Benefits of minimally invasive aortic valve replacement (MIS-AVR)

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MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT ANTONIO MICELI DEPARTMENT OF CARDIOTHORACIC SURGERY FONDAZIONE TOSCANA G. MONASTERIO MASSA, ITALY.

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Presentation transcript:

Benefits of minimally invasive aortic valve replacement (MIS-AVR) Evidence from meta-analyses and key studies

MIS-AVR is as safe as conventional AVR Early mortality rates: comparable with conventional AVR (cAVR) *Odds ratio 0.70 (95% CI 0.46–1.06), p=0.09 †Relative risk 0.74 (95% CI 0.52–1.06), p=0.10 ‡Relative risk 0.74 (95% CI 0.56–0.96), p=0.02 Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511 Lim JY et al. J Card Surg. 2015; 30: 125–34 Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14

MIS-AVR is as safe as conventional AVR Complication rates: comparable with cAVR1 Complication % of MIS-AVR % of cAVR Neurological event 2.2 Atrial fibrillation 23.5 24.7 Pneumonia 3.6 2.9 Sternal infection 0.9 1.5 Pacemaker implant 3.3 4.0 Myocardial infarction 0.4 0.7 Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511

MIS-AVR is as safe as conventional AVR Complication rates: comparable with cAVR1 Complication Risk ratio (RR)/odds ratio (OR) (95% confidence interval, p) Phan et al.1 Phan et al.2 Lim et al.3 Brown et al.4 Stroke/neurological event RR 0.99 (0.73–1.34, 0.93) RR 0.81 (0.55–1.21, 0.20) OR 0.93 (0.55–1.56, 0.79) OR 0.91 (0.60–1.39) Atrial fibrillation RR 0.91 (0.80–1.03, 0.13) – OR 1.08 (0.74–1.57, 0.67) OR 0.87 (0.64–1.20, 0.41) Pneumonia RR 1.23 (0.68–2.23; 0.49) Wound/sternal complication RR 0.71 (0.47–1.08, 0.11) RR 0.72 (0.41–1.27, 0.26) OR 0.57 (0.28–1.14, 0.11) OR 0.86 (0.49–1.49) Pacemaker implant RR 0.82 (0.57–1.16, 0.26) Myocardial infarction RR 0.78 (0.35–1.74, 0.54) RR: risk ratio; RR<1: complication more likely in the cAVR group; RR>1: complication more likely in the MIS-AVR group; RR=1: surgery type does not affect the risk of the complication OR: odds ratio; OR<1: cAVR associated with higher odds of complication than MIS-AVR; OR>1: MIS-AVR associated with higher odds of complication than cAVR; OR=1: surgery type does not affect the odds of complication Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511 Lim JY et al. J Card Surg. 2015; 30: 125–34 Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14 Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5

MIS-AVR is as safe as conventional AVR Blood loss: tends to be less than cAVR (e.g. -154.17 mL [95% CI -324.51 to 16.17, p=0.08]1) Blood transfusion: comparable with cAVR (e.g. 43% MIS-AVR vs 54% cAVR2) Lim JY et al. J Card Surg. 2015; 30: 125–34 Khoshbin E et al. BMJ Open. 2011; 1: e000266

Potential benefit in long-term survival Survival: significantly higher than cAVR in a single centre retrospective study:1 Survival, % At 5 years At 8 years MIS-AVR 89.3 ± 2.4 77.7 ± 4.7 cAVR 81.8 ± 2.2 72.8 ± 2.2 Merk DR et al. Eur J Cardiothorac Surg. 2015; 47: 11–17

Operative times for MIS-AVR Cross-clamp and cardiopulmonary bypass (CPB) times: generally slightly longer than cAVR: But only minithoracotomy, not ministernotomy, is associated with significantly longer cross-clamp (+7.64 minutes) and cardiopulmonary bypass (CPB) times (+9.99 minutes) than full sternotomy2 RCT, randomised controlled trial Phan K, Xie A, Di Eusanio M et al. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg. 2014; 98: 1499–511 Phan K, Xie A, Tsai YC et al. Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis. Ann Cardiothorac Surg. 2015; 4: 3–14 Lim JY, Deo SV, Altarabsheh SE et al. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg. 2015; 30: 125–34 Brown ML, McKellar SH, Sundt TM et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5 5. Borger MA, Dohmen PM, Knosalla C et al. Haemodynamic benefits of rapid deployment aortic valve replacement via a minimally invasive approach: 1-year results of a prospective multicentre randomized controlled trial. Eur J Cardiothorac Surg. 2016: 50: 713–20 Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511 Lim JY et al. J Card Surg. 2015; 30: 125–34 Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14 Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5

Potential of rapid deployment valves Rapid deployment (RD) valves may help to speed up MIS-AVR: MIS-AVR with RD valve vs cAVR with stented valve1 RCT, randomised controlled trial Phan K, Xie A, Di Eusanio M et al. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg. 2014; 98: 1499–511 Phan K, Xie A, Tsai YC et al. Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis. Ann Cardiothorac Surg. 2015; 4: 3–14 Lim JY, Deo SV, Altarabsheh SE et al. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg. 2015; 30: 125–34 Brown ML, McKellar SH, Sundt TM et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5 5. Borger MA, Dohmen PM, Knosalla C et al. Haemodynamic benefits of rapid deployment aortic valve replacement via a minimally invasive approach: 1-year results of a prospective multicentre randomized controlled trial. Eur J Cardiothorac Surg. 2016: 50: 713–20 Borger MA et al. Eur J Cardiothorac Surg. 2016; 50: 713–20

MIS-AVR leads to faster recovery Intensive care unit stay: ~0.5 days less than cAVR Overall hospital stay: ~1–2 days less than cAVR *95% CI -0.72 to -0.20 (ICU stay); 95% CI -1.45 to -0.37 days (hospital stay); †95% CI -0.95 to -0.2, p=0.003 (ICU stay); 95% CI -4.12 to 0.05, p=0.06 (hospital stay); ‡95% CI -0.64 to 0.09, p=0.14 (ICU stay); 95% CI -1.64 to -0.46, p=0.0005 (hospital stay); §95% CI -0.95 to -0.25, p<0.0007 (ICU stay); 95% CI -1.73 to -0.95, p<0.00001 (hospital stay) CI: confidence interval; ICU: intensive care unit Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511 Khoshbin E et al. BMJ Open. 2011; 1: e000266 Lim JY et al. J Card Surg. 2015; 30: 125–34 Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5

Key learnings MIS-AVR can be carried out safely1–4 Minimally invasive surgery improves long-term survival5 Minimally invasive surgery reduces pain1,3,4 Minimally invasive surgery reduces the time spent in the intensive care unit1,4,6 and hospital overall1,3,4,6 MIS-AVR with a rapid deployment valve requires a significantly shorter cross-clamp time than cAVR7 Adequately powered, prospective randomised trials are needed to fully assess the benefits/risks of MIS-AVR1,2,4 Phan K et al. Ann Thorac Surg. 2014; 98: 1499–511 Merk DR et al. Eur J Cardiothorac Surg. 2015; 47: 11–17 Phan K et al. Ann Cardiothorac Surg. 2015; 4: 3–14 Khoshbin E et al. BMJ Open. 2011; 1: e000266 Lim JY et al. J Card Surg. 2015; 30: 125–34 Borger MA et al. Eur J Cardiothorac Surg. 2016; 50: 713–20 Brown ML et al. J Thorac Cardiovasc Surg. 2009; 137: 670–9 e5