Clinical outcomes of right anterior mini-thoracotomy aortic valve surgery: A propensity score matching study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHAO Zeyuan , CUI Chenyi , LI Jiahui , CHEN Xianjie , LI Zhao , QI Zhenchang , WANG Sheng ,  CHENG Zhaoyun

Department of Cardiac Surgery, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 451464, P. R. China;

Corresponding?author：

CHENG Zhaoyun, Email: Chengzhy@zzu.edu.cn

Keywords：

Aortic insufficiency; aortic valve replacement; minimally invasive cardiac surgery; propensity score matching analysis

DOI：

10.7507/1007-4848.202312044

Video：

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Objective To compare perioperative outcomes of minimally invasive aortic valve surgery by a right anterior minithoracotomy (RAMT) and conventional sternotomy. Methods A retrospective analysis of patients who underwent isolated aortic valve surgeries in Central China Fuwai Hospital of Zhengzhou University between May 2021 and August 2023 with a minimal incision via the RAMT approach (a RAMT group) or conventional incision via the full sternotomy approach (a conventional group). A propensity score matching analysis was performed to balance preoperative data and compare perioperative data of the two groups. Results There were 58 patients in the RAMT group, including 46 males and 12 females with an average age of (52.0±14.1) years; 128 patients were enrolled in the conventional group, including 87 males and 41 females with an average age of (60.0±12.4) years. After propensity-score matching, there were 51 patients in each group. The RAMT group had a longer average operation time, cross-clamping time and cardiopulmonary bypass time compared to the conventional group (all P<0.05). However, ICU length of stay, ventilator-assisted time and postoperative hospital stay were significantly shorter in the RAMT group (all P<0.05). Patients in the RAMT group had lower 24 hour chest drain output (P<0.05). RAMT was associated with a trend towards a lower blood transfusion rate in comparison to the sternotomy group, although this was not statistically significant (P>0.05). The occurrence of all-cause death, and perioperative complications was also similar in both groups (P>0.05). Conclusion RAMT has less trauma, faster recovery, less postoperative drainage, and shorter hospital stay than conventional approach. RAMT in patients undergoing isolated aortic valve surgery is a safe approach.

Citation： ZHAO Zeyuan, CUI Chenyi, LI Jiahui, CHEN Xianjie, LI Zhao, QI Zhenchang, WANG Sheng, CHENG Zhaoyun. Clinical outcomes of right anterior mini-thoracotomy aortic valve surgery: A propensity score matching study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(12): 1747-1753. doi: 10.7507/1007-4848.202312044 Copy

