Alternative incision sutureless aortic valve replacement: propensity matched comparison between partial sternotomy and right anterior minithoracotomy.

BACKGROUND: Sutureless aortic valve prostheses have the potential to augment the adoption of alternative incision approaches for aortic valve replacement (AVR). Still, we lack the evidence on which surgical approach is best associated with sutureless AVR. METHODS: Data on 483 patients undergoing sutureless small incision AVR between 2010-2014 in two European institutions (207 with ministernotomy [MS] and 276 via right anterior minithoracotomy [RAMT]) have been retrospectively analyzed. After propensity score matching, 160 pairs of patients have been selected. RESULTS: No significant difference for in-hospital mortality was observed between MS and RAMT (P=0.12). Both perfusion and aortic cross-clamping times were longer in RAMT group (P<0.0005). Lower incidence of third degree atrioventricular block requiring pacemaker implantation (P=0.04), shorter ventilation times (P<0.0005) and less requirement for pleural drainage/thoracentesis (P=0.007) have been registered in the RAMT group. Follow-up was shorter for RAMT group (14.6 vs. 21.7 months, P<0.0005). Survival by Kaplan-Meier was comparable both for unmatched (P=0.79) and matched (P=0.90) cohorts. Cox regression analysis showed no statistically significant difference for mid-term survival between the two approaches (P=0.95 for intercohort comparison [MS vs. RAMT]). Mid-term survival by Cox multivariable proportional hazards regression model was associated with two independent predictors: preoperative left ventricular ejection fraction (P=0.021) and prolonged (>24 h) assisted ventilation (P=0.001). CONCLUSIONS: Small incision sutureless AVR through both partial sternotomy and right anterior minithoracotomy provides excellent clinical outcomes. Right anterior minithoracotomy, though associated with longer operative times compared to partial sternotomy, may result in less perioperative morbidity, with no difference in early and mid-term survival.