Propensity-matched comparison between minimally invasive and conventional sternotomy in aortic valve resuspension

Propensity-matched comparison between minimally invasive and conventional sternotomy in aortic... Abstract OBJECTIVES The aim of the study was to compare the results of David procedure through conventional or minimally invasive approach. METHODS A propensity-matched comparison in patients undergoing a minimally invasive (partial upper sternotomy, n = 103) or complete sternotomy (n = 103) David procedure from 1991 to 2016 was performed. Patients were 57 ± 14 years old on average in both groups. The David technique was modified by generating a neosinus (P < 0.01) in 99 (96%) patients (minimally invasive group) and in 42 (41%) patients (complete sternotomy group), respectively. The average follow-up time was 3 ± 2 years (minimally invasive group) and 8 ± 4 years (complete sternotomy group). RESULTS There was only 1 in-hospital death (in the full sternotomy group, P = 0.5). The applied quantity of packed red blood cells (pRBC) was significantly higher in the complete sternotomy group (3.4 ± 4 vs 1 ± 0.5, P < 0.01). There were no late deaths in the minimally invasive group but 14 died during a longer follow-up period in the full sternotomy group (P < 0.01). Freedom from reoperation or aortic valve insufficiency ≥2° was 95% vs 93% (minimally invasive versus complete sternotomy group) at 5 years and 95% vs 79% at 10 years (P < 0.01). CONCLUSIONS The minimally invasive aortic valve reimplantation procedure for selected patients with aortic root aneurysm and aortic valve incompetence is a durable procedure with minor valve-related morbidity and mortality at the mid-term follow-up. The intra- and perioperative application of pRBC was significantly lower in the minimally invasive group. However, comparison of long-term follow-up data in both groups is necessary to evaluate valve function. Aortic valve sparing, Aortic arch surgery, Minimally invasive surgery INTRODUCTION The minimally invasive approach in valve operations is becoming more popular as patients profit from less pain and fewer surgical injuries [1, 2]. Faster recovery, faster wound healing and the need for packed red blood cells (pRBC) may also be affected advantageously by the minimal access approach. The Bentall procedure has been presented as a good concept for patients with an aortic root aneurysm [3]. However, the aortic root remodelling or reimplantation technique is an alternative way to preserve the aortic valve [4, 5]. The aim of this study was to compare 2 different approaches for the David procedure and to review the outcomes between the 2 groups. Therefore, we report our propensity-matched results of the modified David procedure via the partial upper sternotomy versus complete sternotomy approach. MATERIALS AND METHODS From 1991 till 2016, we performed the David procedure and its modifications in 327 patients with aortic root aneurysm with/without aortic valve incompetence. In the beginning of the series, we started with complete sternotomy and moved on to the minimally invasive approach for the David procedure after gaining more experience. The minimally invasive approach was performed in 120 patients. To compensate for differences in preoperative patient characteristics, a propensity matching was done between the complete and the partial upper sternotomy group, which led to the identification of 103 patients for each group. Patients were 57 ± 14 years old on average in the minimally invasive group and 57 ± 13 years old in the full sternotomy group; 23% were women in each group. Table 1 presents the preoperative characteristics of the patients. Before propensity matching, there were significant differences between the 2 groups concerning the number of Type A dissections and bicuspid valves (Table 2). All 103 patients underwent the David procedure via a partial upper sternotomy up to the left fourth intercostal space (Fig. 1). The decision to use the David procedure was made if the preoperative transoesophageal echocardiographic scans showed no calcified aortic valve cusps and the presence of intact and tender cusps was verified intraoperatively. Table 3 presents the surgical procedures. Table 1: Patient characteristics (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 SD: standard deviation. Table 1: Patient characteristics (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 SD: standard deviation. Table 2: Patient characteristics (not propensity matched) (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 SD: standard deviation. Table 2: Patient characteristics (not propensity matched) (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 SD: standard deviation. Table 3: Perioperative results and surgical procedures Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Table 3: Perioperative results and surgical procedures Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Figure 1: View largeDownload slide Minimally invasive access through a partial upper ministernotomy for the David procedure showing the aortic valve. Figure 1: View largeDownload slide Minimally invasive access through a partial upper ministernotomy for the David procedure showing the aortic valve. Our standardized management protocol for aortic surgery was described previously [6, 7]. Surgical technique and perioperative management The ascending aorta and aortic root were exposed via a partial upper sternotomy. The cannulation strategy and the solution for cardioplegia have been described elsewhere [6, 7]. Cardiopulmonary bypass was started, and the heart was arrested with intermittent and selective antegrade cold blood cardioplegia. A carbon dioxide sufflation line was placed into the situs via a chest tube. We described the rest of the surgical procedure included in the David technique in detail in previous publications [8, 9]. We modified the David technique over the years. At the beginning of our series, we performed the standard David technique [5, 8]. Later, we altered the procedure, initially by creating a pseudosinus to reduce leaflet stress [9]. The fact that the cusp dynamics could be optimized by the pseudosinus technique was described previously [10]. More recently, we performed a neosinus modification that is similar to that achieved with the Vascutek Gelweave