Minimally Invasive Port Access Approach for Reoperations on the Mitral Valve

Late Survival After Redo Mitral Operation With Minithoracotomy Compared With Sternotomy

BACKGROUND

The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach.

METHODS

Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes.

RESULTS

Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001).

CONCLUSIONS

For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy.

Minimally Invasive Procedure versus Conventional Redo Sternotomy for Mitral Valve Surgery in Patients with Previous Cardiac Surgery: A Systematic Review and Meta-Analysis

Background

The heightened morbidity and mortality associated with repeat cardiac surgery are well documented. Redo median sternotomy (MS) and minimally invasive valve surgery are options for patients with prior cardiac surgery who require mitral valve surgery (MVS). We conducted a systematic review and meta-analysis comparing the outcomes of redo MS and minimally invasive MVS (MIMVS) in this population.

Methods

We searched PubMed, EMBASE, and Scopus for studies comparing outcomes of redo MS and MIMVS for MVS. To calculate risk ratios (RRs) for binary outcomes and weighted mean differences (MDs) for continuous data, we employed a random-effects model.

Results

We included 12 retrospective observational studies, comprising 4157 participants (675 for MIMVS; 3482 for redo MS). Reductions in mortality (RR, 0.54; 95% confidence interval [CI], 0.37-0.80), length of hospital stay (MD, -4.23; 95% CI, -5.77 to -2.68), length of intensive care unit (ICU) stay (MD, -2.02; 95% CI, -3.17 to -0.88), and new-onset acute kidney injury (AKI) risk (odds ratio, 0.34; 95% CI, 0.19 to 0.61) were statistically significant and favored MIMVS (p<0.05). No significant differences were observed in aortic cross-clamp time, cardiopulmonary bypass time, or risk of perioperative stroke, new-onset atrial fibrillation, surgical site infection, or reoperation for bleeding (p>0.05).

Conclusion

The current literature, which primarily consists of retrospective comparisons, underscores certain benefits of MIMVS over redo MS. These include decreased mortality, shorter hospital and ICU stays, and reduced AKI risk. Given the lack of high-quality evidence, prospective randomized control trials with adequate power are necessary to investigate long-term outcomes.

Mitral valve surgery via repeat median sternotomy versus right mini-thoracotomy: A systematic review and meta-analysis of clinical outcomes

BACKGROUND

Redo mitral valve surgeries have high mortality and morbidity and can be physically demanding for patients. Median sternotomy remains the gold standard for most cardiac surgeries. To tackle certain risks with a re-sternotomy, alternative procedures such as the right anterolateral minithoracotomy have been explored. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery.

METHODS

A systematic, electronic search was performed according to Preferred Reporting items for Systematic Reviews and Meta-analysis guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via a MS approach.

RESULTS

Twelve studies were identified, enrolling 4514 patients. Length of hospital stay(MD = -3.71, 95% confidence interval [CI] [-4.92, -2.49]), 30-day mortality(odds ratio [OR] = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR = 0.38, 95% CI [0.22, 0.65]) were statistically significant in favor of the MT approach. Infection rates(OR = 0.56, 95% CI[0.25, 1.21]) and length of intensive care unit (ICU) stay (MD = -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD = -2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD = -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR = 1.03, 95% CI[0.55, 1.92]).

CONCLUSION

Right MT is a safe alternative to the traditional re-sternotomy for patients who have had previous cardiac surgery. The approach offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis. This review calls for robust trials in the field to further strengthen the evidence.

Endoscopic Robotic Mitral Valve Surgery in Patients With Previous Sternotomy Cardiac Surgery

Objective: Mitral surgery is higher risk in patients with a previous median sternotomy. We describe an endoscopic robotic approach in this higher-risk cohort by an experienced robotic team. Methods: From January 2006 through June 2021, 152 consecutive patients with previous sternotomy cardiac surgery underwent mitral surgery using endoscopic robotics. Peripheral perfusion with endoaortic balloon occlusion was used in 148 patients (97.4%) and ventricular fibrillation in 4 patients (2.6%). Results: Mitral repair was performed in 73 patients (48%) including primary repair in 57 patients and re-repair in 16 patients, mitral replacement in 78 patients (51.3%) including primary replacement in 26 patients, conversion of a previous repair to replacement in 28 patients, and re-replacement in 24 patients. A paravalvular leak was primarily repaired in 1 patient (0.7%). Concomitant procedures included tricuspid repair in 28 patients (18.4%) and cryoablation in 8 patients (5.3%). Postoperative echocardiography in the mitral repair patients demonstrated none to mild regurgitation in 72 patients (98.6%). One repair patient (1.4%) had severe regurgitation and required robotic mitral replacement 5 days postoperatively. There were no paravalvular leaks in the mitral replacement patients. Operative mortality occurred in 3 patients (1.97%). Stroke occurred in 1 patient (0.7%), prolonged ventilation in 18 patients (11.8%), renal failure in 2 patients (1.4%), and re-exploration for bleeding in 10 patients (6.6%). Mean length of stay for the entire cohort was 5 ± 5.4 days. Conclusions: Robotic mitral valve surgery can be extended to patients with previous sternotomy with satisfactory efficacy and low operative mortality and morbidity.

