higher in patients who had the mini-AVR.
In a large multi-institutional recent cohort, minimal access approach aortic valve replacement is associated with reduced 30-day mortality rates and shorter postoperative lengths of stay compared to standard sternotomy. A prospective randomized trial is needed to overcome the possible biases of a retrospective study.
外科主动脉瓣置换术（AVR）可通过全胸骨切开术或微创入路（mini-AVR）进行。尽管该手术已有长期经验，但mini-AVR并未被常规采用。我们的目标是在一个大型多机构全国队列中比较mini-AVR和传统AVR的当代疗效。
回顾性评估了2011年至2017年来自10个不同中心的5801例接受mini-AVR（2851例）或AVR（2950例）的患者。所有病例均使用标准主动脉假体。多年来，微创入路的使用有所增加。主要结局是mini-AVR和AVR后30天死亡的发生率。次要结局是两种手术术后主要并发症的发生情况。基于多变量逻辑回归模型进行倾向匹配比较。
在总体人群中，根据欧洲心脏手术风险评估系统（EuroSCORE），接受AVR的患者手术风险增加，30天死亡率更高（mini-AVR和AVR分别为1.5%和2.3%；P = 0.048）。倾向评分确定每组2257例患者具有相似的基线特征。在匹配组中，接受mini-AVR的患者尽管体外循环时间（81±32 vs 76±28分钟；P = 0.004）和主动脉阻断时间（64±24 vs 59±21分钟；P≤0.001）更长，但30天死亡率更低（1.2% vs 2.0%；P = 0.036），低心排血量发生率更低（0.8% vs 1.4%；P = 0.046），术后住院时间更短（9±8 vs 10±7天；P = 0.004）。接受mini-AVR的患者输血率（36.4% vs 3０.8%；P≤0.001）和心房颤动发生率（26.0% vs 21.5%，P≤0.001）更高。
在一个大型多机构近期队列中，与标准胸骨切开术相比，微创入路主动脉瓣置换术与降低30天死亡率和缩短术后住院时间相关。需要进行前瞻性随机试验以克服回顾性研究可能存在的偏倚。
