Minimally invasive mitral valve surgery: a systematic review and meta-analysis

Abstract

The mitral valve has been traditionally approached through a median sternotomy. However, significant advances in surgical optics, instrumentation, tissue telemanipulation, and perfusion technology have allowed for mitral valve surgery to be performed using progressively smaller incisions including the minithoracotomy and hemisternotomy. Due to reports of excellent results, minimally invasive mitral valve surgery has become a standard of care at certain specialized centers worldwide. This meta-analysis quantifies the effects of minimally invasive mitral valve surgery on morbidity and mortality compared with conventional mitral surgery and demonstrates equivalent perioperative mortality (1641 patients, odds ratio (OR) 0.46, 95% confidence interval 0.15-1.42, p=0.18), reduced need for reoperation for bleeding (1553 patients, OR 0.56, 95% CI 0.35-0.90, p=0.02) and a trend towards shorter hospital stays (350 patients, weighted mean difference (WMD) -0.73, 95% CI -1.52 to 0.05, p=0.07). These benefits were evident despite longer cardiopulmonary bypass (WMD 25.81, 95% CI 13.13-38.50, p<0.0001) and cross-clamp times (WMD 20.91, 95% CI 8.79-33.04, p=0.0007) in the minimally invasive group. Case-control studies show consistently less pain and faster recovery compared to those having a conventional approach. Data for minimally invasive mitral valve surgery after previous cardiac surgery are limited but consistently demonstrate reduced blood loss, fewer transfusions and faster recovery compared to reoperative sternotomy. Long-term follow-up data from multiple cohort studies are also examined revealing equivalent survival and freedom from reoperation. Thus, current clinical data suggest that minimally invasive mitral valve surgery is a safe and a durable alternative to a conventional approach and is associated with less morbidity.

Anterolateral minithoracotomy versus median sternotomy for mitral valve disease: a meta-analysis

“…Five meta-analyses have already been performed on minimal invasive heart surgery. Modi et al (2008) showed that MIMVS was a safe and durable alternative to MS and was associated with equal mortality and neurologic events, less morbidity in terms of reduced incidence for re-operation for bleeding, a trend towards shorter hospital stay, less pain, and faster return to pre-operative function levels compared with conventional sternotomy, despite longer CPB time and ACCT. Ding et al (2012) evaluated ALMT in congenital heart disease and suggested that this had a longer CPB time and ACCT, but shorter intubation time, ICU time, and LOHS.…”

“…Thus, the question remains as to whether the potential benefits of a minimally invasive approach can outweigh the potential drawbacks of limited operative exposure, longer cardiopulmonary bypass time and aortic crossclamp time. One recent meta-analysis of minimal access mitral valve surgery (Modi et al, 2008), which collected data from 1996 to 2008, suggested some short-and long-term benefits for mortality, reoperation for bleeding, intensive care unit (ICU) stay, and hospital stay over conventional surgery, despite longer operative time. However, this meta-analysis included all kinds of minimally invasive approaches without any subgroups or randomized clinical trials.…”

What Is the Role of Minimally Invasive Mitral Valve Surgery in High-Risk Patients? A Meta-Analysis of Observational Studies

“…In studies that included mainly redo operation patients [12][13][14], both ventricular fibrillation arrest and endoclamping were used, although direct clamping was reported in some cases in one series [12]. As in other reports [1,19], CPB time was significantly longer in the MIMVS group, but heterogeneity was evident as expected for continuous parameters. Overall meta-analysis also showed a reduced rate of postoperative AF with no heterogeneity.…”

“…Cardiac surgeons have been mastering minimally invasive surgery techniques for several years with favorable results [1], and these benefits may be particularly evident in patients at high risk who, more than others, are prone to experience adverse events postoperatively. However, minimally invasive surgery may be associated with an increased incidence of stroke and aortic dissection, as well as significantly longer cardiopulmonary bypass (CPB) time [2], which can be classified as technical-or learning curve-related drawbacks.…”

Cirurgia cardíaca videoassistida: resultados de um projeto pioneiro no Brasil

“…Several studies on video-assisted minimally invasive heart surgery have shown that, in spite of CPB and clamping time are longer when compared with the conventional technique via median thoracotomy, it is a safe procedure and is associated with a lower morbidity: less postoperative pain, less bleeding, time of extubation, ICU stay, and shorter hospital stay and return to activities more quickly [20][21].…”