Partial versus Complete Sternotomy for Aortic Valve Replacement—Multicenter Study

Abstract

Background The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort.

Methods A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy.

Results Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy.

Conclusion In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Keywords

root - aortic valve surgery - minimally invasive surgery - outcomes - surgery/incision

Note

The study results were presented at the 52nd Annual Meeting of the German Society for Thoracic, Cardiac, and Vascular Surgery (DGTHG) in Hamburg, Germany, February 11–14, 2023. The abstract has been awarded the Hans Georg Borst Award for highest ranking in the review process.

Authors' Contribution

Conception and design of the study were performed by N.G., F.S., R.F., H.D., H.H., P.M., M.S., T.F., D.F., and U.F. Acquisition, analysis, and interpretation of data by N.G., T.S., F.P., K.H., H.J., J.S., C.S., T.Z., Y.E., and S.H. Drafting the manuscript by N.G., T.S., F.P., K.H., H.H., P.M., and U.F. Critical revision of the manuscript by H.J., J.S., C.S., T.Z., Y.E., F.S., R.F., H.D., M.S., S.H., T.F., and D.F. All authors approved the final manuscript version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Publication History

Received: 22 November 2023

Accepted: 27 February 2024

Article published online:
16 April 2024

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