Mitral Valve Operations through Standard and Smaller Incisions (original) (raw)
Minimally invasive versus conventional mitral valve surgery: A propensity-matched comparison
The Journal of Thoracic and Cardiovascular Surgery, 2010
Less invasive approaches to mitral valve surgery are increasingly used for improved cosmesis; however, few studies have investigated their effect on outcome. We sought to compare these minimally invasive approaches fairly with conventional full sternotomy by using propensity-matching methods. From January 1995 to January 2004, 2124 patients underwent isolated mitral valve surgery through a minimally invasive approach, and 1047 underwent isolated mitral valve surgery through a conventional sternotomy. Because there were important differences in patient characteristics, a propensity score based on 42 factors was used to obtain 590 well-matched patient pairs (56% of cases). In-hospital mortality was similar for propensity-matched patients: 0.17% (1/590) for those undergoing minimally invasive surgery and 0.85% (5/590) for those undergoing conventional surgery (P = .2). Occurrences of stroke (P = .8), renal failure (P > .9), myocardial infarction (P = .7), and infection (P = .8) were also similar. However, 24-hour mediastinal drainage was less after minimally invasive surgery (median, 250 vs 350 mL; P < .0001), and fewer patients received transfusions (30% vs 37%, P = .01). More patients undergoing minimally invasive surgery were extubated in the operating room (18% vs 5.7%, P < .0001), and postoperative forced expiratory volume in 1 second was higher. Early after operation, pain scores were lower (P < .0001) after minimally invasive surgery. Within that portion of the spectrum of mitral valve surgery in which propensity matching was possible, minimally invasive mitral valve surgery had cosmetic, blood product use, respiratory, and pain advantages over conventional surgery, and no apparent detriments. Mortality and morbidity for robotic and percutaneous procedures should be compared with these minimally invasive outcomes.
Predictors of outcome of non-ischemic mitral valve surgery
International Journal of Cardiology, 2013
Background: Data on the risk stratification of patients undergoing mitral valve (MV) surgery for non-ischemic mitral disease are sparse. The present study seeks to define them in a contemporary cohort. Methods: 193 consecutive patients referred to non-ischemic MV surgery were prospectively studied. Baseline characteristics and the type of surgery were analyzed with regard to operative and late mortality as well as functional outcome. Results: 129 patients underwent MV replacement and 64 MV repair. MV replacement patients presented with more symptoms (p = 0.010), higher EuroSCORE (6.1 versus 5.6; p = 0.009), more frequently underwent additional valve surgery (7.8 versus 0%; p = 0.003) and were more frequently female (p = 0.048). Operative mortality was 3.1%, two thirds of operative deaths had additional surgery of the tricuspid valve (p = 0.019). Patients were followed for 5.2 ± 2.7 years. 1-, 3-, 5-and 7-year survival rates were 93-, 91-, 82-, and 79% in MV replacement patients versus 100-, 98-, 96-, and 89% in patients with MV repair (p = 0.015). However, by multivariate logistic regression, overall mortality was determined by additional surgery of the tricuspid valve (p = 0.0103), multivessel coronary disease (p = 0.026), and age (p b 0.0001), but not by the type of surgery (p = 0.066). Furthermore, the type of surgery did not influence functional outcome (p = 0.515). Conclusions: Apart from age and coronary artery disease the need for additional tricuspid valve surgery significantly determines the outcome of non-ischemic MV surgery. The type of operation appears less important when the need for additional valve surgery and co-morbidities like coronary artery disease are taken into consideration.
Mitral valve repair versus replacement in the elderly: Short-term and long-term outcomes
The Journal of Thoracic and Cardiovascular Surgery, 2014
Objective: To compare the short-term and long-term outcomes of mitral valve repair (MVP) versus mitral valve replacement (MVR) in elderly patients. Methods: All patients, age 70 years or greater, with mitral regurgitation who underwent MVP or MVR with or without coronary artery bypass graft (CABG), tricuspid valve surgery, or a maze procedure between 2002 and 2011 were retrospectively identified. Patients with a rheumatic cause or who underwent concomitant aortic valve or ventricular-assist device procedures were excluded. Results: Overall, 556 patients underwent MVP and 102 patients underwent MVR. The mean age of the patients in the MVR group was 78 years versus 77 years for those in the MVP group (P<.02). The patients in the MVR group had a better mean left ventricular ejection fraction than those in the MVP group (60% vs 55%, P ¼ .04). The incidence of concomitant CABG, tricuspid valve operations, and atrial fibrillation ablation procedures was similar in both groups, but perfusion time was significantly longer for the MVR group (median 177 minutes vs 146 minutes for MVP, P ¼ .001). Postoperatively, patients in the MVR group had a higher incidence of stroke (6% vs 2%, P<.10) and significantly longer intensive care unit stay (median 86 hours vs 55 hours, P ¼ .001) and hospital stay (9 days vs 8 days, P < .01). Operative mortality of patients was significantly higher for the MVR group (8.8% vs 3.6%, P ¼ .03) and remained significant long-term on Kaplan-Meier analysis. Cox regression analysis of all 658 patients and propensity-matched analysis of 96 patients also confirmed these results.
