Training surgeons in minimally invasive mitral valve repair: a single institution experience

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis

OBJECTIVES

Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures.

METHODS

We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed.

RESULTS

Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay.

CONCLUSIONS

In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Conventional sternotomy versus right mini-thoracotomy versus robotic approach for mitral valve replacement/repair; insights from a network meta-analysis

OBJECTIVE

Minimally invasive cardiac surgery (MICS) through right mini-thoracotomy as well as robotic surgery has emerged for the last decade for mitral valve surgery. However, their risks and benefits are not fully understood yet. Thus, we conducted a network meta-analysis comparing the early- and long-term outcomes of mitral valve surgery via the conventional sternotomy, MICS, and robotic approaches.

EVIDENCE ACQUISITION

MEDLINE and EMBASE were searched through November, 2020 to identify randomized controlled trials (RCTs) and propensity-score matched (PSM) trials that investigated early- and long-term outcomes after mitral surgery via the conventional sternotomy, MICS, and robotic approaches. A subalalysis focusing on only subjects who initially underwent mitral valve repair was also conducted.

EVIDENCE SYNTHESIS

Our systematic literature search identified 2 RCTs and 19 PSM studies. MICS was related to significant risk reductions of permanent pacemaker implantation, surgical site infection, and transfusion compared to the sternotomy approach. The robotic approach was associated with a significant increase in re-exploration for bleeding compared to sternotomy. The subanalysis showed that MICS was associated with a significant increase requiring mitral valve reoperation compared to the sternotomy approach (hazard ratio [95% confidence interval] =7.33 [1.54-34.97], p=0.012), while no significant difference was observed between the sternotomy and the robotic approach.

CONCLUSIONS

Our network meta-analysis demonstrated that MICS was associated with better short-term outcomes compared to the sternotomy approach. Mitral valve reoperation was more frequent with MICS compared with the sternotomy approach after mitral valve repair, while no difference was observed between the sternotomy and robotic approaches.

Establishing minimally invasive cardiac surgery in a low-volume mitral surgery centre

INTRODUCTION

Despite early enthusiasm, minimally invasive cardiac surgery has had a low uptake compared with novel techniques in interventional cardiology. Steep learning curves from high-volume centres have deterred smaller units from engaging, even though low-volume centres undertake a large proportion of surgical interventions worldwide. We sought to identify the safety and experience of learning minimally invasive cardiac surgery after undertaking a structured fellowship at Blackpool Victoria Hospital, a low-volume centre.

MATERIALS AND METHODS

A retrospective analysis of outcomes for all consecutive minimally invasive cardiac surgery procedures performed via a right mini-thoracotomy at our institution between 2007 and 2017 was undertaken. Clinical outcomes included death, conversion to sternotomy, stroke, renal failure and other organ support. Cardiopulmonary bypass, aortic cross-clamp times and learning cumulative sum sequential probability method curves were also assessed to determine how safely the procedure was adopted.

RESULTS

A total of 316 patients were operated on for mitral, tricuspid, atrial fibrillation, septal defects or other conditions. The mean logistic European System for Cardiac Operative Risk Evaluation score was 7.0 (± 8.5). Conversion to sternotomy occurred in 12 patients (3.8%) and in-hospital mortality was 7 (2.2%). None of the converted patients died. The learning curves showed an accelerated process of adoption, similar to reference figures from a high-volume German centre.

DISCUSSION

It is possible for low-volume cardiac surgical centres to undertake minimally invasive surgical programmes with good outcomes and short learning curves. Despite technical complexities, with a team approach, the learning curve can be navigated safely.

Mitral valve surgery for rheumatic heart disease: replace, repair, retrain?

PURPOSE OF REVIEW

Rheumatic heart disease (RHD) affects over 30 million people worldwide. Substantial variation exists in the surgical treatment of patients with RHD. Here, we aim to review the surgical techniques to treat RHD with a focus on rheumatic mitral valve (MV) repair. We introduce novel educational paradigms to embrace repair-oriented techniques in cardiac centers.

RECENT FINDINGS

Due to the low prevalence of RHD in high-income countries, limited expertise in MV surgery for RHD, technical complexity of MV repair for RHD and concerns about durability, most surgeons elect for MV replacement. However, in some series, MV repair is associated with improved outcomes, fewer reinterventions, and avoidance of anticoagulation-related complications. In low- and middle-income countries, the RHD burden is large and MV repair is more commonly performed due to high rates of loss-to-follow-up and barriers associated with anticoagulation, international normalized ratio monitoring, and risk of reintervention.

SUMMARY

Increased consideration for MV repair in the setting of RHD may be warranted, particularly in low- and middle-income countries. We suggest some avenues for increased exposure and training in rheumatic valve surgery through international bilateral partnership models in endemic regions, visiting surgeons from endemic regions, simulation training, and courses by professional societies.

Less Invasive Mitral Surgery Versus Conventional Sternotomy Stratified by Mitral Pathology

BACKGROUND

Our objective was to compare national mitral repair rates and outcomes after less invasive mitral surgery (LIMS) vs conventional sternotomy across the spectrum of mitral pathologies and repair techniques.

METHODS

Patients undergoing isolated primary mitral valve surgery in The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2014 to December 2018 were evaluated. Propensity score models were constructed nonparsimoniously, and prediction models used to compute adjusted effects of surgical approach. Hypothesis tests were adjusted for propensity score with inverse-probability weighting.

