Is the Surgical Minimally Invasive Aortic Valve Replacement with Biological Valves a Treatment Option in Patients with BMI >40 kg/m²?

Objectives: Patients with severe obesity (BMI > 40 kg/m²) undergoing aortic valve replacement (AVR) are considered as candidates for longer intensive care stay with prolonged time on respirator, deep sternal wound infection (DSWI) and multiple complications. Despite the sometimes technically complex minimally invasive (MIC) approach in obese patients we offered this option to the patients as an attempt to improve the surgical results.

Methods: Obese patients (11 males, 13 females) with severe aortic valve stenosis in the age of 68.5 ± 7.8 years and with BMI > 40 (43 ± 2 kg/m²) who underwent MIC-AVR (via J-sternotomy) between 2011 until 2018 were included. Mean LVEF was not smaller than 45% in any patient. 12.5% of patients were NYHA IV, the rest NYHA II–III.

Results: The biological prostheses implanted (n = 24) had a mean valve diameter of 22.8 ± 6.7 mm. Mean body surface area was 2.37 ± 0.22 m². Effective orifice area was (EOA) was in mean 0.97 ± 0.06 cm²/m². X-clamp time was 65.5 ± 20.3 minutes, time on respirator was 8.4 ± 5.4 hours, and 30-day mortality was 0%. There was no prolonged in-hospital stay caused by DSWI. Eight-year follow-up was 88%. Recent survival rate is 79%, via Kaplan–Meier 74 (62–86) survival months were calculated. Current averaged mean gradient over the aortic valve prosthesis is 19.6 ± 6.6 mm Hg. Patients postoperatively achieved an averaged loss of weight of 12 kg. Therefore, today only two patients show clinical symptoms like NYHA II, the others all reported to feel well and are clinically asymptomatic. No reoperation was required.

Conclusions: The data stress, that surgical MIC-AVR is an excellent treatment option for obese patients. It seems, as if prolonged intensive care, retarded mobilization and wound infections can be avoided by these approach and on the long run hemodynamically and clinical data are excellent. We conclude, that patients, that are considered as candidates for TAVI for their body weight may have an excellent surgical treatment option.