Surgical Outcomes After Minimally Invasive Versus Full Sternotomy Aortic Valve Replacement: Meta-Analysis of 75 Comparative Studies

OBJECTIVE

Whether minimally invasive aortic valve replacement (MIAVR) offers an advantage over conventional AVR (CAVR) remains a matter of debate. Although some studies have suggested better postoperative outcomes with MIAVR, technical challenges and longer operative times remain major obstacles to the adoption of these techniques. In this meta-analysis, we compare the reported immediate postoperative outcomes of both approaches.

METHODS

Cochrane, MEDLINE, and Embase® databases were searched from inception until January 2022 for studies reporting immediate postoperative outcomes of MIAVR and CAVR. Studies were excluded if they reported on concomitant procedures or enrolled pediatric patients. Random-effects meta-analysis was performed using the restricted maximum likelihood estimator with Hartung-Knapp adjustment.

RESULTS

The literature search yielded 3,921 articles, of which 75 were included in this meta-analysis. The most common techniques were ministernotomy and minithoracotomy. MIAVR was associated with lower 30-day mortality than CAVR (odds ratio [OR] = 0.65, 95% confidence interval [CI]: 0.54 to 0.78, I2 = 0%, P < 0.001). The length of stay (LOS) in the hospital (standardized mean difference [SMD] = -0.44, 95% CI: -0.61 to -0.26, P < 0.001) and in the intensive care unit (SMD = -0.36, 95% CI: -0.57 to -0.15, P < 0.001) were shorter for MIAVR. Individual comparisons of ministernotomy and minithoracotomy to CAVR also yielded similar results. However, aortic cross-clamping and cardiopulmonary bypass times were longer for MIAVR.

CONCLUSIONS

Our meta-analysis suggests that minimally invasive approaches to AVR may provide advantages beyond cosmesis. Despite longer operative times, MIAVR was associated with earlier recovery and shorter hospital LOS. These findings were consistent for both minithoracotomy and ministernotomy.

Midterm Outcomes of Right Anterior Mini Thoracotomy Aortic Valve Replacement

Background

Contemporary surgical approaches for aortic valve replacement (AVR) include full median sternotomy, hemi-sternotomy, and a right anterior mini thoracotomy (RAMT) approach. We report the midterm outcomes of RAMT for isolated AVR.

Methods

A retrospective study was conducted, reporting the midterm outcomes of patients who underwent isolated RAMT AVR. The primary outcomes were death and disabling stroke within 30-days of surgery. The secondary outcomes were survival at latest follow-up assessment, hospital readmission for aortic valve disease, prosthetic valve function, and incidence of structural valve deterioration requiring reintervention on the aortic valve.

Results

Seventy patients underwent isolated RAMT AVR between February 2016 and February 2018. One patient died from a cardiac cause within 30 days of surgery, whereas none experienced disabling postoperative strokes. The mean follow-up period for the cohort was 74.46 ± 7.54 months. At 95 months, a total of 49 patients were alive. During the follow-up period, 2 patients underwent median sternotomy, 1 for mitral valve replacement and tricuspid repair, and 1 for coronary artery bypass grafting. At last follow-up assessment, the average mean transvalvular gradient was 12.11 ± 9.15 mm Hg. One patient developed prosthetic valve infective endocarditis, and 1 patient was found to have prosthetic valve thrombosis. Prosthetic valve function was normal in 66 patients. At 95 months, freedom from aortic valve reintervention was 98.6%, as 1 patient required redo aortic root surgery.

Conclusions

RAMT AVR can be done safely in the appropriate patient population. Midterm outcomes at our centre are promising, and they suggest that this approach is a good option for managing aortic stenosis.

Gender-Tailored Heart Team Decision Making Equalizes Outcomes for Female Patients after Aortic Valve Replacement through Right Anterior Small Thoracotomy (RAST)

BACKGROUND

Little is known about gender-dependent outcomes after aortic valve replacement (AVR) through right anterior thoracotomy (RAST). The aim of our study was to analyze the mid-term outcomes of our cohort.

METHODS

This study is a retrospective analysis of 338 patients (2013-2022). Subgroup analysis included a gender-dependent comparison of age groups ≤60 and >60 years.

