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Papadopoulos N, Ntinopoulos V, Dushaj S, Häussler A, Odavic D, Biefer HRC, Dzemali O. Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation. J Cardiothorac Surg 2024; 19:24. [PMID: 38263168 PMCID: PMC10807125 DOI: 10.1186/s13019-024-02479-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND This study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution. METHODS From January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment. RESULTS Overall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61-11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81-7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65-100 procedures. CONCLUSIONS Mitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve. TRIAL REGISTRATION The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).
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Affiliation(s)
- Nestoras Papadopoulos
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland.
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland.
| | - Vasileios Ntinopoulos
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Stak Dushaj
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Achim Häussler
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Dragan Odavic
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Hector Rodríguez Cetina Biefer
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
- Department of Cardiology, Center of Experimental and Translational Cardiology (CTEC), University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, City Hospital, Birmensdorferstrasse 497, 8063, Zurich, Switzerland
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
- Department of Cardiology, Center of Experimental and Translational Cardiology (CTEC), University Hospital of Zurich, University of Zurich, Zurich, Switzerland
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2
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Shu Y, Zheng Y, He S, Du Y, Zhu D, Shi Z. Attaining competency and proficiency in minimally invasive mitral valve repair: a learning curve assessment using cumulative sum analysis. J Cardiothorac Surg 2023; 18:2. [PMID: 36604696 PMCID: PMC9814195 DOI: 10.1186/s13019-023-02106-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To evaluate the learning curve of minimally invasive mitral valvuloplasty (MVP). BACKGROUND Minimally invasive MVP is characterized by minimal trauma, minimal bleeding, and short postoperative recovery time. The learning curve of any new procedure needs to be evaluated for learning and replication. However, minimally invasive mitral valve technique is a wide-ranging concept, no further analysis of the outcomes and learning curve of minimally invasive Mitral valvuloplasty has been performed. METHODS One hundred and fifty consecutive patients who underwent minimally invasive MVP alone without concurrent surgery were evaluated. Using cardiopulmonary bypass (CPB) time and aortic clamping (AC) time as evaluation variables, we visualized the learning curve for minimally invasive MVP using cumulative sum analysis. We also analyzed important postoperative variables such as postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay. RESULTS The slope of the fitted curve was negative after 75 procedures, and the learning curve could be crossed after the completion of the 75th procedure when AC and CPB time were used as evaluation variables. And as the number of surgical cases increased, CPB, AC, postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay all showed different degrees of decrease. The incidence of postoperative adverse events is similar to conventional Mitral valvuloplasty. CONCLUSION Compared to conventional MVP, minimally invasive MVP provides the same satisfactory surgical results and stabilization can be achieved gradually after completion of the 75th procedure.
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Affiliation(s)
- Yue Shu
- Department of Special Medical Services, Hainan ChengMei Hospital, Haikou, Hainan People’s Republic of China ,Department of Special Medical Services, Hainan Cancer Hospital, Haikou, Hainan People’s Republic of China
| | - Yin Zheng
- Department of Special Medical Services, Hainan ChengMei Hospital, Haikou, Hainan People’s Republic of China ,Department of Special Medical Services, Hainan Cancer Hospital, Haikou, Hainan People’s Republic of China
| | - Shuwu He
- grid.443397.e0000 0004 0368 7493Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, 570311 Hainan People’s Republic of China
| | - Yiping Du
- Department of Special Medical Services, Hainan ChengMei Hospital, Haikou, Hainan People’s Republic of China ,Department of Special Medical Services, Hainan Cancer Hospital, Haikou, Hainan People’s Republic of China
| | - Dan Zhu
- Department of Special Medical Services, Hainan ChengMei Hospital, Haikou, Hainan People’s Republic of China ,Department of Special Medical Services, Hainan Cancer Hospital, Haikou, Hainan People’s Republic of China
| | - Zhensu Shi
- grid.443397.e0000 0004 0368 7493Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, 570311 Hainan People’s Republic of China ,grid.415105.40000 0004 9430 5605Department of Cardiovascular Surgery, Fuwai Hospital, Beijing, People’s Republic of China
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Hashim SW, McMahon SR, Vaitkeviciute IK, Collazo S, Hashim IM, Loya DS, Takata ET, Mather JF, McKay RG. Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:724-733. [PMID: 36106398 DOI: 10.23736/s0021-9509.22.12397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. METHODS We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. RESULTS Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. CONCLUSIONS In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.
