Right Anterolateral Thoracotomy versus Full Sternotomy for Isolated Aortic Valve Replacement: A Dual-Center Propensity Score Matched Analysis

Objectives: Minimally invasive approaches to isolated aortic valve replacement (AVR) continue to gain popularity and have shown excellent results regarding morbidity and mortality. The two most used methods are an upper hemisternotomy and a sternum-sparing right anterolateral thoracotomy (RALT). These minimally invasive AVR procedures have shown to provide with reduced blood loss, shorter ventilation time, lower incidence of postoperative atrial fibrillation, shorter ICU stay and shorter hospitalization time but have also been associated with longer cardiopulmonary bypass (CPB) time and longer aortic cross-clamp time. The purpose of this study was to compare outcomes of patients who underwent RALT-AVR with those of patients who underwent conventional AVR via median sternotomy (MS) at our two institutions.

Methods: This retrospective study was based on an all-comers design. We included all patients who had undergone RALT-AVR at our institutions, as well as the 105 most recent cases of MS-AVR. Exclusion criteria were reoperations, active endocarditis, aortic valve repair, and the need for additional surgical procedures. Peri- and postoperative outcomes of patients of both groups were compared using 1:1 propensity score matched analysis.

Results: Propensity score matching produced 70 matched pairs with balanced preoperative characteristics. The RALT cohort had lower rates of perioperative platelet transfusions (RALT: 1.4%, MS: 12.9%, p ≤ 0.001) and postoperative pneumonia (RALT: 1.4%, MS: 15.7%, p = 0.006). RALT also showed shorter ventilation times (RALT: 457 min, MS: 743 min, p = 0.007) and shorter hospitalization times (RALT: 12 days, MS: 14 days, p = 0.002). CPB time was significantly longer in the RALT cohort (RALT: 103 min, MS: 82 min, p ≤ 0.001). There were no significant differences in 30-day mortality (0% in both groups, p = 1), postoperative stroke (RALT: 0%, MS: 1.43%, p = 1), postoperative atrial fibrillation (RALT: 17.1%, MS: 28.6%, p = 0.185), or postoperative creatinine (RALT: 0.7, MS: 0.7, p = 0.695).

Conclusion: This study found RALT, compared to MS, to be an equally safe, less invasive approach to surgical AVR. While CPB times were longer, there was no difference in cross-clamp times or procedure times. Additionally, RALT showed advantages, especially regarding pulmonary function, as resembled by shorter ventilation times and lower rates of postoperative pneumonia.

No conflict of interest has been declared by the author(s).