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• W4255503453 abstract "In contrast with coronary artery bypass surgery, cardiopulmonary bypass surgery can not be obviated in valve operations. Thus, minimally invasive aortic valve surgery relates only to the extension of the incision. After an initial experience with transverse and parasternal incisions, surgeons have elected to split the sternum in several degrees of length, with lateral extensions at different intercostal levels [1Von Segesser L.K. Westaby S. Pomar J. Loisance D. Groscurth P. Turina M. Less invasive aortic valve surgery rationale and technique.Eur J Cardiothorac Surg. 1999; 15: 781-785Crossref PubMed Scopus (66) Google Scholar]. These incisions, named after alphabetical characters (C, T, L, I, S, j, J) allow a large enough “window” to replace the aortic valve safely. The question is: Is it worth it? The article by Bonacchi and coworkers sheds some light on the problem. Their results favor the minimally invasive approach, which, in their hands, gives decreased blood loss, shorter intensive care unit and hospital stays and better pulmonary function than conventional sternotomy. In our study [2Aris A. Cámara M.L. Montiel J. Delgado L.J. Galán J. Litvan H. Ministernotomy versus median sternotomy for aortic valve replacement a prospective, randomized study.Ann Thorac Surg. 1999; 67: 1583-1588Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar], the first prospective, randomized study comparing ministernotomy versus median sternotomy for aortic valve replacement, the results were quite different. We did not find any advantages in the use of a minimal approach. In view of the larger number of patients included in the present study, one may consider that our conclusions were premature. Will Dr Bonacchi’s article settle the issue? I doubt it. During the past 18 months I have had the privilege of reviewing several manuscripts, submitted for publication at four different specialty journals, on the subject. Some studies were well planned and executed, some were not, but, uniformly, each one reached different conclusions. Statistics, like a bikini, reveals a lot but hides the important parts (the issues of a learning curve, increased perivalvular leaks and long-term sternal stability are not addressed by the authors). Despite an impeccable statistical analysis and convincing clinical results, I do not expect the present study to convert reluctant surgeons to a minimally invasive approach. On the other hand, surgeons who love the challenge of a more difficult operation will welcome this scientific blessing and will pursue their quest for less invasive surgery. After all, each surgeon should choose the procedure he or she is comfortable with. But, we should not forget the patient in this decision. The results of the present study provide enough data to explain the advantages of a minimally invasive operation to a patient, but, to date, patients have voted overwhelmingly (78%) to have a full sternotomy incision when asked [3Ehrlich W. Skwara W. Klövekorn W.-P. Roth M. Bauer E.P. Do patients want minimally invasive aortic valve replacement?.Eur J Cardiothorac Surg. 2000; 17: 714-717Crossref PubMed Scopus (30) Google Scholar]. In contrast with coronary artery bypass surgery, cardiopulmonary bypass surgery can not be obviated in valve operations. Thus, minimally invasive aortic valve surgery relates only to the extension of the incision. After an initial experience with transverse and parasternal incisions, surgeons have elected to split the sternum in several degrees of length, with lateral extensions at different intercostal levels [1Von Segesser L.K. Westaby S. Pomar J. Loisance D. Groscurth P. Turina M. Less invasive aortic valve surgery rationale and technique.Eur J Cardiothorac Surg. 1999; 15: 781-785Crossref PubMed Scopus (66) Google Scholar]. These incisions, named after alphabetical characters (C, T, L, I, S, j, J) allow a large enough “window” to replace the aortic valve safely. The question is: Is it worth it? The article by Bonacchi and coworkers sheds some light on the problem. Their results favor the minimally invasive approach, which, in their hands, gives decreased blood loss, shorter intensive care unit and hospital stays and better pulmonary function than conventional sternotomy. In our study [2Aris A. Cámara M.L. Montiel J. Delgado L.J. Galán J. Litvan H. Ministernotomy versus median sternotomy for aortic valve replacement a prospective, randomized study.Ann Thorac Surg. 1999; 67: 1583-1588Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar], the first prospective, randomized study comparing ministernotomy versus median sternotomy for aortic valve replacement, the results were quite different. We did not find any advantages in the use of a minimal approach. In view of the larger number of patients included in the present study, one may consider that our conclusions were premature. Will Dr Bonacchi’s article settle the issue? I doubt it. During the past 18 months I have had the privilege of reviewing several manuscripts, submitted for publication at four different specialty journals, on the subject. Some studies were well planned and executed, some were not, but, uniformly, each one reached different conclusions. Statistics, like a bikini, reveals a lot but hides the important parts (the issues of a learning curve, increased perivalvular leaks and long-term sternal stability are not addressed by the authors). Despite an impeccable statistical analysis and convincing clinical results, I do not expect the present study to convert reluctant surgeons to a minimally invasive approach. On the other hand, surgeons who love the challenge of a more difficult operation will welcome this scientific blessing and will pursue their quest for less invasive surgery. After all, each surgeon should choose the procedure he or she is comfortable with. But, we should not forget the patient in this decision. The results of the present study provide enough data to explain the advantages of a minimally invasive operation to a patient, but, to date, patients have voted overwhelmingly (78%) to have a full sternotomy incision when asked [3Ehrlich W. Skwara W. Klövekorn W.-P. Roth M. Bauer E.P. Do patients want minimally invasive aortic valve replacement?.Eur J Cardiothorac Surg. 2000; 17: 714-717Crossref PubMed Scopus (30) Google Scholar]." @default.
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