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Affiliation(s)
- Sabet W Hashim
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Irena K Vaitkeviciute
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Susan Collazo
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA -
| | - Jeff F Mather
- Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
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Shim JE, Kim MK, Kim YH, Kim SC. Effect of Quality Control Program in Surgical Management of Early Cervical Cancer. J Korean Med Sci 2021; 36:e316. [PMID: 34811979 PMCID: PMC8608925 DOI: 10.3346/jkms.2021.36.e316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/28/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Regular assessments of clinical performance in gynecologic cancer surgery is important for the safety of patients. We evaluated the effects of quality control (QC) program on the treatment pattern and clinical outcomes of early cervical cancer. METHODS Medical records of cervical cancer patients who received operation in our institution from January 2007 to December 2018 were retrospectively reviewed. Cases were divided into 2 groups, before and after the initiation of QC program, group 1 (2007-2013) and group 2 (2014-2018), based on the operation date. Two groups were compared in clinicopathologic variables, surgical methods, operative details, adjuvant treatments, recurrence and survival. RESULTS A total of 305 cervical cancer patients were included in the analysis, 210 in group 1 and 95 in group 2. In group 2, minimally invasive surgery (MIS) was more frequently performed (60.0% vs. 76.8%, P = 0.004), especially in earlier stages (stage IA, 72.6% vs. 100.0%; stage IB, 52.2% vs. 69.5%). However, the median tumor size treated by MIS was decreased in stage IB (20 mm vs. 17 mm, P = 0.015). Frequency of adjuvant treatment was also reduced in stage IB (56.5% vs. 37.3%, P = 0.016). Recurrence within 3 years, 3-year disease free survival and overall survival did not show significant difference; however, 3-year recurrence after MIS was significantly reduced in stage IB. CONCLUSION QC program enforced stricter patient selection criteria for MIS and positively affected clinical outcomes in cervical cancer patients who underwent surgery. Systemic monitoring should be considered for patient safety.
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Affiliation(s)
- Ji Eun Shim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Mi-Kyung Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Yun Hwan Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Seung Cheol Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
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Objective measure of learning curves for trainees in cardiac surgery via cumulative sum failure analysis. J Thorac Cardiovasc Surg 2020; 160:460-466.e1. [DOI: 10.1016/j.jtcvs.2019.09.147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/07/2019] [Accepted: 09/25/2019] [Indexed: 11/24/2022]
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Glauber M, Di Bacco L, Cuenca J, Di Bartolomeo R, Baghai M, Zakova D, Fischlein T, Troise G, Viganò G, Solinas M. Minimally Invasive Aortic Valve Replacement with Sutureless Valves: Results From an International Prospective Registry. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 15:120-130. [DOI: 10.1177/1556984519892585] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry. Methods Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy ( n = 266) or ministernotomy ( n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients. Results Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%. Conclusions In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up.
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Affiliation(s)
| | | | - Jose Cuenca
- CHUAC - Complexo Hospital Universitario, A Coruña, Coruna, Spain
| | | | | | | | - Theodor Fischlein
- Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
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7
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The learning curve of minimally invasive aortic valve replacement for aortic valve stenosis. Gen Thorac Cardiovasc Surg 2019; 68:565-570. [DOI: 10.1007/s11748-019-01234-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/15/2019] [Indexed: 01/19/2023]
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8
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Wu X, Wei W, He Y, Qin H, Qi F. Analysis of the Learning Curve in Mitral Valve Replacement Through the Right Anterolateral Minithoracotomy Approach: A Surgeon’s Experience with the First 100 Patients. Heart Lung Circ 2019; 28:471-476. [DOI: 10.1016/j.hlc.2018.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 02/05/2018] [Indexed: 11/29/2022]
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9
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Kamiya H, Kitahara H, Kanda H, Ise H, Nakanishi S, Ishikawa N, Kunisawa T, Minol JP, Lichtenberg A, Akhyari P. Transfer of a minimally invasive mitral valve repair program from a high-volume center to a very low volume center: how many cases are necessary to maintain acceptable results? Gen Thorac Cardiovasc Surg 2019; 67:577-584. [PMID: 30659508 DOI: 10.1007/s11748-019-01065-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 01/07/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. METHODS Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. RESULTS In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6 months and 1 year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30 days and within the first year. CONCLUSIONS The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.
