Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy.
Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2023 Mar;165(3):1022-1032.e2. doi: 10.1016/j.jtcvs.2021.03.125. Epub 2021 Apr 23.
Ministernotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.
The data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).
After propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan-Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).
Minimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.
经胸骨下段小切口和右前小开胸术是微创主动脉瓣置换术的两种主要技术。本研究旨在比较两种技术的早期和长期结果。
前瞻性收集了 1999 年至 2019 年间接受单纯微创主动脉瓣置换术的 2419 例患者的数据。回顾性地，将患者分为胸骨下段小切口组（n=1352）和小开胸组（n=1067）。
经过倾向评分匹配后，每组仍有 986 例患者。小开胸组的手术时间和转为全胸骨切开术的比例明显高于胸骨下段小切口组（184.6±45.2 比 241.3±68.6，相对风险，2.54，P=0.005 和 0.09 比 0.23，相对风险，1.45，P=0.013，分别）。胸骨下段小切口组的 30 天死亡率（不包括心脏死亡）低于小开胸组（0.012 比 0.028，相对风险，1.41，P=0.011，分别）；小开胸组的重症监护病房住院时间（12.4 比 16.5，相对风险，1.62，P=0.037，分别）和总住院时间（5.4 比 8.7，相对风险，1.74，P=0.028，分别）明显延长。小开胸手术是早期死亡率的最强独立预测因素（优势比，4.24[1.67-7.35]，P=0.002）。Kaplan-Meier 分析的 1、3、5、10 和 20 年累积生存率在胸骨下段小切口组明显优于小开胸组（P=0.0001）。胸骨下段小切口组的 5 年免于再次手术的生存率为 97.3%±4.4%，小开胸组为 95.8%±5.2%（P=0.087）。
经胸骨下段小切口微创主动脉瓣置换术可缩短手术时间、重症监护病房停留时间、住院时间、减少术后并发症和切口疼痛，改善早期和长期死亡率。