Valsalva prosthesis [11, 12]. In addition, we varied the deepest stitch at the right sinus supra-annularly to prevent warping of the right coronary cusp [13]. Aortic valve function was monitored intraoperatively with transoesophageal echocardiography and postoperatively with transthoracic echocardiography during the hospital stay. Clinical follow-up We contacted the patients by phone or letter and invited them to our polyclinic for echocardiographic scans and clinical status evaluation. The mean follow-up was 3 ± 2 years with cumulative 233 patient-years (minimally invasive group) and 8 ± 4 years with cumulative 667 patient-years (complete sternotomy group), with 97% completeness. Our institutional ethics committee approved this study. Statistical analysis Statistical analyses were performed with the BIAS 11.06 software (University Hospital, Frankfurt, Germany). Categorical variables are expressed as frequencies. Continuous variables are presented as mean ± standard deviation. The χ2 test and the Fisher’s exact test were used to compare qualitative data, and the Mann–Whitney U-test was used to analyse quantitative data between patient groups. To compensate for differences in preoperative patient characteristics, a propensity match was performed with R software (R Foundation for Statistical Computing, Vienna, Austria) and package Matching by J.S. Sekhon using the following parameters: age, sex, Type A dissection, preoperative grade of aortic insufficiency (AI), bicuspid aortic valve, concomitant surgical procedures like coronary artery bypass grafting, atrial septal defect closure or mitral/tricuspid valve repair. Freedom from reoperation or aortic valve insufficiency ≥2° was calculated according to the Kaplan–Meier method. RESULTS Operative and perioperative outcome The operative results are listed in Table 3. There was only 1 in-hospital death (in the complete sternotomy group, P = 0.5). The patient died of multiorgan failure. One (1%) patient suffered a stroke. There was a significant difference between the 2 groups in the quantity of pRBC needed (1 ± 0.5 units in the minimally invasive group vs 3.4 ± 4 units in the full sternotomy group) during the hospital stay (P < 0.01). Sixty-three patients in the minimally invasive group and 52 patients in the complete sternotomy group did not receive pRBC. There was only 1 (1%) case of superficial wound infection in each group. The cardiopulmonary bypass time (202 ± 40 vs 184 ± 49 min, P < 0.01) was significantly longer in the conventional sternotomy group than in the minimally invasive group. This trend was similar for the stay in the intensive care unit (Table 3). Interestingly, the main finding was not divergent before propensity matching: Patients in the minimally invasive group received significantly fewer pRBC units (Table 4). Table 4: Perioperative results and surgical procedures (not propensity matched) Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 CABG: coronary artery bypass grafting; RCA: right coronary artery; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Table 4: Perioperative results and surgical procedures (not propensity matched) Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 CABG: coronary artery bypass grafting; RCA: right coronary artery; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Follow-up Table 5 presents the clinical follow-up data. There was a significant difference in the late mortality rate between the 2 groups (n = 0 vs 14, P < 0.01). We also analysed the late mortality of the 2 groups before propensity matching with a similar result (n = 0 in the minimally invasive group vs n = 28 in the complete sternotomy group, P < 0.01). Fourteen late deaths were observed in the complete sternotomy group. These patients died of intracerebral bleeding (1), sepsis (1), rupture of an abdominal aortic aneurysm (1) and end-stage amyotrophic lateral sclerosis (1). In 10 cases, the cause of death was unknown. We observed 3 cases of endocarditis, all of them within the complete sternotomy group. Two of those 3 patients had bicuspid aortic valves. The linearized reoperation rate was 0.4% per patient-year in the minimally invasive cohort and 1% per patient-year in the full sternotomy group (P = 0.03). We observed 1 patient in the minimally invasive cohort who underwent reoperation of the aortic valve 4 years postoperatively due to severe AI (although there was trace AI at the time of the David operation): A combination of leaflet prolapse and calcifications of all 3 leaflets was identified. In that patient, a mechanical aortic valve replacement was performed. Seven patients in the complete sternotomy group underwent reoperation of the aortic valve because of severe aortic valve insufficiency: 3 due to endocarditis, 2 due to leaflet prolapse, 1 because of leaflet perforation and 1 due to combined aortic valve disease. The result from the echocardiographic scan at the time of the David repair was unremarkable (1 patient with AI Grade 1 and 6 with no AI). Five of them had leaflet plication. Six of the reoperated patients received a mechanical and 1, a biological valve in the complete sternotomy group. We also analysed the reoperation rate of the 2 groups before propensity matching with a similar result (n = 1 with 0.4% per patient-year in the minimally invasive group vs n = 11 with 0.9% per patient-year in the conventional sternotomy cohort, P = 0.01). At the recent follow-up encounter, we could not identify any patients with AI Grade 2 in the minimally invasive group; however, 4 patients in the complete sternotomy group had AI Grade 2 (P = 0.04) (Table 6). We also analysed the 2 groups for AI Grade 2 at follow-up before propensity matching with a similar result (n = 0 in the minimally invasive group vs n = 6 in the full sternotomy group, P = 0.04). Clinical follow-up indicated that a plurality of the patients (71% in the minimally invasive group vs 66% in the conventional sternotomy group) were in New York Heart Association (NYHA) functional class I and 29% vs 34% in functional class II (P = 0.5). Table 5: Follow-up data Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 TIA: transient ischaemic attack. Table 5: Follow-up data Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 TIA: transient ischaemic attack. Table 6: Echocardiographic data Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 a AI ≥3° was not observed. b The patient had AI 1°–2° postoperatively and AI 1° at the latest follow-up. AI: aortic insufficiency; LVEDD: left ventricular end-diastolic diameter; Pmax: maximal pressure; Pmean: mean pressure. Table 6: Echocardiographic data Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 a AI ≥3° was not observed. b The patient had AI 1°–2° postoperatively and AI 1° at the latest follow-up. AI: aortic insufficiency; LVEDD: left ventricular end-diastolic diameter; Pmax: maximal pressure; Pmean: mean pressure. DISCUSSION Lowering surgical trauma benefits the patients in a number of ways. Patients who undergo minimally invasive aortic valve replacement profit from shorter hospital stays, decreased pain and reduced blood loss compared to patients who have a conventional sternotomy [1, 2, 8, 14]. The Bentall and the David or Yacoub techniques for treatment of aortic root diseases are challenging operations, which explains why they are usually not performed using a minimally invasive technique. Yan [15] has already published his data about the positive outcome with the minimally invasive (hemisternotomy up to the fourth intercostal space) Bentall operation. We first gained experience with minimally invasive isolated aortic valve replacement and then performed the David technique via a minimally invasive access through a partial upper sternotomy. In cases of acute Type A dissection, we still use the conventional sternotomy approach and have already published the data of the David repair in that cohort [16]. We compared minimally invasive and complete sternotomy data of patients who underwent the David procedure in our unit in a propensity-matched analysis. The in-hospital deaths were not significantly different between the 2 groups and were comparable to those in other centres performing minimally invasive aortic valve procedures [17, 18]. The cardiopulmonary bypass time and the perioperative stay in the intensive care unit in our series were significantly longer in the full sternotomy group than in the minimally invasive group but are still comparable with those of other centres performing the minimally invasive David procedure [17]. Interestingly, the total amount of blood transfused was significantly lower in our series when we compared the minimally invasive group to the complete sternotomy group (1 ± 0.5 vs 3.4 ± 4 units, P < 0.01), which is similar to the results from other centres [15, 17]. There was only 1 (1%) case of superficial wound infection in each group and no case of sternal instability that is acceptable. Our postoperative echocardiographic data showed excellent aortic valve function in both groups (Table 6). The reoperation rate at follow-up was significantly higher in the conventional sternotomy group than in the minimally invasive cohort, which might be due to a higher rate of endocarditis (Table 5). The 5-year freedom from reoperation or AI ≥2° in our series (Fig. 2) is 95% (minimally invasive group) vs 93% (complete sternotomy group) (P < 0.01) and comparable to that of other centres that perform minimally invasive aortic valve procedures (95%) [19]. Figure 2: View largeDownload slide Kaplan–Meier curve for freedom from reoperation or aortic valve insufficiency ≥2°. Group 1: minimally invasive approach (partial upper sternotomy) and Group 2: complete sternotomy approach. P < 0.01: log-rank test between Group 1 and Group 2. Postop: postoperative. Figure 2: View largeDownload slide Kaplan–Meier curve for freedom from reoperation or aortic valve insufficiency ≥2°. Group 1: minimally invasive approach (partial upper sternotomy) and Group 2: complete sternotomy approach. P < 0.01: log-rank test between Group 1 and Group 2. Postop: postoperative. Limitations When we began the series (1991), we started with the David technique via a full sternotomy access. After gaining more experience with isolated aortic valve replacement and the Bentall procedure through a partial upper sternotomy, we have performed the minimally invasive David technique since 2005. In fact, the 2 groups (minimally invasive versus complete sternotomy David procedure) are different populations as the following bias demonstrates: The full sternotomy group has a longer follow-up period (mean ± SD 8 ± 4 years), because this technique was performed early in the 1990s; thus, the long-term survival of this group is not comparable to that of the minimally invasive David group (mean ± SD 3 ± 2 years of follow-up). Another point is that more David procedures via a complete sternotomy had been performed before we began using the minimally invasive David procedure, so the learning curve associated with the surgical technique may also affect the superior follow-up results of the minimally invasive group regarding freedom from significant AI and reoperation of the aortic valve. In other words, those in the minimally invasive group benefitted from the more extensive experience earned in the complete sternotomy group. Finally, one must consider the number of surgeons involved. Two surgeons performed both the minimally invasive David procedure and the David procedure, whereas 5 surgeons performed the David type repair only through full sternotomy access. So, the experience of the surgeon may also play a significant role regarding operation time (including cross-clamp and cardiopulmonary bypass times) and aortic valve function at follow-up. Finally, our data show that the trend towards the minimally invasive approach seems to be related to a significantly reduced transfusion rate of pRBC. For better evaluation of the differences in valve-related morbidity and mortality between the 2 groups, a greater number of propensity-matched patients in each group is essential. CONCLUSION The minimally invasive surgical approach yields some benefits for patients in terms of a reduced intraoperative blood transfusion rate and superior cosmetic results [8]. The minimally invasive approach in abdominal and thoracic surgery is already standardized [20]. Our data illustrate significantly fewer valve-related complications (reoperation and significant AI), with stable aortic valve function at the mid-term follow-up. However, a series with more patients and long-term follow-up is necessary to support our hypothesis. Conflict of interest: none declared. REFERENCES 1 Bonacchi M , Prifti E , Giunti G , Frati G , Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study . Ann Thorac Surg 2002 ; 73 : 460 – 5 ; discussion 465–6. Google Scholar CrossRef Search ADS PubMed 2 Bakir I , Casselman FP , Wellens F , Jeanmart H , De Geest R , Degrieck I et al. Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients . Ann Thorac Surg 2006 ; 81 : 1599 – 604 . Google Scholar CrossRef Search ADS PubMed 3 Bentall HH , De Bono A. A technique for complete replacement of the ascending aorta . Thorax 1968 ; 23 : 338 – 9 . Google Scholar CrossRef Search ADS PubMed 4 Yacoub MH , Gehle P , Chandrasekaran V , Birks EJ , Child A , Radley-Smith R. Late results of a valve preserving operation in patients with aneurysms of the ascending aorta and root . J Thorac Cardiovasc Surg 1998 ; 115 : 1080 – 90 . Google Scholar CrossRef Search ADS PubMed 5 David TE , Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta . J Thorac Cardiovasc Surg 1992 ; 103 : 617 – 22 . Google Scholar PubMed 6 Zierer A , Aybek T , Risteski P , Dogan S , Wimmer-Greinecker G , Moritz A. Moderate hypothermia (30°C) for surgery of acute type A dissection . Thorac Cardiovasc Surg 2005 ; 53 : 74 – 9 . Google Scholar CrossRef Search ADS PubMed 7 Zierer A , Detho F , Dzemali O , Aybek T , Moritz A , Bakhtiary F. Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single center experience in 245 consecutive patients . Ann Thorac Surg 2011 ; 91 : 1868 – 73 . Google Scholar CrossRef Search ADS PubMed 8 Monsefi N , Risteski P , Miskovic A , Moritz A , Zierer A. Midterm results of a minimally invasive approach in David procedure . Thorac Cardiovasc Surg 2017 [Epub ahead of print]. 9 Aybek T , Sotiriou M , Wöhleke T , Miskovic A , Simon A , Doss M et al. Valve opening and closing dynamics after different aortic valve-sparing operations . J Heart Valve Dis 2005 ; 14 : 114 – 20 . Google Scholar PubMed 10 Bakhtiary F , Monsefi N , Herrmann E , Trendafilow M , Aybek T , Miskovic A et al. Long-term results and cusp dynamics after aortic valve resuspension for aortic root aneurysm . Ann Thorac Surg 2011 ; 91 : 478 – 84 . Google Scholar CrossRef Search ADS PubMed 11 Moritz A , Risteski P , Dogan S , Macit H , Akbulut B , Zierer A et al. Six stitches to create a neosinus in David-type aortic root resuspension . J Thorac Cardiovasc Surg 2007 ; 133 : 560 – 2 . Google Scholar CrossRef Search ADS PubMed 12 Monsefi N , Zierer A , Risteski P , Primbs P , Miskovic A , Karimian-Tabrizi A et al. Long-term results of aortic valve resuspension in patients with aortic valve insufficiency and aortic root aneurysm . Interact CardioVasc Thorac Surg 2014 ; 18 : 432 – 7 . Google Scholar CrossRef Search ADS PubMed 13 Monsefi N , Bakhtiary F , Moritz A. Supra-annular stitch to avoid distortion of the right coronary cusp in aortic root resuspension . J Heart Valve Dis 2010 ; 19 : 371 – 3 . Google Scholar PubMed 14 Mihaljevic T , Cohn LH , Unic D , Aranki SF , Couper GS , Byrne JG. One thousand minimally invasive valve operations: early and late results . Ann Surg 2004 ; 240 : 529 – 34 ; discussion 534. Google Scholar CrossRef Search ADS PubMed 15 Yan TD. Mini-Bentall procedure and hemi-arch replacement . Ann Cardiothorac Surg 2015 ; 4 : 208 – 9 . Google Scholar PubMed 16 Monsefi N , Miskovic A , Moritz A , Zierer A. Long-term results of the David Procedure in patients with acute type A aortic dissection . Int J Surg 2015 ; 22 : 99 – 104 . Google Scholar CrossRef Search ADS PubMed 17 Shrestha M , Krueger H , Umminger J , Koigeldiyev N , Beckmann E , Haverich A et al. Minimally invasive valve sparing aortic root replacement (David procedure) is safe . Ann Cardiothorac Surg 2015 ; 4 : 148 – 53 . Google Scholar PubMed 18 Johnston DR , Roselli EE. Minimally invasive aortic valve surgery: Cleveland Clinic experience . Ann Cardiothorac Surg 2015 ; 4 : 140 – 7 . Google Scholar PubMed 19 Leontyev S , Trommer C , Subramanian S , Lehman S , Dmitrieva Y , Misfeld M et al. The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience . Eur J Cardiothorac Surg 2012 ; 42 : 261 ; discussion 266–7. Google Scholar CrossRef Search ADS PubMed 20 Froeschle GW , Kiraly Z , Broelsch CE. Cholecystectomy by mini-laparotomy with the Jako retractor system . Langenbecks Arch Surg 1997 ; 382 : 274 – 6 . © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Propensity-matched comparison between minimally invasive and conventional sternotomy in aortic valve resuspension

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
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1873-734X
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10.1093/ejcts/ezx489
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Abstract

Abstract OBJECTIVES The aim of the study was to compare the results of David procedure through conventional or minimally invasive approach. METHODS A propensity-matched comparison in patients undergoing a minimally invasive (partial upper sternotomy, n = 103) or complete sternotomy (n = 103) David procedure from 1991 to 2016 was performed. Patients were 57 ± 14 years old on average in both groups. The David technique was modified by generating a neosinus (P < 0.01) in 99 (96%) patients (minimally invasive group) and in 42 (41%) patients (complete sternotomy group), respectively. The average follow-up time was 3 ± 2 years (minimally invasive group) and 8 ± 4 years (complete sternotomy group). RESULTS There was only 1 in-hospital death (in the full sternotomy group, P = 0.5). The applied quantity of packed red blood cells (pRBC) was significantly higher in the complete sternotomy group (3.4 ± 4 vs 1 ± 0.5, P < 0.01). There were no late deaths in the minimally invasive group but 14 died during a longer follow-up period in the full sternotomy group (P < 0.01). Freedom from reoperation or aortic valve insufficiency ≥2° was 95% vs 93% (minimally invasive versus complete sternotomy group) at 5 years and 95% vs 79% at 10 years (P < 0.01). CONCLUSIONS The minimally invasive aortic valve reimplantation procedure for selected patients with aortic root aneurysm and aortic valve incompetence is a durable procedure with minor valve-related morbidity and mortality at the mid-term follow-up. The intra- and perioperative application of pRBC was significantly lower in the minimally invasive