Partial versus Complete Sternotomy for Surgical Aortic Valve Replacement: Results of a Multicenter Study

Background: Even though minimally invasive techniques have already been well established in cardiac surgery, their benefits remain unclear. Surgical aortic valve replacement can safely be performed using partial instead of standard median sternotomy. Aim of the study is to evaluate the short- and midterm outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy in a large German multicenter cohort.

Method: A total of 2,929 patients (1,764 partial upper sternotomy [PUS], 1,165 median sternotomy [MS]) underwent isolated aortic valve replacement at nine participating heart centers between January 2016 and December 2020. Concomitant procedures were atrial ablation, left atrial appendage closure, Morrow myectomy, and aortic anulus enlargement. After propensity score matching, 1,990 patients were eligible for analysis. The primary endpoint was MACCE (composite of death, myocardial infarction, and stroke) at 30 days and in 5-year follow-up. Secondary endpoints were acute kidney injury, length of hospital stay, transfusions, sternal wound infection, Dressler syndrome, rehospitalization, and conversion to sternotomy.

Results: Unadjusted MACCE (major adverse cardiac and cerebrovascular events) rates were significantly lower in the PUS group: at 30 days, 3.5 versus 5.3% in MS group (p = 0.02); in 5-year follow-up, 12.7 versus 16.7% in MS group (p = 0.01). However, after propensity-score matching, differences between groups were no more statistically significant: MACCE rates at 30 days were 3.9% in the PUS group versus 5.4% in MS group (p = 0.14); in 5-year follow-up, 9.9% in the PUS group versus 11.3% in MS group (p = 0.36). There were more acute kidney injuries in the PUS group (17.3 vs. 12.4% in the MS group, p = 0.005). However, in the minimally invasive group, length of ICU stay was shorter (2.0 vs. 2.4 days, p = 0.03), Dressler syndrome occurred less frequently (2.2 vs. 4.6%, p = 0.006), and the rate of rehospitalization was reduced significantly (16.2 vs. 26.4%, p < 0.001). No differences were observed regarding transfusions, overall hospital stay, and in rates of sternal wound infections. There were 3.8% conversions to full sternotomy.

Conclusion: In a large German multicenter cohort, the rates of death, stroke, and myocardial infarction (MACCE) were comparable in surgical aortic valve replacement through partial upper and complete sternotomy. Shorter ICU stay and lower rates of Dressler syndrome and rehospitalization were in favor of the partial sternotomy group. Minimally invasive surgical aortic valve replacement is safe and potentially beneficial, and therefore worth the effort.

Publication History

Article published online:
28 January 2023