Clinical Safety and Efficacy of the Transaxillary Access Route for Minimally Invasive Aortic Valve Replacement

Background: The transaxillary access represents the latest innovation for minimally invasive isolated aortic valve replacement (MICS-AVR). Beside the first description of the technique including a small initial case series, little is known about safety and efficacy of this novel access route. The present study adds a large cohort comparing the results to a propensity-matched control group.

Method: A total of 908 patients undergoing isolated AVR were enrolled in the present study. Mean age was 69.0 years (95% CI: 63.0; 74.0), the logistic EuroSCORE averaged 4.1% (95% CI: 2.7; 6.4) with a mean body mass index (BMI) of 27.3 kg/m² (95% CI: 24.6; 30.2). The treatment group consisted of 454 consecutive patients undergoing MICS-AVR using the transaxillary access route through the 3rd intercostal space in the right axillary line. The control group was generated out of 4.066 AVRs done by sternotomy by 1:1 propensity matching (n = 454). Propensity matching was based on a multivariate model including age, LVEF, logistic EuroSCORE, and BMI.

Results: After propensity-matching both groups were comparable concerning their clinical baselines. Adverse results for MICS-AVR were longer skin-to-skin time (120 min [95% CI: 105; 143] vs. 115 min [95% CI: 98; 135]; p < 0.001) and more frequently bleeding requiring chest reopening (8.2 vs. 2.4%; p < 0.01). In favor of MICS-AVR, less access site wound infections (0.4 vs. 3.5%; p = 0.002), less postoperative kidney injury (4.0 vs. 11.2%), more probable an ICU stay of less than 24 hours (70.0 vs. 57.5%; p < 0.001), and shorter hospital stay (7.0 days [6.0; 10.0] vs. 10.0 [8.0; 13.0]; p < 0.001) observed. No significant differences were observed concerning stroke (MICS-AVR 2.6% vs. sternotomy 1.9%; p = 0.575) and renal replacement therapy (MICS-AVR 1.5% vs. sternotomy 2.2%; p = 0.624). Hospital mortality was similar in both groups (0.9 vs. 1.5%; p = 0.544).

Conclusion: Transaxillary access for MICS-AVR is as safe as AVR by sternotomy. Advantages are less postoperative morbidity as well as shorter ICU and hospital stay. Mortality rates generally were lower than predicted for the studied intermediate-risk group.

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Artikel online veröffentlicht:
28. Januar 2023