Sternotomy-sparing Minimally Invasive Aortic Valve Replacement—more than Cosmetics if Liver Function is Affected?

Background: We had previously demonstrated that avoiding cardiopulmonary bypass in patients with liver dysfunction undergoing coronary bypass grafting is associated with lower mortality. In patients in need of valve surgery, avoidance of CPB is impossible, but minimally invasive strategies are gaining more popularity. However, randomized trials comparing minimally invasive approaches to sternotomy failed to demonstrate superiority, but generally reflect a select, low-risk population. We assessed our database for the role of aortic valve replacement through right anterior mini-thoracotomy in patients with impaired liver function and potential portal hypertension.

Methods: We inspected 1,840 consecutive patients who underwent aortic valve surgery in our department between 5/2007 and 11/2020. Patients with endocarditis were excluded. The Platelet Albumin Bilirubin score (PALBI) was calculated from the preoperative laboratory values for all patients as marker for liver dysfunction and portal hypertension. The prediction probability of PALBI was assessed using ROC analysis and cut off was determined by Youden index. In-hospital mortality and MACCE were determined in patients below (low PALBI) and above the cut-off point (high PALBI). We further divided patients into those receiving aortic valve replacement minimally invasively (MIS) or through full sternotomy (FS) and performed propensity matching for age, creatinine, and LVEF.

Results: 1,404 elective/urgent FS were compared with 324 elective/urgent MIS. Patients were 68.1 years old and 63.2% were male. Age (68.3 vs. 67.1; p = n.s.) and sex (62.7% vs. 63.3% male) did not differ between MIS and FS. The cut off for PALBI was −2.18. There was a significant difference in mortality between low and high PALBI patients (3% vs. 10.2; p < .01). Mortality in MIS and FS did not differ when PALBI was low. In high PALBI patients mortality was significantly lower in MIS (1.4%) compared with FS (11.5%). Propensity matching resulted in 324 pairs of FS and MIS patients. In this matched cohort, mortality in MIS was 1.9% vs. 5.9% in FS (p = 0.003). While in low PALBI, there was no difference between MIS and FS (2% vs. 3.5%, respectively; n.s.), in high PALBI, mortality was significantly lower in MIS (1.4%) compared with FS (9.4%, p < 0.01).

Conclusion: Aortic valve replacement in patients with signs of liver dysfunction and/or portal hypertension may have significantly lower risk of perioperative mortality if surgery is performed through a sternotomy-sparing mini-thoracotomy.

Publikationsverlauf

Artikel online veröffentlicht:
11. Februar 2025