group. However, comparison of long-term follow-up data in both groups is necessary to evaluate valve function. Aortic valve sparing, Aortic arch surgery, Minimally invasive surgery INTRODUCTION The minimally invasive approach in valve operations is becoming more popular as patients profit from less pain and fewer surgical injuries [1, 2]. Faster recovery, faster wound healing and the need for packed red blood cells (pRBC) may also be affected advantageously by the minimal access approach. The Bentall procedure has been presented as a good concept for patients with an aortic root aneurysm [3]. However, the aortic root remodelling or reimplantation technique is an alternative way to preserve the aortic valve [4, 5]. The aim of this study was to compare 2 different approaches for the David procedure and to review the outcomes between the 2 groups. Therefore, we report our propensity-matched results of the modified David procedure via the partial upper sternotomy versus complete sternotomy approach. MATERIALS AND METHODS From 1991 till 2016, we performed the David procedure and its modifications in 327 patients with aortic root aneurysm with/without aortic valve incompetence. In the beginning of the series, we started with complete sternotomy and moved on to the minimally invasive approach for the David procedure after gaining more experience. The minimally invasive approach was performed in 120 patients. To compensate for differences in preoperative patient characteristics, a propensity matching was done between the complete and the partial upper sternotomy group, which led to the identification of 103 patients for each group. Patients were 57 ± 14 years old on average in the minimally invasive group and 57 ± 13 years old in the full sternotomy group; 23% were women in each group. Table 1 presents the preoperative characteristics of the patients. Before propensity matching, there were significant differences between the 2 groups concerning the number of Type A dissections and bicuspid valves (Table 2). All 103 patients underwent the David procedure via a partial upper sternotomy up to the left fourth intercostal space (Fig. 1). The decision to use the David procedure was made if the preoperative transoesophageal echocardiographic scans showed no calcified aortic valve cusps and the presence of intact and tender cusps was verified intraoperatively. Table 3 presents the surgical procedures. Table 1: Patient characteristics (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 SD: standard deviation. Table 1: Patient characteristics (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 Partial upper sternotomy Complete sternotomy P-value Number of patients 103 103 Age (years), mean ± SD 57 ± 14 57 ± 13 0.8 Female, n (%) 24 (23) 24 (23) 1.0 Hypertension, n (%) 51 (50) 56 (54) 0.6 Marfan syndrome, n (%) 9 (9) 6 (6) 0.6 Type A dissection, n (%) 0 3 (3) 0.1 Aortic valve morphology  Bicuspid/tricuspid (n) 23/80 17/86 0.4 SD: standard deviation. Table 2: Patient characteristics (not propensity matched) (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 SD: standard deviation. Table 2: Patient characteristics (not propensity matched) (1991–2016) Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 Partial upper sternotomy Complete sternotomy P-value Number of patients 120 207 Age (years), mean ± SD 56 ± 14 58 ± 14 0.1 Female, n (%) 26 (22) 61 (29) 0.1 Hypertension, n (%) 56 (47) 97 (47) 0.9 Marfan syndrome, n (%) 9 (8) 13 (6) 0.4 Type A dissection, n (%) 0 30 (14) <0.01 Aortic valve morphology  Bicuspid/tricuspid (n) 29/91 18/189 <0.01 SD: standard deviation. Table 3: Perioperative results and surgical procedures Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Table 3: Perioperative results and surgical procedures Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 Partial upper sternotomy (n = 103) Complete sternotomy (n = 103) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 99/1/3 42/17/44 <0.01  Isolated ascending aorta replacement, n (%) 74 (72) 68 (66) 0.5  Ascending aorta + hemiarch replacement, n (%) 11 (10) 28 (27) <0.01  Complete arch replacement, n (%) 12 (12) 3 (3) 0.03  Elephant trunk procedure, n (%) 6 (6) 4 (4) 0.7 Concomitant procedures, n (%) 21 (20) 22 (21) 0.9  CABG, n (%) 5 (5) 17 (7) 0.01  Atrial septal defect closure, n (%) 2 (2) 1 (1) 0.5  Mitral valve repair, n (%) 11 (10) 2 (2) 0.01  Tricuspid valve repair, n (%) 3 (3) 2 (2) 0.5 Leaflet plication of the aortic valve, n (%) 52 (50) 43 (42) 0.3 Supra-annular stitch, n (%) 49 (54) 18 (17) <0.01 Perioperative data  CPB time (min), mean ± SD 184 ± 49 202 ± 40 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 32 151 ± 28 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.5 1.3 ± 0.8 0.02  Rethoracotomy for bleeding, n (%) 8 (9) 13 (13) 0.4  Blood products, pRBC (U), mean ± SD 1 ± 0.5 3.4 ± 4 <0.01  Neurological deficit (stroke), n (%) 1 (1) 1 (1) 1.0  In-hospital deaths, n (%) 0 1 (1) 0.5 CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Figure 1: View largeDownload slide Minimally invasive access through a partial upper ministernotomy for the David procedure showing the aortic valve. Figure 1: View largeDownload slide Minimally invasive access through a partial upper ministernotomy for the David procedure showing the aortic valve. Our standardized management protocol for aortic surgery was described previously [6, 7]. Surgical technique and perioperative management The ascending aorta and aortic root were exposed via a partial upper sternotomy. The cannulation strategy and the solution for cardioplegia have been described elsewhere [6, 7]. Cardiopulmonary bypass was started, and the heart was arrested with intermittent and selective antegrade cold blood cardioplegia. A carbon dioxide sufflation line was placed into the situs via a chest tube. We described the rest of the surgical procedure included in the David technique in detail in previous publications [8, 9]. We modified the David technique over the years. At the beginning of our series, we performed the standard David technique [5, 8]. Later, we altered the procedure, initially by creating a pseudosinus to reduce leaflet stress [9]. The fact that the cusp dynamics could be optimized by the pseudosinus technique was described previously [10]. More recently, we performed a neosinus modification that is similar to