RESULTS

Women were older (69.27 ± 7.98 vs. 64.15 ± 11.47, p < 0.001) with higher Euroscore II (1.25 ± 0.73 vs. 0.94 ± 0.45, p < 0.001). Bypass and cross-clamp time were shorter (109.36 ± 30.8 vs. 117.65 ± 33.1 minutes, p = 0.01; 68.26 ± 21.5 vs. 74.36 ± 23.3 minutes, p = 0.01), while ICU, hospital stay and atrial fibrillation were higher (2.48 ± 8.2 vs. 1.35 ± 1.4 days, p = 0.005; 11 ± 7.8 vs. 9.48 ± 2.3 days, p = 0.002; 6.7% vs. 4.4%, p = 0.024). Mortality was 0.9%, while stroke was 0.6%. Age subgroup analysis showed that women were older (p = 0.025) with longer ICU and hospital stays (p < 0.001, p = 0.007). On mid-term follow-up (4.52 ± 2.67 years) of 315 patients (94.3%), there was no significant difference in survival, MACCE and re-intervention comparing gender and age groups.

CONCLUSIONS

Despite older age, higher Euroscore II, longer ICU and hospital stay in women, mortality, MACCE and reoperation were low and comparable in gender and age groups. We believe that our patient-tailored heart team decision making combined with RAST translates into gender-tailored medicine, which equalizes the widely reported negative outcomes of female patients after cardiac surgery.

Right Anterior Minithoracotomy Approach for Aortic Valve Replacement

By sparing the sternum, the right anterior minithoracotomy (RAMT) approach may facilitate a quicker functional recovery when compared with conventional aortic valve replacement (AVR). In the following review, outcomes after RAMT AVR are compared with full sternotomy AVR. The RAMT approach is described, including suggestions for patient selection. The application of the RAMT approach for other cardiac procedures is also discussed.

Right anterior mini thoracotomy for redo cardiac surgery: case series from North America and Europe

Background

Right anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR.

Methods

This case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery.

Results

Nine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136 min and 90 min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23 mmHg.

Conclusion

The number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR.

Aortic Valve Replacement: Is Minimally Invasive Really Better? A Contemporary Systematic Review and Meta-Analysis

In recent years, minimally invasive cardiac surgery has increased in prevalence. There has been significant debate regarding the optimal approach to isolated aortic valve replacement between conventional midline sternotomy and minimally invasive approaches. We performed a systematic review of the contemporary literature comparing minimally invasive to full sternotomy aortic valve replacement. PubMed and Embase were systematically searched for articles published from 2010-2021. A total of 1215 studies were screened and 45 studies (148,606 patients total) met the inclusion criteria. This study found rates of in-hospital mortality were higher with full sternotomy than ministernotomy ( P = 0.02). 30-day mortality was higher with full sternotomy compared to right anterior thoracotomy ( P = 0.006). Renal complications were more common with full sternotomy versus ministernotomy ( P < 0.00001) and right anterior thoracotomy ( P < 0.0001). Rates of wound infections were greater with full sternotomy than ministernotomy ( P = 0.02) and right anterior thoracotomy ( P < 0.00001). Intensive care unit length of stay ( P = 0.0001) and hospital length of stay ( P < 0.0001) were shorter with ministernotomy compared to full sternotomy. This review found that minimally invasive approaches to isolated aortic valve replacement result in reduced early mortality and select measures of postoperative morbidity; however, long-term mortality is not significantly different based on surgical approach. An analysis of mortality alone is not sufficient for the selection of the optimal approach to isolated aortic valve replacement. Surgeon experience, individual patient characteristics, and preference require thorough consideration, and additional studies investigating quality of life measures will be imperative in identifying the optimal approach to isolated aortic valve replacement.

Prevalence, factors and early outcomes of frailty among hospitalized older patients with valvular heart disease: A prospective observational cohort study

AIM

The aim was to investigate the prevalence of, and factors related to frailty, together with early clinical outcomes, in hospitalized older patients with valvular heart disease (VHD) in China.

DESIGN

A prospective observational cohort study was conducted.

METHODS

A validated prospective survey was conducted to assess the prevalence of frailty, factors associated with it, and early clinical outcomes in hospitalized older patients with VHD, utilizing Fried's criterion. A total of 207 consecutive participants aged 65 years and older who underwent cardiac surgery were included in the study, spanning from September 2021 to December 2021.

