From the Journals

Right-side mini-AVR an option for frail patients

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Sutureless aortic prosthesis shows benefit

“Have we found the end of the road, and the future for isolated AVR is made up of RAMT with sutureless AVR?” asks Dr. Patrick M. McCarthy, chief of cardiac surgery at Northwestern University Feinberg School of Medicine in Chicago, in his invited commentary (J Thorac Cardiovasc Surg. 2015. doi: 10.1016/j.jtcvs.2015.07.007). “The cardiology literature serves as a reality check.”

He noted that results from the NOTION Trial of transaortic valve replacement (TAVR) vs. surgical AVR (J Am Coll Cardiol. 2015;65:2184-94) had 30-day results similar to the G. Pasquinucci Heart Hospital results. However, 34% in the TAVR group in NOTION needed pacemakers, and 16% had moderate or greater valvular regurgitation and higher rates of dyspnea.

Dr. Patrick M. McCarthy

Right anterior minithoracotomy is different from other minimally invasive approaches, Dr. McCarthy said. “It’s more of a tunnel down to the aortic valve which is why patient selection based on anatomic factors determined by preoperative CT scan (which is an unnecessary expense for hemisternotomy) is so important,” he said.

The evolution of TAVR is still in the early stage, so the “flaws” involved in the approach can yet be eliminated, “but the message that TAVR outcomes today are still very different than [surgical] AVR in low-risk patients, the type that have a minimally invasive AVR, may be lost on many readers,” Dr. McCarthy said.

For isolated aortic stenosis, the era of minimally invasive procedures that involve bypass, cross-clamping and a difficult surgical approach may be fading, he said. “The handwriting is on the wall, or in the journals in this case.”

Dr. McCarthy disclosed relationships with Edwards Lifesciences and Abbott Vascular. He is the inventor of the Edwards MC3 Ring and dETlogix Ring and coinventor of the IMR ETlogix Ring.



Many patients with aortic valve disease still undergo conventional aortic valve replacement (AVR) with standard full sternotomy or seek out alternative treatments like transcatheter aortic valve insertion (TAVI). But a minimally invasive approach that uses a sutureless prostheses may reduce operation times and put AVR within reach of more frail patients.

Investigators from G. Pasquinucci Heart Hospital in Massa, Italy, reported on 593 patients who had AVR through right anterior minithoracotomy (RAMT) over 10 years at their institution (J Thorac Cardiovasc Surg. 2015. doi: 10.1016/j.jtcvs.2015.06.045). In 302 of the patients, the researchers used a sutureless or rapidly implantable biological prosthesis.

“More surgeons should enrich their armamentarium by RAMT AVR,” lead author Dr. Mattia Glauber and his coauthors said. “Sutureless prostheses can increase adoption of RAMT AVR.”

The authors acknowledged that minimally invasive approaches to AVR, including partial sternotomy, require longer operation times than open surgery despite reduced aortic cross-clamping and cardiopulmonary bypass times, but have resulted in better outcomes and lower death rates.

A new generation of aortic valve prostheses, including sutureless devices, have emerged in an attempt to further reduce operative times and improve outcomes, so the Italian investigators designed their study to compare early and midterm outcomes after minimally invasive AVR using sutured and sutureless repair at their institution between 2004 and 2014.

In 302 (50.9%) patients, sutureless or rapidly implantable biological prosthesis was used, 23 (3.9%) had a mechanical prosthesis, and the remainder received a conventional biological prosthesis.

The investigators determined patients were suitable for RAMT if CT scan showed specific anatomic features, including rightward positioning of the ascending aorta at the level of the main pulmonary artery. Once the sutureless prostheses became available in 2011, every patient undergoing AVR via RAMT was considered a potential candidate, although the investigators decided that patients with type 1 and 2 bicuspid aortic valves without raphe and asymmetric aortic root were not suitable for the sutureless approach.

The subgroup that underwent sutureless repair tended to be older and sicker than the overall study population and had a higher prevalence of tricuspid aortic valve and aortic stenosis, a slightly higher body mass index, and a higher propensity to be obese. The sutureless subgroup also had fewer smokers.

Cardiopulmonary bypass time averaged 88 minutes and aortic cross-clamping times 55 minutes in the sutureless subgroup vs. 107 and 74 minutes, respectively, in the overall RAMT study subgroup.

The death before discharge rate of patients who had RAMT repair was 1%, and the 30-day in-hospital death rate was 1.5%. Overall, 97% of patients who had RAMT did not require reoperation at 5 years.

Between the sutured and sutureless subgroups, hospital and intensive care unit lengths of stay were similar, as were bleeding rates and in-hospital mortality. One measure in which the two subgroups deviated was prolonged ICU stay – a rate of 11.3% in the sutureless subgroup and 6.6% in the sutured subgroup.

“To the best of our knowledge, this is the largest up-to-date single-center experience on minimally invasive AVR through RAMT,” Dr. Glauber and coauthors said. “Our data along with earlier reports confirm that minimally invasive AVR through RAMT is safe and reproducible. It is associated with low perioperative mortality and morbidity.”

Dr. Glauber and coauthor Dr. Marco Solinas disclosed a commercial/financial relationship with Sorin Group.

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