2020
Background: Minimally invasive mitral valve(MV) surgery(MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcome and secondary organ function effects in a propensity-matched comparison with conventional MV surgery. Methods and Results: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 345 patients were included after propensity-matching: 95 sternotomy patients and 250 MIVT patients. Endpoints focused on survival, quality of MV repair and organ function effects through analysis of biomarkers and functional parameters. Despite longer cardiopulmonary bypass(sternotomy: 96.0(IQR34)min-MIVT:134.0(IQR42)min, p<0.001) and cardioplegic arrest times(sternotomy: 61.0(IQR26)min-MIVT:87.0(IQR34)min, p<0.001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p=0.751-ureum, p=0.538-glomerular filtration, p=0.848), myocardial damage by troponine I level (sternotomy:1.8±3.9ng/ml-MIVT:1.2±1.3ng/ml, p=0.438) and ventilatory support > 24 hours(sternotomy:5.5%-MIVT:9.5%, p=0.240) were comparable. Systemic inflammatory reaction by postoperative CRP count was markedly lower for MIVT(p<0.001). Increased rhadomyolysis was found after MIVT surgery, based on significant elevation of creatinine-kinase levels(sternotomy: 431±237U/L-MIVT: 701±595U/L, p<0.001). Conclusion: Despite an inherent learning curve, minimally invasive MV surgery guarantees a clinical outcome and MV repair quality, at least non-inferior to those of MV surgery via sternotomy. Notwithstanding longer cardiopulmonary bypass and cardiac arrest times, the impact on secondary organ function is negligible, excepted for a lower systemic inflammatory response. The postoperative increase of CK-enzymes suggestive for enhanced rhabdomyolysis needs to be accounted when procedural times tend to exceed the critical time threshold for severe limb ischemia. Analysis of clinical outcome and postoperative organ function effects in a propensity-matched comparison between conventional and minimally invasive mitral valve surgery
Innovations (Philadelphia, Pa.), 2011
This meta-analysis sought to determine whether minimally invasive mitral valve surgery (mini-MVS) improves clinical outcomes and resource utilization compared with conventional open mitral valve surgery (conv-MVS) in patients undergoing mitral valve repair or replacement. Methods: A comprehensive search of MEDLINE, Cochrane Library, EMBASE, CTSnet, and databases of abstracts was undertaken to identify all randomized and nonrandomized studies up to March 2010 of mini-MVS through thoracotomy versus conv-MVS through median sternotomy for mitral valve repair or replacement. Outcomes of interest included death, stroke, myocardial infarction, aortic dissection, need for reintervention, and any other reported clinically relevant outcomes or indicator of resource utilization. Relative risk and weighted mean differences and their 95% confidence intervals were analyzed as appropriate using the random effects model. Heterogeneity was measured using the I 2 statistic. Results: Thirty-five studies met the inclusion criteria (two randomized controlled trials and 33 nonrandomized studies). The mortality rate after mini-MVS versus conv-MVS was similar at 30 days (1.2% vs 1.5%), 1 year (0.9% vs 1.3%), 3 years (0.5% vs 0.5%), and 9 years (0% vs 3.7%). A number of clinical outcomes were significantly improved with mini-MVS versus conv-MVS including atrial fibrillation (18% vs 22%), chest tube drainage (578 vs 871 mL), transfusions, sternal infection (0.04% vs 0.27%), time to return to normal activity, and patient scar satisfaction. However, the 30-day risk of stroke (2.1% vs 1.2%), aortic dissection/injury (0.2% vs 0%), groin infection (2% vs 0%), and phrenic nerve palsy (3% vs 0%) were significantly increased for mini-MVS versus conv-MVS. Other clinical outcomes were similar between groups. Cross-clamp time, cardiopulmonary bypass time, and procedure time were significantly increased with mini-MVS; however, ventilation time and length of stay in intensive care unit and hospital were reduced. Conclusions: Current evidence suggests that mini-MVS maybe associated with decreased bleeding, blood product transfusion, atrial fibrillation, sternal wound infection, scar dissatisfaction, ventilation time, intensive care unit stay, hospital length of stay, and reduced time to return to normal activity, without detected adverse impact on long-term need for valvular reintervention and survival beyond 1 year. However, these potential benefits for mini-MVS may come with an increased risk of stroke, aortic dissection or aortic injury, phrenic nerve palsy, groin infections/complications, and increased cross-clamp, cardiopulmonary bypass, and procedure time. Available evidence is largely limited to retrospective comparisons of small cohorts comparing mini-MVS versus conv-MVS that provide only short-term outcomes. Given these limitations, randomized controlled trials with adequate power and duration of follow-up to measure clinically relevant outcomes are recommended to determine the balance of benefits and risks.