RESULTS

Frailty was detected in 78 patients (37.7%). Patients with multimorbidity, a New York Heart Association (NYHA) class of III/IV, or masticatory dysfunction had a greater incidence of frailty (p < 0.05). Patients with a normal albumin level and a higher frequency of exercise had a lower incidence of frailty (p < 0.05). Patients with frailty had longer hospital and intensive care unit stays and greater hospitalization costs than did those without frailty (p < 0.05). The 30-day adverse event rate of the frail group was also greater (11.5% vs. 3.1%). Therefore, early screening for conditions such as multimorbidity, cardiac dysfunction, and hypoalbuminemia is urgently needed to effectively address frailty, as it has been linked to unfavourable early outcomes. Moreover, promoting exercise and improving masticatory function and nutrition are crucial for preventing and managing frailty in older patients with VHD.

Minimally invasive approach associated with lower resource utilization after aortic and mitral valve surgery

Objective

To investigate the effect of minimally invasive cardiac surgery (MICS) on resource utilization, cost, and postoperative outcomes in patients undergoing left-heart valve operations.

Methods

Data were retrospectively reviewed for patients undergoing single-valve surgery (eg, aortic valve replacement, mitral valve replacement, or mitral valve repair) at a single center from 2018 to 2021, stratified by surgical approach: MICS vs full sternotomy (FS). Baseline characteristics and postoperative outcomes were compared. Primary outcome was high resource utilization, defined as direct procedure cost higher than the third quartile or either postoperative LOS ≥7 days or 30-day readmission. Secondary outcomes were direct cost, length of stay, 30-day readmission, in-hospital and 30-day mortality, and major morbidity. Multiple regression analysis was conducted, controlling for baseline characteristics, operative approach, valve operation, and lead surgeon to assess high resource utilization.

Results

MICS was correlated with a significantly lower rate of high resource utilization (MICS, 31.25% [n = 115] vs FS 61.29% [n = 76]; P < .001). Median postoperative length of stay (MICS, 4 days [range, 3-6 days] vs FS, 6 days [range, 4 to 9 days]; P < .001) and direct cost (MICS, $22,900 [$19,500-$28,600] vs FS, $31,900 [$25,900-$50,000]; P < .001) were lower in the MICS group. FS patients were more likely to experience postoperative atrial fibrillation (P = .040) and renal failure (P = .027). Other outcomes did not differ between groups. Controlling for stratified Society of Thoracic Surgeons predicted risk of mortality, cardiac valve operation, and lead surgeon, FS demonstrated increased likelihood of high resource utilization (P < .001).

Conclusions

MICS for left-heart valve pathology demonstrated improved postoperative outcomes and resource utilization.

Comparative Evaluation of the Incidence of Postoperative Pulmonary Complications After Minimally Invasive Valve Surgery vs. Full Sternotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity Score-Matched Studies

Background: Postoperative pulmonary complications remain a leading cause of increased morbidity, mortality, longer hospital stays, and increased costs after cardiac surgery; therefore, our study aims to analyze whether minimally invasive valve surgery (MIVS) for both aortic and mitral valves can improve pulmonary function and reduce the incidence of postoperative pulmonary complications when compared with the full median sternotomy (FS) approach. Methods: A comprehensive systematic literature research was performed for studies comparing MIVS and FS up to February 2021. Randomized controlled trials (RCTs) and propensity score-matching (PSM) studies comparing early respiratory function and pulmonary complications after MIVS and FS were extracted and analyzed. Secondary outcomes included intra- and postoperative outcomes. Results: A total of 10,194 patients from 30 studies (6 RCTs and 24 PSM studies) were analyzed. Early mortality differed significantly between the groups (MIVS 1.2 vs. FS 1.9%; p = 0.005). Compared with FS, MIVS significantly lowered the incidence of postoperative pulmonary complications (odds ratio 0.79, 95% confidence interval [0.67, 0.93]; p = 0.004) and improved early postoperative respiratory function status (mean difference -24.83 [-29.90, -19.76]; p < 0.00001). Blood transfusion amount was significantly lower after MIVS (p < 0.02), whereas cardiopulmonary bypass time and aortic cross-clamp time were significantly longer after MIVS (p < 0.00001). Conclusions: Our study showed that minimally invasive valve surgery decreases the incidence of postoperative pulmonary complications and improves postoperative respiratory function status.