that achieved with the Vascutek Gelweave Valsalva prosthesis [11, 12]. In addition, we varied the deepest stitch at the right sinus supra-annularly to prevent warping of the right coronary cusp [13]. Aortic valve function was monitored intraoperatively with transoesophageal echocardiography and postoperatively with transthoracic echocardiography during the hospital stay. Clinical follow-up We contacted the patients by phone or letter and invited them to our polyclinic for echocardiographic scans and clinical status evaluation. The mean follow-up was 3 ± 2 years with cumulative 233 patient-years (minimally invasive group) and 8 ± 4 years with cumulative 667 patient-years (complete sternotomy group), with 97% completeness. Our institutional ethics committee approved this study. Statistical analysis Statistical analyses were performed with the BIAS 11.06 software (University Hospital, Frankfurt, Germany). Categorical variables are expressed as frequencies. Continuous variables are presented as mean ± standard deviation. The χ2 test and the Fisher’s exact test were used to compare qualitative data, and the Mann–Whitney U-test was used to analyse quantitative data between patient groups. To compensate for differences in preoperative patient characteristics, a propensity match was performed with R software (R Foundation for Statistical Computing, Vienna, Austria) and package Matching by J.S. Sekhon using the following parameters: age, sex, Type A dissection, preoperative grade of aortic insufficiency (AI), bicuspid aortic valve, concomitant surgical procedures like coronary artery bypass grafting, atrial septal defect closure or mitral/tricuspid valve repair. Freedom from reoperation or aortic valve insufficiency ≥2° was calculated according to the Kaplan–Meier method. RESULTS Operative and perioperative outcome The operative results are listed in Table 3. There was only 1 in-hospital death (in the complete sternotomy group, P = 0.5). The patient died of multiorgan failure. One (1%) patient suffered a stroke. There was a significant difference between the 2 groups in the quantity of pRBC needed (1 ± 0.5 units in the minimally invasive group vs 3.4 ± 4 units in the full sternotomy group) during the hospital stay (P < 0.01). Sixty-three patients in the minimally invasive group and 52 patients in the complete sternotomy group did not receive pRBC. There was only 1 (1%) case of superficial wound infection in each group. The cardiopulmonary bypass time (202 ± 40 vs 184 ± 49 min, P < 0.01) was significantly longer in the conventional sternotomy group than in the minimally invasive group. This trend was similar for the stay in the intensive care unit (Table 3). Interestingly, the main finding was not divergent before propensity matching: Patients in the minimally invasive group received significantly fewer pRBC units (Table 4). Table 4: Perioperative results and surgical procedures (not propensity matched) Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 CABG: coronary artery bypass grafting; RCA: right coronary artery; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Table 4: Perioperative results and surgical procedures (not propensity matched) Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 Partial upper sternotomy (n = 120) Complete sternotomy (n = 207) P-value Surgical procedures  Neosinus/pseudosinus/standard (n) 116/1/3 80/42/85 <0.01  Isolated ascending aorta replacement, n (%) 83 (69) 134 (65) 0.4  Ascending aorta + hemiarch replacement, n (%) 15 (13) 55 (27) <0.01  Complete arch replacement, n (%) 15 (13) 9 (4) <0.01  Elephant trunk procedure, n (%) 7 (5) 9 (4) 0.4 Concomitant procedures, n (%) 22 (18) 56 (27) 0.07  CABG, n (%) 5 (4) 45 (22) <0.01  Atrial septal defect closure, n (%) 2 (2) 3 (1) 0.6  Mitral valve repair, n (%) 12 (10) 6 (3) 0.01  Tricuspid valve repair, n (%) 3 (2) 2 (1) 0.4 Leaflet plication of the aortic valve, n (%) 65 (54) 67 (32) <0.01 Supra-annular stitch, n (%) 53 (44) 30 (15) <0.01 Perioperative data  CPB time (min), mean ± SD 183 ± 46 200 ± 42 <0.01  Myocardial ischaemic time (min), mean ± SD 136 ± 31 146 ± 31 <0.01  Intensive care unit stay (days), mean ± SD 1.1 ± 0.7 1.4 ± 1 <0.01  Rethoracotomy for bleeding, n (%) 8 (7) 27 (13) 0.05  Blood products, pRBC (U), mean ± SD 1.1 ± 1.8 3 ± 2.5 <0.01  Neurological deficit (stroke), n (%) 1 (1) 3 (1) 0.5  In-hospital deaths, n (%) 0 6 (3) 0.06 CABG: coronary artery bypass grafting; RCA: right coronary artery; CPB: cardiopulmonary bypass; pRBC: packed red blood cells; SD: standard deviation. Follow-up Table 5 presents the clinical follow-up data. There was a significant difference in the late mortality rate between the 2 groups (n = 0 vs 14, P < 0.01). We also analysed the late mortality of the 2 groups before propensity matching with a similar result (n = 0 in the minimally invasive group vs n = 28 in the complete sternotomy group, P < 0.01). Fourteen late deaths were observed in the complete sternotomy group. These patients died of intracerebral bleeding (1), sepsis (1), rupture of an abdominal aortic aneurysm (1) and end-stage amyotrophic lateral sclerosis (1). In 10 cases, the cause of death was unknown. We observed 3 cases of endocarditis, all of them within the complete sternotomy group. Two of those 3 patients had bicuspid aortic valves. The linearized reoperation rate was 0.4% per patient-year in the minimally invasive cohort and 1% per patient-year in the full sternotomy group (P = 0.03). We observed 1 patient in the minimally invasive cohort who underwent reoperation of the aortic valve 4 years postoperatively due to severe AI (although there was trace AI at the time of the David operation): A combination of leaflet prolapse and calcifications of all 3 leaflets was identified. In that patient, a mechanical aortic valve replacement was performed. Seven patients in the complete sternotomy group underwent reoperation of the aortic valve because of severe aortic valve insufficiency: 3 due to endocarditis, 2 due to leaflet prolapse, 1 because of leaflet perforation and 1 due to combined aortic valve disease. The result from the echocardiographic scan at the time of the David repair was unremarkable (1 patient with AI Grade 1 and 6 with no AI). Five of them had leaflet plication. Six of the reoperated patients received a mechanical and 1, a biological