Reoperative Mitral Valve Surgery Through Port Access

Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR < 60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature.

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

BACKGROUND

Although the incidence of mitral valve (MV) surgery after previous open-heart surgery is increasing, there is no consensus regarding the optimal surgical approach. Reoperative MV surgery is most commonly performed via sternotomy (ST). We sought to determine whether minimally-invasive (MIS) reoperative MV surgery is safe and feasible.

METHODS

All patients with a history of ST undergoing MV surgery with or without concomitant tricuspid or atrial fibrillation surgery at a single institution from 2007 to 2018 were retrospectively reviewed. ST and MIS approaches were compared using propensity-matched analysis. The coprimary endpoints were operative mortality and 1-year survival, and secondary endpoints were operative complications and length of stay.

RESULTS

A total of 305 isolated MV reoperations were performed: 199 (65%) MIS and 106 (35%) ST. MIS patients were older than ST patients (71 [63, 76.5] vs. 66 [56, 72] years, p < .01), more likely to have undergone prior coronary artery bypass grafting (57% vs. 27%, p < .01), and less likely to have had prior valve surgery (55% vs. 78%, p < .01). In unmatched comparisons, operative mortality was significantly lower among MIS patients (3.0% vs. 8.5%, p = .04), but 1-year mortality was similar (14.4% vs. 15.6%, p = .8). After propensity matching, 88 pairs had excellent balance across baseline characteristics. Mortality was similar among MIS and ST patients at 30 days (3.4% vs. 8%, p = .19) and 1 year (15.9% vs. 16.5%, p = .9). RBC and fresh frozen plasma transfusions were significantly lower in the MIS group (p < .01).

CONCLUSIONS

A minimally invasive approach is a safe alternative in patients with prior ST undergoing MV surgery.

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

OBJECTIVE

Redo mitral valve surgery has traditionally been performed via a median sternotomy. It is often challenging and is associated with increased perioperative mortality. Advances in cardiac surgical techniques over the last two decades have led to an increase in the use of a minimally invasive approach via a right anterolateral mini-thoracotomy as opposed to a repeat median sternotomy. However, despite these advances, there is no general consensus on the best form of entry, and as of yet, there are no randomized controlled trials. We performed a meta-analysis of observational studies to aid in determining the best approach for redo mitral valve surgery.

METHOD

The MEDLINE and EMBASE databases were conducted up until 1 June 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random effects modelling and the I²-test for heterogeneity. Seven retrospective observational studies were included, enrolling a total of 1070 patients.

RESULTS

There were a total of 1070 patients. Of these 364 had non-sternotomy approach compared with 707 patients who had median sternotomy. Further subgroup analysis revealed that 327 of the 364 patients had a mini-thoracotomy approach while the remaining 37 patients had a full thoracotomy approach. In-hospital mortality and length of stay were less in non-sternotomy group compared to median sternotomy group. There were no differences in stroke, CPB time and wound infections between the two groups.

CONCLUSION

Redo mitral valve surgery can be performed safely with satisfactory outcomes via a mini-thoracotomy approach. This meta-analysis shows comparable results with reduced in-hospital mortality and hospital length of stay with a mini-thoracotomy approach.

Excellent long-term results with minimally invasive edge-to-edge repair in myxomatous degenerative mitral valve regurgitation

OBJECTIVES

Previous series of minimally invasive mitral valve repairs showed excellent results at up to 10 years of follow-up. The goal of this study was to assess the long-term durability beyond 10 years of the edge-to-edge repair for myxomatous degeneration performed through a minimally invasive approach.

METHODS

Ninety-seven consecutive patients (mean age 35 ± 9 years; left ventricular ejection fraction 63 ± 6%) with severe myxomatous mitral regurgitation (MR) underwent mitral valve repair through a right minithoracotomy between 1999 and 2006. MR was due to lesions involving the posterior leaflet (7.2% of patients), anterior leaflet (12.4%) and both leaflets (80.4%).

