Authors
Niyazov S.S.1, Kovalyov A.I.1,2, Kambarov S. Yu.1
1 N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow
2 A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow
Abstract
Objective: compare the immediate results of aortic valve replacement through J-shaped ministernotomy in the 3rd and 4th intercostal space in patients over 65 years old.
Materials and methods: A retrospective cohort clinical study of the surgical intervention outcomes was conducted in 35 patients over 65 years old who underwent isolated aortic valve replacement through upper J-shaped ministernotomy. The first group included 26 (74.3%) patients who had access through the 3rd intercostal space, while the second group included 9 (25.7%) patients with J-shaped ministernotomy in the 4th intercostal space. The analysis covered intraoperative results, the volume of perioperative blood loss and blood component transfusion, duration of artificial ventilation of lungs, patients' stay in the intensive care unit, postoperative complications, hospital mortality, and postoperative hospitalization.
Results: According to the results of our study, aortic valve replacement through ministernotomy in the 4th intercostal space was statistically significantly associated with a shorter duration of mechanical ventilation compared to the 3rd intercostal space (p=0.007). No differences were found between the groups in terms of ICU duration, aortic clamping time, operation duration, volume of perioperative blood loss, duration of stay in the ICU, frequency of complication development, duration of postoperative hospital stay, and mortality. A tendency was noted for a higher frequency of intraoperative need for red blood cell transfusion when the access was localized in the 4th intercostal space (p=0.51), which is most likely related to the statistically significant lower level of hemoglobin (133.3 (±13.8) and 119.9 (±9.3) respectively, p=0.004) before surgery in this group of patients.
Conclusion: In our study, the use of J-shaped ministernotomy in the 3rd and 4th intercostal spaces for aortic valve replacement in elderly patients was statistically significantly different only in the shorter duration of mechanical ventilation when accessed through the 4th intercostal space. In elderly patients, when performing upper J-shaped ministernotomy, the localization of access in the 4th intercostal space is preferable to reduce the risks of complication development due to better exposure and maneuverability, and to achieve the maximum benefit of minimally invasive access. The choice in favor of the 3rd intercostal space for cosmetic effect may be made if it is possible to perform the surgical intervention through a skin incision of 5-6 cm and can be a choice for younger patients.
Keywords: aortic valve replacement, minimally invasive access, J-shaped ministernotomy in the 3rd and 4th intercostal space, elderly age.
References
1. Rao PN, Kumar AS. Aortic valve replacement through right thoracotomy. Tex Heart Inst J. 1993; 20(4): 307-8.
2. Van Praet KM, Nersesian G, Kukucka M, et al. Minimally invasive surgical aortic valve replacement via a partial upper ministernotomy. Multimed Man Cardiothorac Surg. 2022; doi: 10.1510/mmcts.2022.093.
3. Meyer A, van Kampen A, Kiefer P, et al. Minithoracotomy versus full sternotomy for isolated aortic valve replacement: Propensity matched data from two centers. J Card Surg. 2021; 36(1): 97-104. doi: 10.1111/jocs.15177.
4. Ogami T, Yokoyama Y, Takagi H, et al. Minimally invasive versus conventional aortic valve replacement: The network meta-analysis. J Card Surg. 2022; 37(12): 4868-4874. doi: 10.1111/jocs.17126.
5. Vukovic PM, Milojevic P, Stojanovic I, et al. The role of ministernotomy in aortic valve surgery-A prospective randomized study. J Card Surg. 2019; 34(6): 435-439. doi: 10.1111/jocs.14053.
6. Faraz A, Fundano N, Qureshi AI, et al. Comparison Between Mini-Sternotomy and Full Sternotomy for Aortic Valve Replacement: A 10-Year Retrospective Study. Cureus. 2022; 14(11): e31627. doi: 10.7759/cureus.31627.
7. The EuroSCORE Risk Calculator. Royal Papworth Hospital. [URL] Accessed September 21, 2023.
8. Hancock HC, Maier RH, Kasim A, et al. Mini-sternotomy versus conventional sternotomy for aortic valve replacement: a randomised controlled trial. BMJ Open. 2021; 11(1): e041398. doi: 10.1136/bmjopen-2020-041398.
9. Kaczmarczyk M, Pacholewicz J, Kaczmarczyk A, et al. Ministernotomy for aortic valve replacement improves early recovery and facilitates proper wound healing - forced propensity score matching design with reference full sternotomy. Kardiochir Torakochirurgia Pol. 2022; 19(1): 1-10. doi: 10.5114/kitp.2022.114548.
10. Bakr Ali MK, Abdelaal MM, Elfeky WM, Abdou Ettish AA. Mini-Sternotomy Versus Conventional Sternotomy In Aortic Valve Replacement Surgery; A Comparative Study. J Pak Med Assoc. 2023; 73(4): S56-S60. doi: 10.47391/JPMA.EGY-S4-13.
11. Liu R, Song J, Chu J, et al. Comparing mini-sternotomy to full median sternotomy for aortic valve replacement with propensity-matching methods. Front Surg. 2022; 9: 972264. doi: 10.3389/fsurg.2022.972264.
12. Semsroth S, Matteucci Gothe R, Raith YR, et al. Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement. Ann Thorac Surg. 2017; 104(3): 877-883. doi: 10.1016/j.athoracsur.2017.01.095.
13. Charchian ÉR, Breshenkov DG, Belov IuV. Minimally invasive approach in thoracic aortic surgery: a single center experience. Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2019; 12(6): 522‑535. (In Russ.) doi: 10.17116/kardio201912061522.
14. Chernov II, Makeev SA, Kozmin DYu, Tarasov DG. Correction of multivalvular heart diseases from mini-access. Clinical and experiment. chir. zhurn. by Acad. B.V. Petrovsky. 2018; 1: 21-26. (In Russ.) doi: 10.24411/2308-1198-2018-00003.
15. Hlavicka J, Janda D, Budera P, et al. Partial upper sternotomy for aortic valve replacement provides similar mid-term outcomes as the full sternotomy. J Thorac Dis. 2022; 14(4): 857-865. doi: 10.21037/jtd-21-1494.