valve in the complete sternotomy group. We also analysed the reoperation rate of the 2 groups before propensity matching with a similar result (n = 1 with 0.4% per patient-year in the minimally invasive group vs n = 11 with 0.9% per patient-year in the conventional sternotomy cohort, P = 0.01). At the recent follow-up encounter, we could not identify any patients with AI Grade 2 in the minimally invasive group; however, 4 patients in the complete sternotomy group had AI Grade 2 (P = 0.04) (Table 6). We also analysed the 2 groups for AI Grade 2 at follow-up before propensity matching with a similar result (n = 0 in the minimally invasive group vs n = 6 in the full sternotomy group, P = 0.04). Clinical follow-up indicated that a plurality of the patients (71% in the minimally invasive group vs 66% in the conventional sternotomy group) were in New York Heart Association (NYHA) functional class I and 29% vs 34% in functional class II (P = 0.5). Table 5: Follow-up data Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 TIA: transient ischaemic attack. Table 5: Follow-up data Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 Partial upper sternotomy Complete sternotomy P-value Late deaths, n (% per patient-year) 0 14 (2) <0.01 Endocarditis, n (% per patient-year) 0 3 (0.4) 0.12 Late neurological events  Total n (% per patient-year) 2 (1) 4 (0.6) 0.34   Stroke and TIA, n (% per patient-year) 2 (1) 3 (0.4) 0.5   Cerebral bleeding, n (% per patient-year) 0 1 (0.1) 0.5  All cases of bleeding, n (% per patient-year) 0 2 (0.3) 0.25  Anticoagulation-related bleeding 0 1 (0.1) 0.5  Reoperation, n (% per patient-year) 1 (0.4) 7 (1) 0.03 TIA: transient ischaemic attack. Table 6: Echocardiographic data Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 a AI ≥3° was not observed. b The patient had AI 1°–2° postoperatively and AI 1° at the latest follow-up. AI: aortic insufficiency; LVEDD: left ventricular end-diastolic diameter; Pmax: maximal pressure; Pmean: mean pressure. Table 6: Echocardiographic data Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 Partial upper sternotomy Complete sternotomy P-value Preoperative n = 103 n = 103 AI ≤2°, n (%) 45 (44) 47 (49) 0.8 AI ≥3°, n (%) 58 (56) 56 (54) 0.8 Ejection fraction (%), mean ± SD 60 ± 10 57 ± 10 0.07 LVEDD (cm), mean ± SD 5.9 ± 1 6 ± 1 0.6 Pmax aortic valve (mmHg), mean ± SD 12 ± 6 13 ± 7 0.6 Pmean aortic valve (mmHg), mean ± SD 7 ± 3 7 ± 4 0.6 Ascending aorta diameter (cm), mean ± SD 5.2 ± 1 5.6 ± 1 0.01 Postoperative (before discharge from hospital) n = 102 n = 102 AI <2°, n (%) 101 (99) 101 (99) 1 AI=2°,an (%) 1 (1)b 1 (1) 1 Ejection fraction (%), mean ± SD 56 ± 10 55 ± 10 0.7 LVEDD (cm), mean ± SD 5.2 ± 1 5.5 ± 1 0.2 Pmax aortic valve (mmHg), mean ± SD 13 ± 6 13 ± 7 0.9 Pmean aortic valve (mmHg), mean ± SD 8 ± 3 8 ± 4 0.8 Latest follow-up n = 99 n = 77 AI <2°, n (%) 99 (100) 73 (95) 0.04 AI=2°,an (%) 0 4 (5) 0.04 Ejection fraction (%), mean ± SD 61 ± 10 60 ± 12 0.5 LVEDD (cm), mean ± SD 5.2 ± 1 5.4 ± 1 0.1 Pmax aortic valve (mmHg), mean ± SD 9 ± 5 12 ± 6 0.2 Pmean aortic valve (mmHg), mean ± SD 6 ± 3 7 ± 4 0.3 a AI ≥3° was not observed. b The patient had AI 1°–2° postoperatively and AI 1° at the latest follow-up. AI: aortic insufficiency; LVEDD: left ventricular end-diastolic diameter; Pmax: maximal pressure; Pmean: mean pressure. DISCUSSION Lowering surgical trauma benefits the patients in a number of ways. Patients who undergo minimally invasive aortic valve replacement profit from shorter hospital stays, decreased pain and reduced blood loss compared to patients who have a conventional sternotomy [1, 2, 8, 14]. The Bentall and the David or Yacoub techniques for treatment of aortic root diseases are challenging operations, which explains why they are usually not performed using a minimally invasive technique. Yan [15] has already published his data about the positive outcome with the minimally invasive (hemisternotomy up to the fourth intercostal space) Bentall operation. We first gained experience with minimally invasive isolated aortic valve replacement and then performed the David technique via a minimally invasive access through a partial upper sternotomy. In cases of acute Type A dissection, we still use the conventional sternotomy approach and have already published the data of the David repair in that cohort [16]. We compared minimally invasive and complete sternotomy data of patients who underwent the David procedure in our unit in a propensity-matched analysis. The in-hospital deaths were not significantly different between the 2 groups and were comparable to those in other centres performing minimally invasive aortic valve procedures [17, 18]. The cardiopulmonary bypass time and the perioperative stay in the intensive care unit in our series were significantly longer in the full sternotomy group than in the minimally invasive group but are still comparable with those of other centres performing the minimally invasive David procedure [17]. Interestingly, the total amount of blood transfused was significantly lower in our series when we compared the minimally invasive group to the complete sternotomy group (1 ± 0.5 vs 3.4 ± 4 units, P < 0.01), which is similar to the results from other centres [15, 17]. There was only 1 (1%) case of superficial wound infection in each group and no case of sternal instability that is acceptable. Our postoperative echocardiographic data showed excellent aortic valve function in both groups (Table 6). The reoperation rate at follow-up was significantly higher in the conventional sternotomy group than in the minimally invasive cohort, which might be due to a higher rate of endocarditis (Table 5). The 5-year freedom from reoperation or AI ≥2° in our series (Fig. 2) is 95% (minimally invasive group) vs 93% (complete sternotomy group) (P < 0.01) and comparable to that of other centres that perform minimally invasive aortic valve procedures (95%) [19]. Figure 2: View largeDownload slide Kaplan–Meier curve for freedom from reoperation or aortic valve insufficiency ≥2°. Group 1: minimally invasive approach (partial upper sternotomy) and Group 2: complete sternotomy approach. P < 0.01: log-rank test between Group 1 and Group 2. Postop: postoperative. Figure 2: View largeDownload slide Kaplan–Meier curve for freedom from reoperation or aortic valve