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J Thorac Cardiovasc Surg 2009;138:1067-1072
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Is transapical aortic valve implantation really less invasive than minimally invasive aortic valve replacement?

Division of Cardiothoracic Surgery, Hospital of the Johann Wolfgang Goethe University Frankfurt am Main, Germany

Received for publication May 9, 2008; revisions received February 7, 2009; accepted for publication April 27, 2009.

^_* Address for reprints: Mirko Doss, MD, Division of Cardiothoracic Surgery, Hospital of the Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590 Frankfurt/Main, Germany. (Email: mirko.doss{at}kgu.de).

Background: Transcatheter valve implants currently draw their justification for use from reduction of perioperative risk. However, patient age and comorbidities are independent predictors of adverse outcome after aortic valve replacement, regardless of surgical approach. Therefore, it is unclear whether transapical aortic valve implantation really improves outcomes in high-risk patients.

Methods: We included a total of 51 high-risk patients with severe aortic valve stenosis. Patients were allocated to transapical aortic valve implantation (n = 21) or minimally invasive aortic valve replacement via a partial upper sternotomy (n = 30), in a nonrandomized fashion. Patient age, preoperative comorbidities, and perioperative risk, expressed as logistic EuroSCORE (38% ± 14% vs 35% ± 9%), were matched between the 2 groups.

Results: Early morbidity and mortality were comparable between groups, but transapical aortic valve implantation was associated with shorter operative time (P = .004), ventilation time (P < .001), intensive care unit stay (P < .001), and hospital stay (P < .001). Thirty-day mortality was 14% (n = 3) in the transcatheter group versus 10% (n = 3) in the surgical group. After a mean follow-up of 12 ± 4 months (100% complete), there were a total of 5 (24%) deaths in the transapical group versus 5 (17%) deaths in the open surgery group. There was 1 intraoperative death in the transapical group versus none in the surgery group. In the transapical group, there were 2 re-explorations for bleeding, 2 intraoperative conversions, 1 case of prosthesis migration, and 2 impairments of coronary arteries. The surgery group included 1 re-exploration, 1 stroke, 1 pacemaker implantation for complete atrioventricular block, and 3 cases of atrial fibrillation.

Conclusions: Current data suggest a faster postoperative recovery after transapical aortic valve implantation, with early and late morbidity and mortality comparable with those of minimally invasive aortic valve replacement via partial upper sternotomy.