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Affiliation(s)
- Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan.
| | - Hiroto Kitahara
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Hayato Ise
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Sentaro Nakanishi
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Takayuki Kunisawa
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Jan-Philipp Minol
- Department of Cardiovascular Surgery, Duesseldorf University, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Duesseldorf University, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery, Duesseldorf University, Moorenstrasse 5, 40225, Duesseldorf, Germany
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Colli A, Adams D, Fiocco A, Pradegan N, Longinotti L, Nadali M, Pandis D, Gerosa G. Transapical NeoChord mitral valve repair. Ann Cardiothorac Surg 2018; 7:812-820. [PMID: 30598897 DOI: 10.21037/acs.2018.11.04] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transapical off-pump mitral valve repair (MVr) with NeoChord implantation has become widely applied in Europe for patients presenting with severe mitral regurgitation due to leaflet prolapse or flail. The procedure is performed under real-time 2D- and 3D-transesophageal echocardiography (TEE) for both implantation and neochordae tension adjustment allowing real-time monitoring of hemodynamic recovery. Preoperative anatomic and echocardiographic selection criteria, procedure refinement, as well as innovative ex-vivo surgical simulator training have been developed and strategically employed in the past few years, to generate a robust precision-based procedural framework with significantly enhanced operator use, patient safety and clinical outcomes. The procedure has evolved into a reproducibly successful and safe approach, which complements existing surgical treatment strategies available to eligible patients with chronic severe degenerative mitral regurgitation.
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Affiliation(s)
- Andrea Colli
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - David Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alessandro Fiocco
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Nicola Pradegan
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Lorenzo Longinotti
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Matteo Nadali
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Dimosthenis Pandis
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gino Gerosa
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Sakaguchi T, Totsugawa T, Kuinose M, Tamura K, Hiraoka A, Chikazawa G, Yoshitaka H. Minimally Invasive Mitral Valve Repair Through Right Minithoracotomy ― 11-Year Single Institute Experience ―. Circ J 2018; 82:1705-1711. [DOI: 10.1253/circj.cj-17-1319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Masahiko Kuinose
- Department of Cardiovascular Surgery, Kawasaki Medical School General Medical Center
| | - Kentaro Tamura
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama
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Colli A, Bagozzi L, Banchelli F, Besola L, Bizzotto E, Pradegan N, Fiocco A, Manzan E, Zucchetta F, Bellu R, Pittarello D, Gerosa G. Learning curve analysis of transapical NeoChord mitral valve repair†. Eur J Cardiothorac Surg 2018; 54:273-280. [DOI: 10.1093/ejcts/ezy046] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/19/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andrea Colli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Lorenzo Bagozzi
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Federico Banchelli
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Laura Besola
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Eleonora Bizzotto
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Nicola Pradegan
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alessandro Fiocco
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Erica Manzan
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Fabio Zucchetta
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Roberto Bellu
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
- Cardiology Unit, Policlinico di Abano Terme, Abano Terme, Italy
| | - Demetrio Pittarello
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Murzi M, Cerillo AG, Gasbarri T, Margaryan R, Kallushi E, Farneti P, Solinas M. Antegrade and retrograde perfusion in minimally invasive mitral valve surgery with transthoracic aortic clamping: a single-institution experience with 1632 patients over 12 years. Interact Cardiovasc Thorac Surg 2017; 24:363-368. [PMID: 28040754 DOI: 10.1093/icvts/ivw370] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/19/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives The aim of the present study was to evaluate the impact of a retrograde arterial perfusion (RAP) strategy versus an antegrade arterial perfusion (AAP) strategy in a consecutive, large cohort of patients who underwent minimally invasive mitral valve surgery with transthoracic aortic clamping through a right minithoracotomy. Methods Between 2003 and 2015, 1632 consecutive patients underwent first-time minimally invasive mitral valve surgery with transthoracic aortic clamping at our institution; 141 (8.6%) of these patients received retrograde perfusion with femoral artery cannulation, whereas 1421 (91.4%) received antegrade perfusion with ascending aorta cannulation. Logistic regression was used to evaluate outcomes and risk factors for death and stroke between groups. Results The overall frequency of 30-day mortality was 0.7% (13/1632) and was similar between groups (retrograde arterial perfusion RAP 0.7% vs AAP 0.8%; P = 0.903). The overall postoperative stroke rate was 1.3% (22/1632). The stroke rate was significantly higher in patients receiving retrograde perfusion (3.5% vs 1.1%; P = 0.005). Risk factors for death were advanced age (odds ratio (OR) = 1.3; P = 0.004), mitral valve replacement (OR = 3.9; P = 0.05), emergent procedure (OR = 3.4; P = 0.014) and conversion to sternotomy (OR = 3.7; P = 0.001). Multivariable regression analysis revealed that retrograde perfusion was an independent risk factor for stroke (OR = 3.3; P = 0.004). Other risk factors were conversion to sternotomy (OR = 12; P = 0.001), active endocarditis (OR = 5.8; P = 0.07) and hypercholesterolaemia (OR = 2.4; P = 0.048). Interaction modelling revealed that the only significant risk factor for a neurological event was the use of retrograde perfusion in patients older than 70 years with an atherosclerotic burden (OR = 6.4; P = 0.033). Conclusions Minimally invasive mitral valve procedures can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications in older patients with atherosclerotic burden. Central aortic cannulation permits avoidance of complications associated with retrograde perfusion and extends the suitability of minimally invasive mitral procedures to those patients who have an absolute contraindication for femoral artery cannulation.