insufficiency ≥2°. Group 1: minimally invasive approach (partial upper sternotomy) and Group 2: complete sternotomy approach. P < 0.01: log-rank test between Group 1 and Group 2. Postop: postoperative. Limitations When we began the series (1991), we started with the David technique via a full sternotomy access. After gaining more experience with isolated aortic valve replacement and the Bentall procedure through a partial upper sternotomy, we have performed the minimally invasive David technique since 2005. In fact, the 2 groups (minimally invasive versus complete sternotomy David procedure) are different populations as the following bias demonstrates: The full sternotomy group has a longer follow-up period (mean ± SD 8 ± 4 years), because this technique was performed early in the 1990s; thus, the long-term survival of this group is not comparable to that of the minimally invasive David group (mean ± SD 3 ± 2 years of follow-up). Another point is that more David procedures via a complete sternotomy had been performed before we began using the minimally invasive David procedure, so the learning curve associated with the surgical technique may also affect the superior follow-up results of the minimally invasive group regarding freedom from significant AI and reoperation of the aortic valve. In other words, those in the minimally invasive group benefitted from the more extensive experience earned in the complete sternotomy group. Finally, one must consider the number of surgeons involved. Two surgeons performed both the minimally invasive David procedure and the David procedure, whereas 5 surgeons performed the David type repair only through full sternotomy access. So, the experience of the surgeon may also play a significant role regarding operation time (including cross-clamp and cardiopulmonary bypass times) and aortic valve function at follow-up. Finally, our data show that the trend towards the minimally invasive approach seems to be related to a significantly reduced transfusion rate of pRBC. For better evaluation of the differences in valve-related morbidity and mortality between the 2 groups, a greater number of propensity-matched patients in each group is essential. CONCLUSION The minimally invasive surgical approach yields some benefits for patients in terms of a reduced intraoperative blood transfusion rate and superior cosmetic results [8]. The minimally invasive approach in abdominal and thoracic surgery is already standardized [20]. Our data illustrate significantly fewer valve-related complications (reoperation and significant AI), with stable aortic valve function at the mid-term follow-up. However, a series with more patients and long-term follow-up is necessary to support our hypothesis. Conflict of interest: none declared. REFERENCES 1 Bonacchi M , Prifti E , Giunti G , Frati G , Sani G. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study . Ann Thorac Surg 2002 ; 73 : 460 – 5 ; discussion 465–6. Google Scholar CrossRef Search ADS PubMed 2 Bakir I , Casselman FP , Wellens F , Jeanmart H , De Geest R , Degrieck I et al. Minimally invasive versus standard approach aortic valve replacement: a study in 506 patients . Ann Thorac Surg 2006 ; 81 : 1599 – 604 . Google Scholar CrossRef Search ADS PubMed 3 Bentall HH , De Bono A. A technique for complete replacement of the ascending aorta . Thorax 1968 ; 23 : 338 – 9 . Google Scholar CrossRef Search ADS PubMed 4 Yacoub MH , Gehle P , Chandrasekaran V , Birks EJ , Child A , Radley-Smith R. Late results of a valve preserving operation in patients with aneurysms of the ascending aorta and root . J Thorac Cardiovasc Surg 1998 ; 115 : 1080 – 90 . Google Scholar CrossRef Search ADS PubMed 5 David TE , Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta . J Thorac Cardiovasc Surg 1992 ; 103 : 617 – 22 . Google Scholar PubMed 6 Zierer A , Aybek T , Risteski P , Dogan S , Wimmer-Greinecker G , Moritz A. Moderate hypothermia (30°C) for surgery of acute type A dissection . Thorac Cardiovasc Surg 2005 ; 53 : 74 – 9 . Google Scholar CrossRef Search ADS PubMed 7 Zierer A , Detho F , Dzemali O , Aybek T , Moritz A , Bakhtiary F. Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single center experience in 245 consecutive patients . Ann Thorac Surg 2011 ; 91 : 1868 – 73 . Google Scholar CrossRef Search ADS PubMed 8 Monsefi N , Risteski P , Miskovic A , Moritz A , Zierer A. Midterm results of a minimally invasive approach in David procedure . Thorac Cardiovasc Surg 2017 [Epub ahead of print]. 9 Aybek T , Sotiriou M , Wöhleke T , Miskovic A , Simon A , Doss M et al. Valve opening and closing dynamics after different aortic valve-sparing operations . J Heart Valve Dis 2005 ; 14 : 114 – 20 . Google Scholar PubMed 10 Bakhtiary F , Monsefi N , Herrmann E , Trendafilow M , Aybek T , Miskovic A et al. Long-term results and cusp dynamics after aortic valve resuspension for aortic root aneurysm . Ann Thorac Surg 2011 ; 91 : 478 – 84 . Google Scholar CrossRef Search ADS PubMed 11 Moritz A , Risteski P , Dogan S , Macit H , Akbulut B , Zierer A et al. Six stitches to create a neosinus in David-type aortic root resuspension . J Thorac Cardiovasc Surg 2007 ; 133 : 560 – 2 . 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Long-term results of the David Procedure in patients with acute type A aortic dissection . Int J Surg 2015 ; 22 : 99 – 104 . Google Scholar CrossRef Search ADS PubMed 17 Shrestha M , Krueger H , Umminger J , Koigeldiyev N , Beckmann E , Haverich A et al. Minimally invasive valve sparing aortic root replacement (David procedure) is safe . Ann Cardiothorac Surg 2015 ; 4 : 148 – 53 . Google Scholar PubMed 18 Johnston DR , Roselli EE. Minimally invasive aortic valve surgery: Cleveland Clinic experience . Ann Cardiothorac Surg 2015 ; 4 : 140 – 7 . Google Scholar PubMed 19 Leontyev S , Trommer C , Subramanian S , Lehman S , Dmitrieva Y , Misfeld M et al. The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience . Eur J Cardiothorac Surg 2012 ; 42 : 261 ; discussion 266–7. Google Scholar CrossRef Search ADS PubMed 20 Froeschle GW , Kiraly Z , Broelsch CE. Cholecystectomy by mini-laparotomy with the Jako retractor system . Langenbecks Arch Surg 1997 ; 382 : 274 – 6 . © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Jan 16, 2018

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