Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes

Abstract

Background: Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. Methods:We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. Results:We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/ 30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. Conclusion:A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS. Possible clinically relevant differences in perioperative complications require assessment in randomized clinical trials.Contexte : Les réopérations de la valve mitrale (VM) sont associées à une morbidité et à une mortalité importantes. Cependant, il semblerait que les techniques chirurgicales endoscopiques à effraction minimale préservent les avantages des opérations traditionnelles de la VM tout en réduisant potentiellement les risques périopératoires et la durée d'hospitalisation.Méthodes : Nous avons comparé les résultats de patients consécutifs ayant subi une réopération de la VM entre 2000 et 2014 selon une approche endoscopique à effraction minimale (groupe MINI) à ceux de patients ayant subi une sternotomie classique (groupe STERN). Le résultat primaire à l'étude était la mortalité intrahospitalière ou dans les 30 premiers jours, et les résultats secondaires, la transfusion de produits sanguins, la durée du séjour à l'hôpital et à l'unité des soins intensifs (USI), ainsi que les complications postopératoires.Résultats : Nous avons retenu 132 pa...

Minimally Invasive Versus Sternotomy for Mitral Surgery in the Elderly: A Systematic Review and Meta-Analysis

“…There were 10 retrospective observational cohort studies providing a head-to-head comparison between MIMVS and CS in elderly patients (≥65 years old), with a total of 1,897 patients (929 patients in the MIMVS group and 968 patients in the CS group). 4,6,[8][9][10][11][12][13][14][15][16] We had access to the full texts of 7 studies 4,6,[8][9][10][11][12] and only to the abstracts of 3 studies. [13][14][15][16] After reviewing these 3 abstracts along with their accompanying materials, it was believed that we had access to enough information to make an assessment of the quality of the studies and to extract the appropriate information for our systematic review and meta-analysis.…”

Minimally invasive (mini-thoracotomy) versus median sternotomy in redo mitral valve surgery: A meta-analysis of observational studies

“…There were seven studies included in the meta-analyses. [18][19][20][21][22][23][24] Table 1 outlines the studies included. Table 2 has supplementary data on individual studies.…”

Minimally invasive mitral valve surgery after previous sternotomy: A propensity‐matched analysis

“…MV surgery in the setting of prior open-heart surgery can be challenging in patients with patent coronary bypass grafts or rigid aortic valve prostheses due to high risk of conduit injury and Previous studies investigating the MIS approach for reoperative MV surgery are limited by the lack of a comparison group 7 , 8 or the use of a nonrandomized, unadjusted comparison cohorts., 12,13 Losenno et al 13 described outcomes of 132 patients who underwent MIS and re-ST MV surgery after previous MV surgery via ST. 11 In their study, the MIS approach was found to be safe and effective compared to re-ST (inhospital/30-day mortality 5% vs. 11%, p = .35; composite any of 10 complications 28% vs. 41%, p = .13). However, the baseline characteristics of both groups had significant and clinically relevant differences and One other propensity-matched comparison has been previously reported by Patel et al, 14 in which 30-day mortality was found to be similar among 90 pairs of propensity-matched patients undergoing redo MV surgery via MIS and ST (1.1% vs. 5.6%; p = .21).…”