Resultados del abordaje minimamente invasivo en el recambio valvular aórtico /

Abstract

Objective This study hypothesizes that cardiac surgery minimally invasive aortic valve replacement by ministernotomy "J" is not inferior in terms of perioperative morbidity and mortality comparing to the conventional approach. Minimmally invasive approach could be advantageous in terms of recovery and less transfusion requirements. It could also be an option for high-risk patients included in the "gray area" currently undergoing transcatheter valve replacements (TAVI). Methods Retrospective study at a single center (Consortium General Hospital Universitario de Valencia, Spain). We collected patients undergoing isolated aortic valve replacement between 2005 and 2013. 618 patients were included: 498 in the median sternotomy group (E group) and 120 in the minimally invasive approach (group M). After a propensity score matching considering the main preoperative variables, 120 cases were included in the control group E and 120 for group M. We performed a statistical analysis between groups for preoperative variables, perioperative morbidity and hospital mortality, transfusion requirements and hospital length of stay. A univariate and multivariate analysis was also performed to identify independent predictors of morbidity, mortality and transfusion requirements. A subgroup of patients at high risk with EuroScore Logistics I = or> 15 were identified and analyzed in terms of morbidity and hospital mortality. Results No significant differences in the score of surgical risk or other preoperative variables between the groups were found. Times of cardiopulmonary bypass (CPB) and aortic clamping were significantly higher in group E; 94.44 ± 32.55 vs 82.19 ± 24.53 and 73.06 ± 26.87 vs 63.26 ± 16.24 respectively. No significant differences in mortality or postoperative morbidity was found between groups. Intensive Care Unit (ICU) and the total hospital length of stay were significantly higher in group E; 4.61 ± 6.92 vs 3.09 ± 1.69 (p 0.020) and 10.51 ± 7.82 vs 7.35 ± 3.21 (p <0.001) respectively. The group E registered the highest packed red blood cells transfusion rate 63.3% vs 52.5% (p 0.089), units of platelets 24.1% vs 11.6% (p 0.012) and fresh frozen plasma 27.5% vs 14.1% (p 0.011). CPB time was found as a predictor of morbidity, mortality plasma transfusion and minimally invasive approach as a protective factor against platelet transfusion requirements. The high-risk group reported no mortality. Total hospital and ICU length of stay was slightly longer than the average for the whole group. hemodynamic and wound complications were recorded in the 14,3% of patients in this group. Discussion The increasing patients with high comorbidity undergoing cardiac surgery has increased the interest in minimally invasive aortic approach As new technique should guarantee the same outcomes in terms of morbidity and mortality safety comparing to the standardized technique. This study supports the hypothesis that this approach is as safe as conventional; demonstrating advantages in the postoperative recovery and decreased transfusion requirements. In high-risk patients, now considered "gray area", this treatment might be the best. With the advent of new implant devices such as prosthetics "sutureless" valves, minimally invasive approaches could become a valid treatment option for these patients.