1.	《中國心血管健康與疾病報告2022》編寫組. 《中國心血管健康與疾病報告2022》概述. 中國心血管病研究, 2023, 21(7): 577-600.The Writing Committee of the Report on Cardiovascular Health and Diseases in China 2022. Overview of report on cardiovascular health and diseases in China 2022. Chin J Cardiovasc Res, 2023, 21(7): 577-600.
2.	Ueno G, Ohno N. Aortic valve approaches in the era of minimally invasive cardiac surgery. Surg Today, 2020, 50(8): 815-820.
3.	Bonacchi M, Dokollari A, Parise O, et al. Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery. J Thorac Cardiovasc Surg, 2023, 165(3): 1022-1032.
4.	Olds A, Saadat S, Azzolini A, et al. Improved operative and recovery times with mini-thoracotomy aortic valve replacement. J Cardiothorac Surg, 2019, 14(1): 91.
5.	Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat, 2011, 10(2): 150-161.
6.	Gasparovic I, Artemiou P, Hudec V, et al. Long-term outcomes following minimal invasive versus conventional aortic valve replacement: a propensity match analysis. Bratisl Lek Listy, 2017, 118(8): 479-484.
7.	Bakhtiary F, Salamate S, Amer M, et al. Comparison of right anterior mini-thoracotomy versus partial upper sternotomy in aortic valve replacement. Adv Ther, 2022, 39(9): 4266-4284.
8.	Roussakis A, Gavalaki A, Contrafouris C, et al. Minimally invasive aortic valve replacement: initial experience of the 1st Cardiac Surgery Department of Onassis Cardiac Surgery Center. A propensity score-adjusted analysis. Hellenic J Cardiol, 2020, 61(5): 346-348.
9.	顏磊, 陳慶偉, 陳國慶, 等. 經右胸第3肋間小切口與胸骨正中切口行單純主動脈瓣置換術療效比較的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2023, 30(4): 540-545.Yan L, Chen QW, Chen GQ, et al. Efficacy of aortic valve replacement through the right third intercostal small incision versus median sternal incision: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(4): 540-545.
10.	吳保星, 張紅強, 馮宇佳, 等. 經右胸前外側肋間小切口行微創主動脈瓣置換術的臨床效果. 中國當代醫藥, 2022, 29(35): 57-61.Wu BX, Zhang HQ, Feng YJ, et al. Clinical effect of right anterior mini-thoracotomy approach aortic valve replacement. Chin Mod Med, 2022, 29(35): 57-61.
11.	尹力, 陳文, 邱志兵, 等. 右胸小切口與常規正中切口瓣膜置換術的手術效果及術后早期并發癥對比. 中國臨床研究, 2022, 35(10): 1396-1400.Yin L, Chen W, Qiu ZB, et al. Comparison of the surgical effect and early postoperative complications of valve replacement through right-sided minithoracotomy and conventional median sternotomy. Chin J Clin Res, 2022, 35(10): 1396-1400.
12.	Glauber M, Miceli A, Gilmanov D, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg, 2013, 145(5): 1222-1226.
13.	Solinas M, Bianchi G, Chiaramonti F, et al. Right anterior mini-thoracotomy and sutureless valves: the perfect marriage. Ann Cardiothorac Surg, 2020, 9(4): 305-313.
14.	Mohamed MA, Ding S, Ali Shah SZ, et al. Comparative evaluation of the incidence of postoperative pulmonary complications after minimally invasive valve surgery vs. full sternotomy: a systematic review and meta-analysis of randomized controlled trials and propensity score-matched studies. Front Cardiovasc Med, 2021, 8: 724178.
15.	Pojar M, Karalko M, Dergel M, et al. Minimally invasive or sternotomy approach in mitral valve surgery: a propensity-matched comparison. J Cardiothorac Surg, 2021, 16(1): 228.
16.	Grant SW, Hickey GL, Modi P, et al. Propensity-matched analysis of minimally invasive approach versus sternotomy for mitral valve surgery. Heart, 2019, 105(10): 783-789.
17.	Mkalaluh S, Szczechowicz M, Dib B, et al. Early and long-term results of minimally invasive mitral valve surgery through a right mini-thoracotomy approach: a retrospective propensity-score matched analysis. Peer J, 2018, 6: e4810.
18.	Paparella D, Fattouch K, Moscarelli M, et al. Current trends in mitral valve surgery: a multicenter national comparison between full-sternotomy and minimally-invasive approach. Int J Cardiol, 2020, 306: 147-151.
19.	Seitz M, Goldblatt J, Paul E, et al. Minimally invasive aortic valve replacement via right anterior mini-thoracotomy: propensity matched initial experience. Heart Lung Circ, 2019, 28(2): 320-326.
20.	Pojar M, Vojacek J, Karalko M, et al. Single-center experience with minimally invasive mitral operations through right minithoracotomy. Ann Thorac Cardiovasc Surg, 2019, 25(1): 18-25.
21.	Chivasso P, Bruno VD, Farid S, et al. Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The mitral surgery in octogenarians study. J Thorac Cardiovasc Surg, 2018, 155(4): 1474-1482.
22.	Liang L, Ma X, Kong Q, et al. Comparing patient outcomes following minimally invasive coronary artery bypass grafting surgery vs. coronary artery bypass grafting: a single-center retrospective cohort study. Cardiovasc Diagn Ther, 2022, 12(3): 378-388.
23.	Abud B, Saydam O, Engin AY, et al. Outcomes of aortic valve replacement via right anterior minithoracotomy and central cannulation versus conventional aortic valve replacement in obese patients. Braz J Cardiovasc Surg, 2022, 37(6): 875-882.
24.	Plestis K, Orlov O, Shah VN, et al. Facilitating technologies in minimally invasive aortic valve replacement: a propensity score analysis. Interact Cardiovasc Thorac Surg, 2018, 27(2): 202-207.
25.	Murzi M, Cerillo AG, Bevilacqua S, et al. Traversing the learning curve in minimally invasive heart valve surgery: a cumulative analysis of an individual surgeon's experience with a right minithoracotomy approach for aortic valve replacement. Eur J Cardiothorac Surg, 2012, 41(6): 1242-1246.
26.	Klein P, Klop IDG, Kloppenburg GLT, et al. Planning for minimally invasive aortic valve replacement: key steps for patient assessment. Eur J Cardiothorac Surg, 2018, 53(suppl_2): ii3-ii8.

