More for less - long-term survival modeling for surgical aortic valve replacement follow-up: The division between a ministernotomy and a full sternotomy approach

Background: This study aimed to assess long-term results after surgical AVR (sAVR) depending on the used surgical technique (ministernotomy vs. full sternotomy) and to determine which patient-and treatment-related attributes were most associated with shorter time to the main endpoint. Methods: Out of 2147 patients, who underwent sAVR from January 2006 to December 2017, 615 patients were treated minimally invasively (MIAVR) and 1532 patients received conventional full sternotomy aortic valve replacement (FSAVR). Multiple Cox regressive models corresponding to the four major endpoints were developed. Long-term survival and a time to re-hospitalization for acute coronary syndrome, stroke, and heart failure (HF) were analyzed independently. Kaplan-Meier actuarial analysis was performed for univariate comparison. Results: The median follow-up time was 71.9 months. No significant difference in terms of long-term survival was found between MIAVR and FSAVR (hazard ratio [HR], 0.99; P= 0.91). Novel advantages of MIAVR in preventing re-hospitalization for late cerebrovascular events and the progression of HF were observed (HR, 0.53; P= 0.03; HR, 0.64, P= 0.005; respectively). Importantly, for the late mortality risk, early in-hospital complications dominated. However, the baseline atrial fibrillation (AF), diabetes, pulmonary disease, and impaired mobility showed the strongest patient-specific prediction for the other three long-run models. Conclusions: MIAVR through ministernotomy provides at least as good long-term survival as FSAVR. Nevertheless, it should be recommended for diabetic, poor-mobility patients with pre-existing AF to reduce their high cerebrovascular risk and to limit the progression of HF. MIAVR also needs to be considered in patients with chronic lung diseases to improve their extremely poor survival prognosis.