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Affiliation(s)
- Michele Murzi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Alfredo G Cerillo
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Tommaso Gasbarri
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Rafik Margaryan
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Enkel Kallushi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Pierandrea Farneti
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
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Sakaguchi T. Minimally invasive mitral valve surgery through a right mini-thoracotomy. Gen Thorac Cardiovasc Surg 2016; 64:699-706. [PMID: 27638268 DOI: 10.1007/s11748-016-0713-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/09/2016] [Indexed: 11/29/2022]
Abstract
Since its introduction in the mid-1990s, minimally invasive mitral valve surgery (MIMVS) has been shown to be a feasible alternative to a conventional full-sternotomy approach, and several studies have reported excellent clinical outcomes with low perioperative morbidity and mortality. As a result, MIMVS is being increasingly employed as a routine procedure worldwide. On the other hand, several issues have been raised, including complications specific to this technique and its steep learning curve, while there are also concerns regarding the durability of a mitral valve repair through a limited access. In this study, the current status and future perspectives of MIMVS were examined.
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Affiliation(s)
- Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakai-cho, Kita-ku, Okayama, Okayama, 700-0804, Japan.
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Murzi M, Cerillo AG, Gilmanov D, Concistrè G, Farneti P, Glauber M, Solinas M. Exploring the learning curve for minimally invasive sutureless aortic valve replacement. J Thorac Cardiovasc Surg 2016; 152:1537-1546.e1. [PMID: 27262361 DOI: 10.1016/j.jtcvs.2016.04.094] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 03/29/2016] [Accepted: 04/28/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The study objective was to assess the learning process and quality of care of right minithoracotomy aortic valve replacement with a sutureless bioprosthesis at a single institution. METHODS We performed an analysis of the first 300 consecutive patients (aged 76 ± 6 years; logistic European System for Cardiac Operative Risk Evaluation 9 ± 6) who underwent sutureless valve implantation via a right minithoracotomy by 6 surgeons at the G. Pasquinucci Heart Hospital between 2011 and 2015. The learning curve was analyzed by dividing the study population into tertiles of 100 patients each. Departmental and individual learning curves were calculated using sequential probability cumulative sum failure analysis. Quality indicators were 2 composite end points reflecting the technical success and 30-day complications. RESULTS The overall mortality was 0.7% (2 patients). No significant differences were noted in terms of mortality and complications between tertiles. The sutureless valve was implanted successfully in 99% of patients (298/300). Cumulative sum analysis failed to identify any significant learning effects for technical success. Nevertheless, surgeons A, B, and C had a small initial learning curve, and surgeons D, E, and F did not, reflecting a trend toward a positive effect of cumulative institutional experience on the individual learning curve. The 30-day complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients' selection process. Consecutively, the procedure returned in control. CONCLUSIONS Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cumulative sum analysis is a valuable tool to describe and monitor the learning process. The analysis can identify periods of less than expected performance and alert the team to react.