1. 《中國心血管健康與疾病報告2022》編寫組. 《中國心血管健康與疾病報告2022》概述. 中國心血管病研究, 2023, 21(7): 577-600.The Writing Committee of the Report on Cardiovascular Health and Diseases in China 2022. Overview of report on cardiovascular health and diseases in China 2022. Chin J Cardiovasc Res, 2023, 21(7): 577-600.
2. Ueno G, Ohno N. Aortic valve approaches in the era of minimally invasive cardiac surgery. Surg Today, 2020, 50(8): 815-820.
3. Bonacchi M, Dokollari A, Parise O, et al. Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery. J Thorac Cardiovasc Surg, 2023, 165(3): 1022-1032.
4. Olds A, Saadat S, Azzolini A, et al. Improved operative and recovery times with mini-thoracotomy aortic valve replacement. J Cardiothorac Surg, 2019, 14(1): 91.
5. Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat, 2011, 10(2): 150-161.
6. Gasparovic I, Artemiou P, Hudec V, et al. Long-term outcomes following minimal invasive versus conventional aortic valve replacement: a propensity match analysis. Bratisl Lek Listy, 2017, 118(8): 479-484.
7. Bakhtiary F, Salamate S, Amer M, et al. Comparison of right anterior mini-thoracotomy versus partial upper sternotomy in aortic valve replacement. Adv Ther, 2022, 39(9): 4266-4284.
8. Roussakis A, Gavalaki A, Contrafouris C, et al. Minimally invasive aortic valve replacement: initial experience of the 1st Cardiac Surgery Department of Onassis Cardiac Surgery Center. A propensity score-adjusted analysis. Hellenic J Cardiol, 2020, 61(5): 346-348.
9. 顏磊, 陳慶偉, 陳國慶, 等. 經右胸第3肋間小切口與胸骨正中切口行單純主動脈瓣置換術療效比較的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2023, 30(4): 540-545.Yan L, Chen QW, Chen GQ, et al. Efficacy of aortic valve replacement through the right third intercostal small incision versus median sternal incision: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(4): 540-545.
10. 吳保星, 張紅強, 馮宇佳, 等. 經右胸前外側肋間小切口行微創主動脈瓣置換術的臨床效果. 中國當代醫藥, 2022, 29(35): 57-61.Wu BX, Zhang HQ, Feng YJ, et al. Clinical effect of right anterior mini-thoracotomy approach aortic valve replacement. Chin Mod Med, 2022, 29(35): 57-61.
11. 尹力, 陳文, 邱志兵, 等. 右胸小切口與常規正中切口瓣膜置換術的手術效果及術后早期并發癥對比. 中國臨床研究, 2022, 35(10): 1396-1400.Yin L, Chen W, Qiu ZB, et al. Comparison of the surgical effect and early postoperative complications of valve replacement through right-sided minithoracotomy and conventional median sternotomy. Chin J Clin Res, 2022, 35(10): 1396-1400.
12. Glauber M, Miceli A, Gilmanov D, et al. Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score matched study. J Thorac Cardiovasc Surg, 2013, 145(5): 1222-1226.
13. Solinas M, Bianchi G, Chiaramonti F, et al. Right anterior mini-thoracotomy and sutureless valves: the perfect marriage. Ann Cardiothorac Surg, 2020, 9(4): 305-313.
14. Mohamed MA, Ding S, Ali Shah SZ, et al. Comparative evaluation of the incidence of postoperative pulmonary complications after minimally invasive valve surgery vs. full sternotomy: a systematic review and meta-analysis of randomized controlled trials and propensity score-matched studies. Front Cardiovasc Med, 2021, 8: 724178.
