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Minimally invasive aortic valve replacement with central cannulation: A cost-benefit analysis in a developing country
The Cardiothoracic Surgeon  (IF),  Pub Date : 2020-03-06, DOI: 10.1186/s43057-020-00019-y
Mohammed Sanad, Hatem Beshir

Minimally-invasive approaches to aortic valve replacement (MIAVR) are technically and logistically demanding. However, few centers have started using these approaches with standard equipment because of the limited resources. We sought to report intra- and postoperative clinical outcomes and address health resource utilization after MIAVR. A total of 102 eligible patients who had aortic valve replacement were enrolled in a prospective, multicenter cohort study conducted from June 2015 to December 2017. Fifty patients underwent aortic valve surgery via upper inverted T-shaped hemi-sternotomy (MS), and 52 patients were operated using full sternotomy (FS) in two centers in a developing country. Central cannulation was performed in all cases. Major adverse cardiac events, pain, and wound complications were compared. A cost analysis was performed, and exposure and feasibility for cannulation were assessed. The mean length of MS skin incision was 5.82 ± 0.67 cm. Cumulative cross-clamp time was insignificant between both groups (91.87 ± 34.41 versus 94.91 ± 33.96 min; p = 0.66). MS exhibited shorter ventilation time (6.18 ± 1.86 versus 10.68 ± 12.78 h; p = 0.029) and intensive care stays (33.27 ± 19.75 versus 49.42 ± 47.1 h; p = 0.037). Major adverse cardiac events (MACEs) were compared, and MS group exhibited fewer transfusions (1.18 ± 0.89 versus 1.7 ± 0.97 units; p = 0.002), fewer pulmonary complications (1 (2%) versus 2 (3.8%); p < 0.001), and less sternotomy wound infection (1 (2%) versus 5 (9.6%); p = 0.048). Total operative mortality of 4.46% was recorded (n = 5). Significant cost reduction was recorded favoring MS; central cannulation saved $907.16 and carried a total cost reduction of $580 (9.3%) when compared with the FS approach (p < 0.0001). With a lack of logistics in developing countries, MIAVR not only has a cosmetic advantage but carries a significant reduction in blood use, respiratory complications, pain, and cost. MIAVR can be feasible, with a rapid learning curve in developing centers.