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Affiliation(s)
- Michele Murzi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
| | | | - Danyar Gilmanov
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Giovanni Concistrè
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Pierandrea Farneti
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Mattia Glauber
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
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Alternative peripheral perfusion strategies for safe cardiopulmonary bypass in atrial septal defect closure via a right minithoracotomy approach. Gen Thorac Cardiovasc Surg 2015; 64:131-7. [DOI: 10.1007/s11748-015-0611-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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17
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Glauber M, Miceli A, Canarutto D, Lio A, Murzi M, Gilmanov D, Ferrarini M, Farneti PA, Quaini EL, Solinas M. Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients. J Cardiothorac Surg 2015; 10:181. [PMID: 26643038 PMCID: PMC4672482 DOI: 10.1186/s13019-015-0390-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 11/23/2015] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Mattia Glauber
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Antonio Miceli
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Daniele Canarutto
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Antonio Lio
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Michele Murzi
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Daniyar Gilmanov
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Matteo Ferrarini
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Pier A Farneti
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Eugenio L Quaini
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
| | - Marco Solinas
- Cardiothoracic department, Fondazione Toscana G. Monasterio, Via Aurelia Sud, Massa, Italy.
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Hassan M, Miao Y, Lincoln J, Ricci M. Cost-Benefit Analysis of Robotic versus Nonrobotic Minimally Invasive Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mohammed Hassan
- Division of Cardiothoracic Surgery, Department of Surgery, University of New Mexico, Albuquerque, NM USA
| | - Yongjie Miao
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital Research Institute, Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Joy Lincoln
- Center for Cardiovascular and Pulmonary Research, Nationwide Children's Hospital Research Institute, Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Marco Ricci
- Division of Cardiothoracic Surgery, Department of Surgery, University of New Mexico, Albuquerque, NM USA
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Cost-Benefit Analysis of Robotic versus Nonrobotic Minimally Invasive Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:90-5. [DOI: 10.1097/imi.0000000000000136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective To date, a direct comparison of minimally invasive mitral valve repair or replacement (mini-MVR) versus robotic MVR is lacking; therefore, the purpose of this study was to address this deficit and compare mini-MVR with robotic MVR from a cost-benefit perspective. Methods From a total of 759 literature citations, 21 studies were included for statistical comparisons of benefit outcomes, whereas 3 studies and our institutional experience were used to compare costs. Results The total cost per case exceeding that of conventional MVR is approximately $2063.90 for robotic MVR and $271 for mini-MVR. Mean 30-day mortality rates for mini-MVR and robotic MVR groups were 1.24% and 0.55%, respectively [106/8548 vs 6/1089; odds ratio (OR), 2.27; P = 0.052]. The conversion rate to conventional MVR was 0.77% in mini-MVR and 1.83% in robotic MVR (35/5092 vs 22/1046; OR, 0.32; P < 0.001). The rate of neurologic events was 1.32% in mini-MVR and 2.37% in robotic MVR (109/8257 vs 20/845; OR, 0.55; P = 0.02). Postoperative atrial fibrillation was seen in 11.42% of mini-MVR patients and in 19.67% of robotic MVR patients (371/3249 vs 203/1032; OR, 0.53, P < 0.001). Mean cardiopulmonary bypass time was longer in mini-MVR (137.4 vs 130.4 minutes), whereas cross-clamp time was shorter (82.2 vs 96.7 minutes). Conclusions Our comparative analysis provides insights into the clinical benefits versus variable costs relationship related to mini-MVR and robotic MVR.
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20
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Mazine A, Vistarini N, Ghoneim A, Lebon JS, Demers P, Jeanmart H, Pellerin M, Bouchard D. Very high repair rate using minimally invasive surgery for the treatment of degenerative mitral insufficiency. Can J Cardiol 2015; 31:744-51. [PMID: 25913471 DOI: 10.1016/j.cjca.2014.12.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/14/2014] [Accepted: 12/05/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Minimally invasive mitral valve surgery (MIMVS) is an established alternative to median sternotomy for mitral valve repair. However, this technique has yet to gain widespread adoption, partly because of concerns that this approach might yield lower repair rates or repairs that are less durable than those performed through a sternotomy. The purpose of this study was to report our inaugural experience with MIMVS, with a focus on mitral valve repair rate and midterm outcomes. METHODS Between May 2006 and April 2012, minimally invasive mitral valve repair was attempted in 200 consecutive patients with degenerative mitral disease. The approach used was a 4- to 5-cm right anterolateral minithoracotomy with femorofemoral cannulation for cardiopulmonary bypass. Mean follow-up was 2.9 ± 1.8 years, and follow-up was 99% complete. RESULTS The mitral valve was successfully repaired in all but 2 patients, yielding a repair rate of 99%. Hospital mortality occurred in 2 patients (1%). Intraoperative conversion to sternotomy was necessary in 12 patients (6%), including 1 of the 2 unsuccessful repairs. Mean cardiopulmonary bypass and aortic cross-clamp times were 130.8 ± 41.3 minutes and 104.8 ± 35.6 minutes, respectively. Median hospital stay was 5 days. The 5-year survival and freedom from reoperation were 97.9% ± 1.5% and 98.1% ± 1.3%, respectively. CONCLUSIONS A very high repair rate can be achieved using MIMVS for the treatment of degenerative mitral regurgitation, including during the learning phase. Midterm survival and freedom from valve-related reoperation are excellent. MIMVS is a safe and effective alternative to mitral valve repair through a sternotomy.
