Mini-Stern Trial: A randomised trial comparing mini-sternotomy to full median sternotomy for aortic valve replacement

Objective Aortic valve replacement (AVR) can be performed either through full median sternotomy (FS) or upper mini-sternotomy (MS). The Mini-Stern trial aimed to establish whether MS leads to quicker postoperative recovery and shorter hospital stay after first-time isolated AVR. Methods This pragmatic, open-label, parallel RCT compared MS with FS for first-time isolated AVR in two UK NHS hospitals. Primary endpoints were duration of postoperative hospital stay and the time to fitness for discharge from hospital after AVR, analysed in the intent-to-treat population. Results In this RCT, 222 patients were recruited and randomised (118 MS, 104 FS). Compared to FS patients, MS patients had longer hospital stay (mean 9.5 vs. 8.6 days) and took longer to achieve fitness for discharge home (mean 8.5 vs. 7.5 days). Adjusting for valve type, sex and surgeon, hazard ratios (HR) from Cox models did not show a statistically significant effect of MS (relative to FS) on either hospital stay (HR 0.874, 95% CI 0.668-1.143, p-value 0.3246) or time to fitness for discharge (HR 0.907, 95% CI 0.688-1.197, p-value 0.4914). During mean follow up of 760 days (MS:745 and FS:777 days), 12 (10%) MS and 7 (7%) FS patients died (HR 1.871, 95% CI 0.723-4.844, p-value 0.1966). Average extra cost for MS was £1,714, during the first 12 months after AVR. Conclusions Compared to FS for AVR, MS did not result in shorter hospital stay, faster recovery or improved survival and was not cost-effective. MS approach is not superior to FS for performing AVR

Patients with prior coronary artery bypass grafting have a poor outcome after myocardial infarction: an analysis of the VALsartan in acute myocardial iNfarcTion trial (VALIANT)

The number of patients presenting with an acute myocardial infarction (MI) and prior coronary artery bypass grafting (CABG) is increasing. We compared the baseline characteristics, treatment, and clinical outcomes of patients with and without prior CABG in the VALIANT trial. Of the 14 703 patients with heart failure (HF), left ventricular systolic dysfunction, or both enrolled in VALIANT, 1026 (7%) had prior CABG. Prior CABG patients were older [mean age (SD): 67 (10) vs. 65 (12) years; P less than 0.0001], had more comorbidity, and more frequent non-Q wave MI (66 vs. 30%; P less than 0.0001). At hospital presentation, prior CABG patients received less aspirin (82 vs. 90%; P less than 0.0001) and thrombolysis (21 vs. 36%; P less than 0.0001), but had a similar rate of primary percutaneous coronary intervention (14 vs. 15%; P = 0.2). Prior CABG patients were more likely to experience the composite outcome of cardiovascular death, MI, HF, resuscitated cardiac arrest, or stroke; 3 year Kaplan-Meier rate, 64 vs. 39% (adjusted hazard ratio 1.29, 95% confidence interval 1.17-1.43; P less than 0.0001). Patients with prior CABG had a worse clinical profile and experienced more fatal and non-fatal outcomes. Greater recognition is necessary for these high-risk patients including optimization of evidence-based secondary preventive therapy