Operative and mid-term outcomes of minimally invasive ascending aortic surgery: a propensity match study.

P0232 

Abstract Submission 

Francesco Pollari (1), Matthias Angerer (1), Wolfgang Hitzl (2), Lucia Weber (1), Joachim Sirch (1), Theodor (Teddy) Fischlein (3)

(1) Klinikum Nürnberg – Paracelsus Medical University, Nuremberg, NA, (2) Research and Innovation Management (RIM), Team Biostatistics, Paracelsus Medical University, Salzburg, NA, (3) Klinikum Nürnberg – Paracelsus Medical University, Nuremberg, Bavaria

Francesco Pollari    -  Contact Me
Klinikum Nürnberg – Paracelsus Medical University

Matthias Angerer    -  Contact Me
Klinikum Nürnberg – Paracelsus Medical University

Wolfgang Hitzl    -  Contact Me
Research and Innovation Management (RIM), Team Biostatistics, Paracelsus Medical University

Lucia Weber    -  Contact Me
Klinikum Nürnberg – Paracelsus Medical University

Joachim Sirch    -  Contact Me
Klinikum Nürnberg – Paracelsus Medical University

*Theodor (Teddy) Fischlein    -  Contact Me
Klinikum Nürnberg – Paracelsus Medical University

Francesco Pollari    -  Contact Me
N/A

Objective
Minimally invasive approaches, such as partial-sternotomy (PS), could reduce the surgical trauma and were proven to be safe for valve-related procedures. We aimed to investigate the in-hospital and mid-term outcomes of patients undergoing ascending aortic surgery (AAS) through a partial or a full-sternotomy approach through a propensity matching analysis.

Methods
We retrospectively included all patients (n=167), who underwent elective AAS for aneurysm in our institution between 2013 and 2020. Patients, who received a surgical treatment in cases of emergency situations for aortic dissection were excluded. Study population was divided in two groups according to the surgical access (n=40 in partial sternotomy or "PS", and n=127 in full sternotomy, or "FS"). Due to the significant differences between the groups, a propensity matching 1:3 was applied. Age, BMI, gender and EuroSCORE II were used as covariate variables and the propensity score was computed based on the combined aortic valve operation. The Mahalanobis distance including the propensity score was used as distance calculation method. The order for matching was done at random. No maximum number of iterations were set for the optimization algorithm. After propensity matching, only the preoperative EF was significantly different between the two groups. In-hospital complications, survival and reoperation at follow-up were investigated.

Results
No operation started with a partial upper sternotomy had to be converted into a median full sternotomy during the operation. The majority of patients were operated with a brachiocephalic cannulation (PS=70% vs FS=61%, p=0.3) and selective cerebral perfusion (PS=65% vs FS=58%, p=0.3) in both groups. A combined aortic valve surgery was performed in the 92% of patients in the PS-group and 76% of patients in FS-group (p=0.06). PS group showed higher X-clamp and cardiopulmonary bypass times (94.2 min vs. 83 min and 164.2 min vs. 126.8 min). Moreover, the mean postoperative ventilation time was significantly higher in the PS group (41.5 hours±98.8 versus 22.5 hours±58.5), however not affecting the length of stay in ICU (3.6 days±4.7 versus 2.9 days±3.3; p=0.1). The incidence of bleeding, stroke and in-hospital mortality were similar between PS and FS group (11% vs. 3%, 3% vs. 6%, 5% vs 3%, respectively). After a median follow-up of 2±1.98 years, the Kaplan-Meier analysis showed not significant differences between the PS and FS group (log-rank, p=0.17) in term of survival. Cardiac reoperations were observed in 2 cases (6%) of the PS-group and in 8 (7%) of the FS-group. In the PS group the reason accounted for hemodynamic relevant pericardial effusion, that was successfully treated with a subxiphoidal drainage placement. In the FS-group patients were reoperated because of pericardial effusion (n=3), sternal complications (n=2), tricuspidal valve insufficiency (n=1), aortic valve replacement (n=1) or tube prosthesis endocarditis by Streptococcus gallolyticus (n=1).

Conclusions
The surgical ascending aorta replacement through a partial sternotomy is associated with longer operative times, but this does not affect the early as well as the long-term follow-up. Surgical ascending aorta replacement can be safely performed through a minimally invasive approach.

Ascending Aorta