Minimally invasive aortic valve surgery

Since their introduction, it has been demonstrated that minimally invasive aortic valve replacement (MIAVR) approaches are safe and effective for the treatment of aortic valve diseases. To date, the main advantage of these approaches is represented by the reduced surgical trauma, with a subsequent reduced complication rate and faster recovery. This makes such approaches an appealing choice also for frail patients [obese, aged, chronic obstructive pulmonary disease (COPD)]. The standardization of the minimally invasive techniques, together with the implementation of preoperative workup and anesthesiological intra- and post-operative care, led to an amelioration of surgical results and reduction of surgical times. Moreover, the improvement of surgical technology and the introduction of new devices such as sutureless and rapid deployment (SURD) valves, has helped the achievement of comparable results to traditional surgery. However, transcatheter technologies are nowadays more and more important in the treatment of aortic valve disease, also in low risk patients. For this reason surgeons should put new efforts for further reducing the surgical trauma in the future, even taking inspiration from other disciplines. In this review, we aim to present a review of literature evidences regarding minimally invasive treatment of aortic diseases, also reflecting our personal experience with MIAVR techniques. This review could represent a tool for a well-structured patient assessment and preoperative planning, in order to safely carrying out an MIAVR procedure with satisfactory outcomes.

Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: the Conventional Procedure Performed Through a Smaller Incision

Minimally invasive aortic valve replacement has gained consent due to its good results in terms of minimized surgical trauma, faster rehabilitation, pain control and patient compliance. In our experience, we have tried to replicate the conventional and gold standard approach through a smaller incision. Sparing the right internal thoracic artery, avoiding rib fractures and performing total central cannulation is important to make this procedure minimally invasive from a biological point of view too. In addition, the total central cannulation is pivotal to simplify perfusion and drainage. Moreover, a complete step-by-step procedure optimization and-when possible-the use of sutureless prosthesis help to reduce the cross-clamping and perfusion times. After more than 1000 right anterior thoracotomy (RAT) aortic valve replacements, we have found tips and tricks to make our technique more effective.

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Background

New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed.

Methods

Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis.

Results

Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups.

Conclusions

Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

Minimally invasive surgical aortic valve replacement: The RALT approach

Less-invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but the technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography and our cannulation strategy. We also sought to define the anatomical ascending aorta-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.

Does minimal invasive cardiac surgery reduce the incidence of post-operative atrial fibrillation?

Atrial fibrillation (AF) is the most common post-operative complication and tends to be the most common arrhythmia after cardiac surgery. The etiology and risk factors for post-operative AF are poorly understood, but older age, large left atrium, diffuse coronary artery disease, a history of AF paroxysms and in general, pre-existing cardiac conditions that cause restricting and susceptibility towards inflammation have been consistently linked with post-operative atrial fibrillation (POAF). It has been traditionally thought that post-operative AF is transient, well-tolerated, benign to the patient and self-limiting complication of cardiac surgery that was temporary and easily treated. However, recent evidence suggests that POAF may be more "malignant" than previously thought, associated with follow-up mortality and morbidity. Several minimally invasive approaches, including the right parasternal approach, upper and lower mini-sternotomy (MS), V-shaped, Z-shaped, inverse-T, J-, reverse-C and reverse-L partial MS, transverse sternotomy and right mini-thoracotomy, have been developed for cardiac surgery operations since 1993 and have been associated with better outcomes and lower perioperative morbidity compared to full sternotomy (FS). The common goal of several minimally invasive approaches is to reduce invasiveness and surgical trauma. According to a statement from the American Heart Association (AHA), the term "minimally invasive" refers to a small chest wall incision that does not include a FS. This review is aimed to evaluate the use of minimally invasive techniques like mini-sternotomy, mini-thoracotomy and hybrid techniques versus conventional techniques which are used in cardiac surgery and to compare the frequency of post-operative AF and its effect on post-operative complications, morbidity and mortality, after cardiac surgery operations with FS versus cardiac surgery operations with the use of minimally invasive techniques.

Recent advances in aortic valve replacement

Aortic valve replacement has stood the test of time but is no longer an operation that is exclusively approached through a median sternotomy using only sutured prostheses. Currently, surgical aortic valve replacement can be performed through a number of minimally invasive approaches employing conventional mechanical or bioprostheses as well as sutureless valves. In either case, the direct surgical access allows inspection of the valve, complete excision of the diseased leaflets, and debridement of the annulus in a controlled and thorough manner under visual control. It can be employed to treat aortic valve pathologies of all natures and aetiologies. When compared with transcatheter valves in patients with a high or intermediate preoperative predictive risk, conventional surgery has not been shown to be inferior to transcatheter valve implants. As our understanding of sutureless valves and their applicability to minimally invasive surgery advances, the invasiveness and trauma of surgery can be reduced and outcomes can improve. This warrants further comparative trials comparing sutureless and transcatheter valves.