The Annals of Thoracic Surgery, 2015
Background. Minimally invasive valve surgery is related to certain better postoperative outcomes. We aimed to assess the role of minimally invasive mitral valve surgery in high-risk patients. Methods. A systematic literature review identified eight studies of which seven fulfilled criteria for metaanalysis. Outcomes for a total of 1,254 patients (731 were conventional standard sternotomy and 523 were minimally invasive mitral valve surgery) were submitted to meta-analysis using random effects modeling. Heterogeneity and subgroup analysis with quality scoring were assessed. The primary end point was early mortality. Secondary end points were intraoperative and postoperative outcomes and long-term follow-up. Results. Minimally invasive mitral valve surgery conferred comparable early mortality to standard sternotomy (p [ 0.19); it was also associated with a lower number of units of blood transfused (weighted mean difference, L1.93; 95% confidence interval [CI], L3.04
Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease
The Journal of Thoracic and Cardiovascular Surgery, 2003
We began minimally invasive mitral valve surgery in August, 1996, to reduce hospital costs, to improve patient recovery, cosmetic appearance, and to decrease trauma, yet maintain the same quality of surgery. To validate this approach we reviewed our entire experience through May 2002. Methods: From August 1996 to May 2002, we performed 413 minimally invasive mitral valve operations including 51 mitral valve replacements and 362 mitral valve repairs. Excluding 4 robotically assisted repairs, we evaluated 358 patients, using the mitral valve repairs as the basis for this retrospective survey. These operations were performed through a 6-to 8-cm minimally invasive incision, beginning with parasternal and, most recently, lower ministernotomy (181 patients). The mitral valve reparative techniques include repair of 94 prolapsed anterior leaflets, posterior leaflet resection, leaflet advancement, commissuroplasty, Polytetrafluoroethylene (PTFE; Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) chordal placement, and ring annuloplasty. Cannulation sites varied but primarily utilized a miniaturized system of 24F catheters in both the inferior and superior venae cavae with assisted venous suction. The Cosgrove ring was used in 95% of the patients undergoing this procedure. Results: The operative mortality was 0/358. Perioperative morbidity included a 26% incidence of new atrial fibrillation, 2% incidence of pacemaker implantation, 0.5% incidence of deep sternal wound infection, and 1.9% incidence of stroke after an operation. There were 10 arterial and 3 venous complications. The mean length of stay was 6 days and 208 patients stayed Յ5 days. Only 25% of the patients underwent homologous blood transfusion. The mean follow-up was 36 months with 1.4% lost to follow-up. There were 12 late deaths and a survival at 5 years of 95%. There were 21 valves requiring reoperation for structural valve failure of 5.8%. The probability of freedom from reoperation at 5 years was 92%. Conclusion: This study documents the safety of minimally invasive mitral valve repair surgery in 358 patients. It also documents a low incidence of homologous blood use, requirement for post-hospital rehabilitation, and general morbidity.
Circulation Journal
Background: Despite the cosmetic benefits of the minimally invasive approach for mitral disease, the clinical benefit and risk are not fully known. We investigated the benefit and risk of minimally invasive mitral valve (MV) repair for type II dysfunction using propensity score-matched analysis. Methods and Results: Since 2001, 602 patients have undergone MV repair for type II dysfunction (464 with conventional median sternotomy and 138 with the minimally invasive approach). One-to-one matched analysis using the estimated propensity score based on 23 factors resulted in 93 well-matched patient pairs. There was no in-hospital death in both groups. The operation time was significantly shorter (P=0.002), blood transfusion was less frequent (P=0.04), extubation at the day of surgery was more frequently performed (P=0.017), and the length of hospital stay was significantly shorter in the minimally invasive group than in the sternotomy group (P<0.0001). On postoperative (P=0.02) and 1-year echocardiography (P=0.04), ejection fraction was lower in the minimally invasive group than in the sternotomy group. There were no significant differences in postoperative cerebral infarction, aortic dissection, deep sternal infection, or mid-term outcome between the groups. Conclusions: Standard sternotomy and the minimally invasive approach provide similar good quality of MV repair for type II dysfunction. The minimally invasive approach is more likely to contribute to fast-track perioperative treatment than the standard sternotomy approach.