Measuring What Matters
2018; Elsevier BV; Volume: 106; Issue: 6 Linguagem: Inglês
10.1016/j.athoracsur.2018.08.019
ISSN1552-6259
Autores Tópico(s)Aortic Disease and Treatment Approaches
ResumoMinimally invasive aortic valve replacement (mini-AVR) has been with us as an option since 1996 [1Cosgrove 3rd, D.M. Sabik J.F. Minimally invasive approach for aortic valve operations.Ann Thorac Surg. 1996; 62: 596-597Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 2Cohn L.H. Adams D.H. Couper G.S. et al.Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.Ann Surg. 1997; 226 (discussion 427–8): 421-426Crossref PubMed Scopus (433) Google Scholar]. Now, with over 20 years of experience behind us, mini-AVR is an established option in our armamentarium with multiple modifications and enthusiastic supporters. I must confess at the outset that I am not one of them. I do not see a “significant” advantage and I find it much easier to teach via a full sternotomy. Accordingly, like any carbon-based life form, I look for studies to confirm my bias. So what am I to do with the data presented here?For related articles, see pages 1782 and 1881 For related articles, see pages 1782 and 1881 I could acknowledge that Chang and associates’ meta-analysis [3Chang C. Raza S. Altarabsheh S.E. et al.Minimally invasive approaches to surgical aortic valve replacement: a meta-analysis.Ann Thorac Surg. 2018; 106: 1881-1889Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar] demonstrates shorter length of stay for mini-AVR, perhaps because of demonstrably lower incidence of atrial fibrillation. Length of stay is of course an important parameter to my hospital administrators; they want me to reduce hospital costs. Or I could protest that there are subtle biases that cannot be accounted for statistically—subtleties both of selection bias for the procedure performed and biases of patients and caregivers who are invested in earlier discharge of the min-AVR patients. And I could counter with the Italian study by Mikus and colleagues [4Mikus E. Calvi S. Campo G. et al.Full sternotomy, hemisternotomy, and minithoracotomy for aortic valve surgery: is there a difference?.Ann Thorac Surg. 2018; 106: 1782-1788Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] that showed no difference in postoperative arrhythmia. Advantage mini? Perhaps. What about pump time and crossclamp time? Mikus and associates [4Mikus E. Calvi S. Campo G. et al.Full sternotomy, hemisternotomy, and minithoracotomy for aortic valve surgery: is there a difference?.Ann Thorac Surg. 2018; 106: 1782-1788Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] report a lower crossclamp time for mini-thoracotomy approach. But Chang and colleagues report the opposite. To be fair, Chang and associates report a savings of 4 minutes with the use of a sutureless valve (the number 4 approximating the factor by which the cost of the sutureless valve prosthesis is increased over a conventional pericardial valve in my hospital). Perhaps the lower operative time is attributable to a nonrandom surgeon effect. At the Maria Cecilia Hospital, only 4 of the 8 surgeons performed AVR via thoracotomy. Could they be the most-experienced or highest-volume surgeons? The most efficient? Let’s call this one a draw. How about mortality? Now this is an important parameter to be sure. But both studies demonstrate no difference between approaches, with patient risk factors dominating this outcome. So without significant differences in outcomes maybe I am okay smugly hunkering down and sticking with full sternotomy—or maybe not. The history of our specialty has been to refine operations with the aim to reduce the outcomes that we as surgeons care about—mortality, morbidity, and so forth. The early reports of mini-AVR focused on these outcomes, initially suggesting, but never clearly proving, an advantage. Still, the procedure has caught on, perhaps not overwhelmingly so, but solidly. Is it just marketing? Having lived through the growth of percutaneous coronary intervention, and now seeing the expansion of transcatheter aortic valve replacement, I find myself asking the somewhat existential question, “Are we measuring what matters . . . to patients?” I am beginning to think not. In a recent study performed by investigators at Dartmouth-Hitchcock, elderly patients (89% of whom were 75 years of age or older) prioritized ability to pursue activities, maintaining independence, and reducing symptoms over mortality benefit [5Coylewright M. Palmer R. O'Neill E.S. Robb J.F. Fried T.R. Patient-defined goals for the treatment of severe aortic stenosis: a qualitative analysis.Health Expect. 2016; 19: 1036-1043Crossref PubMed Scopus (52) Google Scholar]. Maybe a mini-AVR really would be more in alignment with their values and preferences! To be sure, these sorts of “soft” outcome variables are challenging to us. We think of ourselves—at least I do—as medical scientists interested in “hard” endpoints. Let’s stick to the facts. But our patients are challenging us to consider what they value most, not what we can measure easily. I’d say it is time for us to broaden our horizons and revisit how we can better measure what matters. Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference?The Annals of Thoracic SurgeryVol. 106Issue 6PreviewThis study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others. Full-Text PDF Minimally Invasive Approaches to Surgical Aortic Valve Replacement: A Meta-AnalysisThe Annals of Thoracic SurgeryVol. 106Issue 6PreviewLimited data exist studying the outcomes of the 2 minimally invasive aortic valve replacement (AVR) strategies—mini-sternotomy (AVR-st) and right anterior thoracotomy (AVR-th). We conducted an indirect meta-analysis to compare the outcomes of these minimally invasive approaches with each other and with conventional AVR (cAVR). Full-Text PDF
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