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Aortic Valve Replacement in Heart Failure Patients: Full Sternotomy or Minimally Invasive Access?
Sven Lehmann, Sergey Leontyev, Christian D. Etz, Anna Funkat, Jens Garbade, Martin Misfeld, Michael Borger, Friedrich W. Mohr.
Heartcenter Leipzig, Leipzig, Germany.

OBJECTIVE: Minimally invasive techniques are progressively challenging traditional approaches in cardiothoracic surgery_even for patients with a higher operative mortality. The aim of this study was to compare mortality and morbidity after minimally invasive (MIC) vs conventional (CON) access for aortic valve replacement in patients with severely reduced ejection fraction (EF). Methods: 354 consecutive patients with severely reduced EF ≤30% had undergone aortic valve replacement at our institution from 11/94 to 10/12: 39 patients had a MIC access and 315 a CON access. Results: There were no significant differences between the two groups (CON vs. MIV) in terms of mean age (65±10 vs. 67±13 years), EF (24±5 vs. 15±5%) and logEuroscore (17.7±17.2 vs. 15.0±9.3) MIC patients remained longer cross clamp time (53±17 vs. 63±16 min p=0.004) but are not longer on cardiopulmonary bypass (87±33 vs. 92±29 min) than CON patients. 30 day survival rate was 94.9±3.5 (MIC) and 89.6±1.7 (CON; p=0.32). The Survival rate after 13 years was 23.2±9.3% (MIC) vs. 27.1±3.5% (CON; p=0.34). Univariate analysis indicated dialyses, atrial fibrillation, PM and ICD device, urgent or emergency operation, endocarditis and cardiogenic shock as risk factors for long term mortality. The multivariate analysis revealed urgent or emergency operation (p<0.01) as independent risk factors for long-term mortality. Cox analysis revealed the following predictors for long term mortality: permanent haemodialysis (p<0.01, OR=5.0) , active endocarditis (p<0.01, OR=6.1) and ICD wearer (p=0.04, OR=9.3). Conclusions: In this heart failure cohort minimally invasive access for aortic valve replacement is at least as safe as the conventional approach. Emergency indication, permanent haemodialysis and active endocarditis are independent predictor for mortality. The operative trauma is clearly reduced. The main indication for full median sternotomy should be in emergency indications.

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