Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

Background: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. Methods: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. Results: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p =.012) and aortic cross-clamp time (p =.022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p =.010), incidence of wound infection (p =.009), need of inotropic support (p =.004), and blood transfusion (p =.001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p =.026), active smoking (p =.009), peripheral vascular disease (p =.003), ejection fraction (p =.026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p =.015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. Conclusions: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.