15. Pojar M, Karalko M, Dergel M, et al. Minimally invasive or sternotomy approach in mitral valve surgery: a propensity-matched comparison. J Cardiothorac Surg, 2021, 16(1): 228.
16. Grant SW, Hickey GL, Modi P, et al. Propensity-matched analysis of minimally invasive approach versus sternotomy for mitral valve surgery. Heart, 2019, 105(10): 783-789.
17. Mkalaluh S, Szczechowicz M, Dib B, et al. Early and long-term results of minimally invasive mitral valve surgery through a right mini-thoracotomy approach: a retrospective propensity-score matched analysis. Peer J, 2018, 6: e4810.
18. Paparella D, Fattouch K, Moscarelli M, et al. Current trends in mitral valve surgery: a multicenter national comparison between full-sternotomy and minimally-invasive approach. Int J Cardiol, 2020, 306: 147-151.
19. Seitz M, Goldblatt J, Paul E, et al. Minimally invasive aortic valve replacement via right anterior mini-thoracotomy: propensity matched initial experience. Heart Lung Circ, 2019, 28(2): 320-326.
20. Pojar M, Vojacek J, Karalko M, et al. Single-center experience with minimally invasive mitral operations through right minithoracotomy. Ann Thorac Cardiovasc Surg, 2019, 25(1): 18-25.
21. Chivasso P, Bruno VD, Farid S, et al. Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The mitral surgery in octogenarians study. J Thorac Cardiovasc Surg, 2018, 155(4): 1474-1482.
22. Liang L, Ma X, Kong Q, et al. Comparing patient outcomes following minimally invasive coronary artery bypass grafting surgery vs. coronary artery bypass grafting: a single-center retrospective cohort study. Cardiovasc Diagn Ther, 2022, 12(3): 378-388.
23. Abud B, Saydam O, Engin AY, et al. Outcomes of aortic valve replacement via right anterior minithoracotomy and central cannulation versus conventional aortic valve replacement in obese patients. Braz J Cardiovasc Surg, 2022, 37(6): 875-882.
24. Plestis K, Orlov O, Shah VN, et al. Facilitating technologies in minimally invasive aortic valve replacement: a propensity score analysis. Interact Cardiovasc Thorac Surg, 2018, 27(2): 202-207.
25. Murzi M, Cerillo AG, Bevilacqua S, et al. Traversing the learning curve in minimally invasive heart valve surgery: a cumulative analysis of an individual surgeon's experience with a right minithoracotomy approach for aortic valve replacement. Eur J Cardiothorac Surg, 2012, 41(6): 1242-1246.
26. Klein P, Klop IDG, Kloppenburg GLT, et al. Planning for minimally invasive aortic valve replacement: key steps for patient assessment. Eur J Cardiothorac Surg, 2018, 53(suppl_2): ii3-ii8.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Clinical outcomes of right anterior mini-thoracotomy aortic valve surgery: A propensity score matching study

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