Should less-invasive aortic valve replacement be avoided in patients with pulmonary dysfunction?

J Thorac Cardiovasc Surg. 2014 Jan;147(1):355-361.e5. doi: 10.1016/j.jtcvs.2012.12.014. Epub 2013 Jan 16.

Abstract

Objective: In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate.

Methods: From January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs.

Results: Patients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P = .001) and postoperative (7.1 vs 6.1 days, P < .0001) lengths of stay than those without chronic lung disease. At normal values of FEV1%, little difference was observed in either of these times for J-incision versus full sternotomy; however, at progressively lower FEV1%, these times lengthened, with increasing benefit for J-incision. Among propensity-matched patients, other postoperative complications were similar. Early survival (93% vs 89% at 1 year, P = .07) was possibly higher in matched patients with J-incision, but late survival was similar (P = .9). Patients with FEV1% less than 50 who underwent J-incision had the greatest survival advantage, which persisted for 5 years.

Conclusions: In patients with preoperative respiratory dysfunction, a less-invasive partial upper J-incision for aortic valve replacement can lead to more favorable outcomes than a full sternotomy, including shorter intensive care unit and postoperative lengths of stay and better early survival, which are amplified with decreasing pulmonary function.

Keywords: 11; 28; 35; AVR; CABG; CLD; FEV1; FEV1%; ICU; aortic valve replacement; chronic lung disease; coronary artery bypass grafting; forced expiratory volume in 1 second; forced expiratory volume in 1 second, percent of predicted; intensive care unit.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve / physiopathology
  • Aortic Valve / surgery*
  • Chronic Disease
  • Female
  • Forced Expiratory Volume*
  • Heart Valve Diseases / complications
  • Heart Valve Diseases / diagnosis
  • Heart Valve Diseases / mortality
  • Heart Valve Diseases / physiopathology
  • Heart Valve Diseases / surgery*
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis Implantation* / mortality
  • Hospital Mortality
  • Humans
  • Intensive Care Units
  • Kaplan-Meier Estimate
  • Length of Stay
  • Logistic Models
  • Lung / physiopathology*
  • Lung Diseases / complications
  • Lung Diseases / diagnosis
  • Lung Diseases / mortality
  • Lung Diseases / physiopathology*
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Patient Selection
  • Postoperative Complications / mortality
  • Postoperative Complications / therapy
  • Propensity Score
  • Registries
  • Risk Factors
  • Sternotomy / adverse effects
  • Sternotomy / methods*
  • Time Factors
  • Treatment Outcome