RESULTS

No hospital deaths occurred. At hospital discharge all patients had no or trivial MR. Follow-up was 100% complete (median 15.5 years; interquartile range 13.6-17.0, max 19.3 years). The 16-year overall survival rate was 95.9 ± 2.02% [95% confidence interval (CI) 89.39-98.43]. At 16 years, the cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 3.1 ± 1.75 (95% CI 0.83-8.02). Only 3 patients (4.1%) had redo operations for recurrent severe MR. At 16 years, the cumulative incidence functions of reoperation for and recurrence of MR ≥3+, with death as a competing risk, were 3.1 ± 1.76% (95% CI 0.83-8.02) and 5.6 ± 2.47% (95% CI 2.06-11.83), respectively. No predictors of recurrence of MR ≥3+ were identified. At the last follow-up, moderate MR (2+/4+) was detected in 17 patients (17.5%); most of the patients were in New York Heart Association functional class I-II (97%) and in sinus rhythm (90%).

CONCLUSIONS

Minimally invasive mitral valve edge-to-edge repair through a right minithoracotomy for myxomatous degeneration appears to be an effective and durable approach even in the long-term follow-up (up to 19 years).

Minimally invasive beating heart technique for mitral valve surgery in patients with previous sternotomy and giant left ventricle

PURPOSE

To analyze the efficacy of minimally invasive beating heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle.

METHODS

Eighty cardiac patients with previous sternotomy and giant left ventricle according to the diagnostic criteria that left ventricular end diastolic diameter (LVEDD) was ≥70 mm, who underwent mitral valve surgery at our center from January 2006 to January 2019 were analyzed. We divided all patients into minimally invasive beating heart technique group (n = 30) and conventional median resternotomy arrested heart technique group (n = 50) according to the surgical methods. Preoperative, intraoperative, and postoperative variables were compared between two groups.

RESULTS

Minimally invasive beating heart technique compared to the conventional median resternotomy arrested heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle had significant differences in operation time(P = 0.002), cardiopulmonary bypass (CPB) time(P < 0.001), intraoperative blood loss(P < 0.001), postoperative transfusion ratio(P = 0.01), postoperative transfusion amount(P < 0.001), postoperative drainage volume(P = 0.001), extubation time(P = 0.04), intensive care unit (ICU) stay time(P = 0.04) and postoperative hospital stay time(P < 0.001), but no significant differences in re-exploration for bleeding, postoperative 30-day mortality, postoperative complications and 6 months postoperative echocardiographic parameters.

CONCLUSIONS

Using the method of minimally invasive beating heart technique for mitral valve surgery in the cardiac patients with previous sternotomy and giant left ventricle is effective and reliable, meanwhile reduce the operation time and CPB time, decrease the transfusion ratio and transfusion amount, shorten postoperative ICU stay and hospital stay time, promote the early extubation so that accelerate the patients' early recovery. All of these show a benefit of minimally invasive beating heart technique compared to conventional median resternotomy arrested heart technique.

Minimally Invasive Redo Mitral Valve Replacement under Fibrillatory Arrest in a Patient with a Calcified Aorta and Patent Previous Bypass Grafts

A 73-year-old woman who underwent combined bioprosthetic mitral valve replacement, tricuspid ring annuloplasty, and coronary artery bypass grafting 12 years previously visited our clinic due to aggravated dyspnea caused by structural valve deterioration of the mitral prosthesis. Because aortic or femoral artery cannulation and cross-clamping would have a high risk of stroke owing to severe calcification of the ascending aorta and ilio-femoral vessels, and because there was a risk of redo sternotomy due to the patent bypass grafts, a comprehensive approach including axillary artery cannulation, a minimally invasive right thoracotomy approach, and a clampless hypothermic fibrillatory arrest technique was used during redo mitral valve replacement.

Is minimally invasive thoracoscopic surgery the new benchmark for treating mitral valve disease?

The treatment of mitral valve disease remains dynamic; surgeons and patients must now choose between many different surgical options when addressing mitral regurgitation and mitral stenosis. Notably, advances in imaging and surgical instrumentation allow surgeons to perform less invasive mitral valve surgery that spares the sternum. With favorable long-term data now emerging, we compare the benefits and risks of thoracoscopic mitral valve surgery with that through conventional sternotomy or surgery that is robot-assisted.