Concomitant Annular Enlargement in Minimally Invasive Aortic Valve Replacement

OBJECTIVE

Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy.

METHODS

Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed.

RESULTS

Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m². All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%.

CONCLUSIONS

Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.

The Opportunities and Limitations of Minimally Invasive Cardiac Surgery

BACKGROUND

Over the past two decades, minimally invasive techniques for classic heart valve surgery and isolated bypass surgery have been developed that enable access to the heart via partial sternotomy for most aortic valve procedures and via sternotomy-free mini-thoracotomy for other procedures.

METHODS

We review the current evidence on minimally invasive cardiac surgery on the basis of pertinent randomized studies and database studies retrieved by a selective search in the MEDLINE and PubMed Central databases, as well as by the Google Scholar search engine.

RESULTS

A PubMed search employing the search term "minimally invasive cardiac surgery" yielded nearly 10 000 hits, among which there were 7 prospective, randomized, controlled trials (RCTs) on aortic valve replacement, with a total of 477 patients, and 3 RCTs on mitral valve surgery, with a total of 340 patients. Only limited reports of specified centers are currently available for multiple valvular procedures and multiple coronary artery bypass procedures. The RCTs reveal that the minimally invasive techniques are associated with fewer wound infections and faster mobilization, without any difference in survival. Minimally invasive procedures are technically demanding and have certain anatomical prerequisites, such as appropriate coronary morphology for multiple bypass operations and the position of the aorta in the chest for sternotomy-free aortic valve procedures. The articles reviewed here were presumably affected by selection bias, in that patients in the published studies were preselected, and there may have been negative studies that were not published at all.

CONCLUSION

Specialized surgeons and centers can now carry out many cardiac valvular and bypass operations via minithoracotomy rather than sternotomy. According to current evidence, these minimally invasive techniques yield results that are at least as good as classic open-heart surgery.

Surgical treatment of elderly patients with severe aortic stenosis in the modern era - review

Surgical treatment of severe aortic stenosis offers good early and long-term results, even in elderly patients. Despite the implementation of percutaneous methods for the very high-risk group, surgical valve replacement remains the gold standard. The advanced age of patients should not be the only indicator limiting the possibility of surgery. In this review we present the most important information on the results of aortic stenosis surgical treatment in the groups of older patients. New methods such as percutaneous and minimally invasive methods of surgery are also discussed. Additionally, the presented information is referred to current guidelines for the treatment of severe aortic stenosis.

Minimally invasive aortic valve replacement through a right anterolateral mini-thoracotomy for the treatment of octogenarians with aortic valve stenosis

Because of concerns about the high risk of perioperative complications, the feasibility of minimally invasive aortic valve replacement (MIAVR) for elderly patients remains controversial. Here, we review our results of MIAVR in octogenarians with aortic valve stenosis (AS). Between October 2012 and December 2017, 110 patients with AS underwent MIAVR via a right anterolateral mini-thoracotomy; 41 patients were octogenarian (Group O). The perioperative outcomes of these patients were compared with those of the 69 patients who were less than 80 years of age (Group Y). A preoperative contrast-enhanced computed tomography (CT) scan was performed in all patients to guide the patient selection and aid the decision regarding cannulation sites. Among all cases of isolated aortic valve replacement, MIAVR accounted for 47% cases during this study period. The mean age of Group O was 83.6 ± 2.9 years, with a maximum age of 89. In Group O, there were no in-hospital deaths or morbidity, including stroke. The rate of blood transfusion was significantly higher in Group O than in Group Y (P = 0.01). However, there was no significant difference in ventilation time, the length of intensive care unit stay, the length of hospital stay, or in the rates of cumulative survival and freedom from valve-related complications. With careful patient selection and a perfusion strategy based on preoperative CT scan, equivalent outcomes of MIAVR were even achieved in octogenarians.

Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

The aim of this literature review was to evaluate existing evidence on exercise-based cardiac rehabilitation (CR) as a treatment option for elderly frail patients with valvular heart disease (VHD). Pubmed database was searched for articles between 1980 and January 2018. From 2623 articles screened, 61 on frailty and VHD and 12 on exercise-based training for patients with VHD were included in the analysis. We studied and described frailty assessment in this patient population. Studies reporting results of exercise training in patients after surgical/interventional VHD treatment were analyzed regarding contents and outcomes. The tools for frailty assessment included fried phenotype frailty index and its modifications, multidimensional geriatric assessment, clinical frailty scale, 5-meter walking test, serum albumin levels, and Katz index of activities of daily living. Frailty assessment in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (mobility, muscle mass and strength, independence in daily living, cognitive functions, nutrition, and anxiety and depression evaluation). Participating in comprehensive exercise-based CR could improve short- and long-term outcomes (better quality of life, physical and functional capacity) in frail VHD patients. Such CR program should be led by cardiologist, and its content should include (1) exercise training (endurance and strength training to improve muscle mass, strength, balance, and coordination), (2) nutrition counseling, (3) occupational therapy (to improve independency and cognitive function), (4) psychological counseling to ensure psychosocial health, and (5) social worker counseling (to improve independency). Comprehensive CR could help to prevent, restore, and reduce the severity of frailty as well as to improve outcomes for frail VHD patients after surgery or intervention.

A Retrospective Analysis of the Variability in Case Duration for Aortic Valve Replacement and Association With Hospital Facility Types

OBJECTIVE

Currently, there are no large-scale studies that compare differences in case duration of aortic valve replacements (AVRs). The primary objective of this study was to determine associations of hospital facility type, geographic location, case volume per year, and time of day with duration of valve replacement surgery.

DESIGN

Retrospective.

SETTING

Data from the National Anesthesia Clinical Outcomes Registry.

PARTICIPANTS

National data from university and non-university hospitals.

INTERVENTIONS

No interventions.

MEASUREMENTS AND MAIN RESULTS

All AVRs from the National Anesthesia Clinical Outcomes Registry were identified from 2010 to 2014. Mean case duration for all AVRs was 360.8 ± 95.8 minutes and was presented based on facility type (university hospital, large community hospital, medium-sized community hospital, and other); US geographic region; time of day (cases performed after 5 pm and before 7 am v day shift); and case volume per year. A multivariable linear regression model was built to determine the association of various patient, procedural, and facility characteristics with case duration. University hospitals were associated with increased case duration for AVRs (p < 0.0001).

CONCLUSIONS

With this large national database, the authors demonstrated that academic hospitals, time of day of the surgery, US region, and case volume per year for a facility are related to the case duration of AVRs.

Minimally invasive aortic valve replacement in high risk patient groups

Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts.

Health-Related Quality of Life after Minimally Invasive Cardiac Surgery

Objective

Factors influencing health-related quality of life (HRQL) after minimally invasive cardiac surgery have not been well described. We examined the trajectory of HRQL after minimally invasive cardiac surgery and the role of perioperative factors and rhythm on HRQL changes.

Methods

Patients underwent minimally invasive surgical ablation for atrial fibrillation and/or valve surgery (n = 235). Health-related quality of life (SF-12) and clinical status were assessed preoperatively and postoperatively.

Results

Physical summary HRQL (F = 36.2, P < 0.001) and mental summary HRQL (F = 3.2, P = 0.047) improved significantly by 12 months after surgery. Improvement on HRQL peaked at 6 months and plateaued between 6 and 12 months. Physical HRQL was similar to age-based normal values before surgery (P = 0.66) and surpassed norms by 6 months after surgery (P < 0.001). Younger age (r = −0.15, P = 0.02) and lower EuroSCORE II (r = −0.19, P = 0.003) correlated with greater HRQL improvements by 6 months. Only lower EuroSCORE II (r = −0.14, P = 0.04) correlated with greater HRQL improvement by 12 months. Length of stay and major morbidity were not related to HRQL improvement. In surgical ablation patients, restoration of stable sinus rhythm throughout the first 12 months was associated with greater physical HRQL improvement by 6 months compared with patients who had atrial arrhythmia recurrences (change, 5.0 vs. −1.0, P = 0.02).

Conclusions

Health-related quality of life improved significantly after minimally invasive cardiac surgery. These improvements were influenced by age, operative risk, symptoms, and rhythm status. Even patients with HRQL in a normal range before surgery can experience improved HRQL after surgery. Minimally invasive cardiac surgery can offer decreased postoperative complications and also improved HRQL.

Expectation and Quality of Life after Aortic Valve Replacement over 85 Years of Age Match those of the Contemporary General Population

Background

In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS.

Methods

Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics.

Results

Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population.

Conclusions

Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.