RESULTS

A total of 41,082 patients met inclusion criteria; comprising 10,238 (24.9%) LIMS and 30,844 (75.1%) conventional sternotomy, with increased LIMS adoption annually. Surgeons reporting LIMS cases had higher annual median mitral case volumes than those who did not (23 vs 8, P < .001). Groups were well-balanced after propensity adjustment including mitral pathology. Propensity score-adjusted outcomes showed increased procedural volume (odds ratio 1.030 [95% confidence interval: 1.028-1.031]) and LIMS (odds ratio 2.139 [95% confidence interval 2.032-2.251]) were independently associated with higher mitral repair rates. Propensity-adjusted outcomes included reduced stroke (P < .001), atrial fibrillation (P < .001), pacemaker (P < .001), renal failure (P < .001), and length of stay (P < .001) for LIMS vs sternotomy, without differences in mortality. Operative volume influenced outcomes in both groups.

CONCLUSIONS

LIMS was associated with higher mitral repair rates, and lower morbidity. Further studies regarding the impact of surgeon volume on choice of operative approach are necessary.

Mitral valve replacement via minimally invasive totally thoracoscopic surgery versus traditional median sternotomy: a propensity score matched comparative study

Background

To compare surgical outcomes after mitral valve replacement via either minimally invasive thoracoscopic (MIs) or traditional median sternotomy (MS) surgery and determine the short- and mid-term clinical outcomes of the MI approach.

Methods

All patients who received either MIs (n=405) or MS (n=691) mitral valve replacement surgery at the Guangdong Cardiovascular Institute between January 2012 and July 2015 were analyzed for outcome differences due to surgical approach using propensity score matching. The best 202 matches from the MI group and the MS group were analyzed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and follow-up.

Results

A final total of 404 patients were included in this study after propensity score matching; the MIs group and the MS group each contained 202 patients. The two groups were similar in age, weight, pathological changes, and surgical approach. Compared with the MS group, the MIs group had a longer cardiopulmonary bypass time (P<0.001), aortic cross-clamping time (P<0.001), and total procedure time (P<0.001). There were no significant differences between the groups regarding in-hospital mortality, stroke, pneumonia, acute renal failure, arrhythmia, and chylothorax. The MS group had significantly more patients with poor wound healing than the MIs group (P=0.004). The MI group had a lower rate of transfusion (P=0.037), shorter ventilation time (P=0.041), shorter ICU stay (P=0.033), reduced chest tube drainage and length of chest tube stay (P<0.001), and shorter hospital stay (P<0.001). There was no significant difference between the groups in hospital re-admission for bleeding, but the total hospitalization cost was higher in the MIs group (P=0.002). The mean follow-up was 26.59±12.33 months, the 1-year postoperative survival rate was 98.86%, and the overall survival rate was 97.44%. Compared with the MS group, the MIs group recovered earlier (P<0.05), and returned to work or study earlier (P<0.05). More patients in the MIs group were satisfied with the wound (P<0.001). The MS group had a higher incidence of postoperative osteomyelitis than the MIs group (P=0.028). There were no significant differences between groups in rates of mortality, stroke, pacemaker, reoperation, or 36-item Short Form Health Survey score.

Conclusions

Compared with the MS approach, the MIs method of mitral valve replacement has longer cardiopulmonary bypass time and aortic cross-clamp time; however, it does not increase the risk of mortality and complications. Furthermore, MIs causes less trauma, fewer transfusions, less wound infection, faster recovery, faster return to work or study, and greater satisfaction with the incision in the mid-term. MI cardiac surgery is safe, effective, and feasible.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients

Background

To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period.

Methods

From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT.

Results

The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %.

Conclusions

Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Minimally invasive mitral valve repair through right minithoracotomy in the setting of degenerative mitral regurgitation: early outcomes and long-term follow-up

BACKGROUND

Mitral valve (MV) repair is the gold standard for the treatment of degenerative MV regurgitation. Recently, minimally invasive mitral valve surgery (MIMVS) has shown excellent postoperative outcomes compared with conventional surgery. The aim of our study is to report early and long-term outcomes of patients undergoing MIMVS through right mini-thoracotomy (RT) over an eight year period.

METHODS

From September 2003 to December 2011, a total of 1,604 consecutive patients underwent MIMVS through RT.

RESULTS

The mean age was 62±13 years, 295 (42%) patients were female and 16 (2.3%) had previous cardiac operations. MV repair was successfully performed in 670 patients, with a rate of success of 95.3%. Repair techniques included annuloplasty (89%), leaflet resection (n=54.2%), neochordae implantation (12.1%), and sliding plasty (10.5%). Overall in-hospital mortality was 0.1%. Incidence of stroke was 1.3%. At eight-year follow-up, overall survival was 90.1%, freedom from reoperation 93%, and freedom from recurrent mitral regurgitation was 90%.

CONCLUSIONS

MIMV repair through right minithoracotomy is a safe and reproducible procedure associated with high rate of MV repair, and excellent early postoperative and long-term results.

Recent Developments in Minimally Invasive Cardiac Surgery: Evolution or Revolution?

Intraluminal aortic clamping has been achieved until now by means of a sophisticated device consisting of a three-lumen catheter named Endoclamp, which allows at the same time occlusion of the aorta, antegrade delivering of cardioplegia, and venting through the aortic root. This tool has shown important advantages allowing aortic occlusion and perfusate delivering without a direct contact with ascending aorta reducing meanwhile the risk of traumatic and/or iatrogenic injuries. Recently, a new device (Intraclude catheter) with the same characteristics and properties has been proposed and introduced in clinical practice. The aim of this paper is to investigate the differences between Endoclamp and Intraclude catheters and to analyze the advantages advocated by this new device for intraluminal aortic occlusion since it is noticeable as these new technological tools are gaining more and more attractiveness due to their appraised clinical efficacy.