Effect of minimally invasive mitral valve surgery compared to sternotomy on short- and long-term outcomes: a retrospective multicentre interventional cohort study based on Netherlands Heart Registration

Abstract

OBJECTIVES Minimally invasive mitral valve surgery (MIMVS) has been performed increasingly for the past 2 decades; however, large comparative studies on short- and long-term outcomes have been lacking. This study aims to compare short- and long-term outcomes of patients undergoing MIMVS versus median sternotomy (MST) based on real-world data, extracted from the Netherlands Heart Registration. METHODS Patients undergoing mitral valve surgery, with or without tricuspid valve, atrial septal closure and/or rhythm surgery between 2013 and 2018 were included. Primary outcomes were short-term morbidity and mortality and long-term survival. Propensity score matching analyses were performed. RESULTS In total, 2501 patients were included, 1776 were operated through MST and 725 using an MIMVS approach. After propensity matching, no significant differences in baseline characteristics persisted. There were no between-group differences in 30-day mortality (1.1% vs 0.7%, P = 0.58), 1-year mortality (2.6% vs 2.1%, P = 0.60) or perioperative stroke rate (1.1% vs 0.6%, P = 0.25) between MST and MIMVS, respectively. An increased rate of postoperative arrhythmia was observed in the MST group (31.3% vs 22.4%, P < 0.001). A higher repair rate was found in the MST group (80.9% vs 76.3%, P = 0.04). No difference in 5-year survival was found between the matched groups (95.0% vs 94.3%, P = 0.49). Freedom from mitral reintervention was 97.9% for MST and 96.8% in the MIMVS group (P = 0.01), without a difference in reintervention-free survival (P = 0.30). CONCLUSIONS The MIMVS approach is as safe as the sternotomy approach for the surgical treatment of mitral valve disease. However, it comes at a cost of a reduced repair rate and more reinterventions in the long term, in the real-world.

Minimally invasive approach compared to resternotomy for mitral valve surgery in patients with prior cardiac surgery: retrospective multicentre study based on the Netherlands Heart Registration

“…However, mortality is reported to range up to 11.1% in the Society of Thoracic Surgeons (STS) database [ 13 ], which is based on a multicentre registry, potentially more accurately reflecting real-world results. In accordance with a prior comparison between MIMVS and sternotomy in primary MV surgery of the Dutch national registry, no difference in 30-day mortality regarding surgical approach was observed [ 14 ]. Of note, in a previous meta-analysis by our research group, a significant early mortality benefit of the MIMVS approach in a reoperative setting was found [ 9 ].…”

“…In terms of morbidity and complication rate, a low incidence of major postoperative complications for both repeated sternotomy as MIMVS was observed. As known from other large registries and a recent analysis of primary MV surgery [ 14 ], MV surgery through a minimally invasive approach is associated with a lower incidence of new-onset postoperative arrythmia compared to sternotomy. This finding is confirmed in the current analysis of patients undergoing reoperative procedures and is potentially explained by less need of adhesiolysis, less cardiac manipulation and a subsequent reduction in inflammation [ 18 ].…”

“…The repair rate, when specified for patients without prior MV intervention, is considerably lower (33.3%) compared to the repair rate in primary MV surgery. In a previous analysis of patients undergoing primary MV surgery, repair rate for all-comers approached through sternotomy was 80.0%, while repair rate was 75.9% for MIMVS patients [ 14 ]. In contrast to the prior findings in primary MV surgery, we did not observe a difference in surgical approach in terms of repair rate in patients undergoing MV surgery after prior cardiac surgery through sternotomy.…”

At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology

“…Despite many studies that included a large number of patients undergoing MIMVS, there is still debate regarding the superiority of a particular mini-access route and even conventional sternotomy [ 71 ]. A recent study which included the same mitral valve surgery data from the NHR concluded that based on an analysis of registry data there was no reason to assume superiority of MIMVS in general [ 72 ].…”

Mitral Valve Repair: Regulatory or Ethical Problem?

“…Optimal results have been published, but data from the real world have not been extensively reported. A recent Nationwide survey 16 analyzed the outcome in 2,501 patients who underwent MVr between 2013 and 2018 through different approaches. In propensity score matched groups (718 each) the Authors found that patients undergoing MVr through a right mini-thoracotomy had a lower rate of repair (76.3% versus 80.9%, p=0.04).…”