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Affiliation(s)
- Amine Mazine
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada
| | - Nicola Vistarini
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada; Department of Cardiac Surgery, Pavia University School of Medicine, Pavia, Italy
| | - Aly Ghoneim
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada
| | - Jean-Sébastien Lebon
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Anesthesiology, Montreal Heart Institute, Montreal, Québec, Canada
| | - Philippe Demers
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada
| | - Hugues Jeanmart
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada
| | - Michel Pellerin
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada
| | - Denis Bouchard
- Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Québec, Canada.
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Murzi M, Miceli A, Di Stefano G, Cerillo AG, Farneti P, Solinas M, Glauber M. Minimally invasive right thoracotomy approach for mitral valve surgery in patients with previous sternotomy: A single institution experience with 173 patients. J Thorac Cardiovasc Surg 2014; 148:2763-8. [DOI: 10.1016/j.jtcvs.2014.07.108] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/26/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022]
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Murzi M, Miceli A, Cerillo AG, Di Stefano G, Kallushi E, Farneti P, Solinas M, Glauber M. Training surgeons in minimally invasive mitral valve repair: a single institution experience. Ann Thorac Surg 2014; 98:884-9. [PMID: 25087930 DOI: 10.1016/j.athoracsur.2014.05.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND We aimed to study the results of minimally invasive mitral valve repair performed by 5 young surgeons who were trained in mitral valve repair directly through a minimally invasive approach, and a senior surgeon who introduced the technique at our institution and was responsible for the training program. METHODS This was a retrospective, observational cohort study of prospectively collected data from 595 consecutive patients who underwent minimally invasive mitral repair performed by 5 trainees (n = 240, 40.3%) and by our lead consultant (n = 355, 59.7%) between 2007 and 2013. Treatment selection bias was controlled by constructing a propensity score from core patient characteristics and it was included along with the comparison variable in the multivariable analyses of outcome. RESULTS Patients operated on by trainees were more likely to be female (p = 0.04), older (p = 0.001), and with history of atrial fibrillation (p = 0.001). Trainees required a significant longer cardiopulmonary bypass (137 ± 56 vs 123 ± 52 minutes; p = 0.003) and aortic clamp time (97 ± 41 vs 83 ± 40 minutes; p = 0.001). I-hospital mortalities were 1.3% in the trainees group and 0.8% in the senior surgeon group (p = 0.6). The incidence of stroke (1.7% vs 2.5%; p = 0.5), conversion to sternotomy (2.6% vs 3.5%; p = 0.5), and conversion to mitral valve replacement (12.5% vs 10.9%; p = 0.6) were similar between groups. No differences were found regarding other complications. Five-year survival (88.9% vs 89.5%; p = 0.4) and freedom from reoperation (94.5% vs 95.1; p = 0.6) were similar between groups. CONCLUSIONS Minimally invasive mitral valve repair is a safe and reproducible surgical technique that can be taught successfully to cardiac trainees.
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Affiliation(s)
- Michele Murzi
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Antonio Miceli
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Alfredo G Cerillo
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Gioia Di Stefano
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Enkel Kallushi
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Pierandrea Farneti
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy
| | - Mattia Glauber
- Fondazione Toscana G. Monasterio, "G. Pasquinucci" Heart Hospital, Massa, Italy.
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Usluer O, Kaya SO. Endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymphadenopathy: effect of the learning curve. Interact Cardiovasc Thorac Surg 2014; 19:693-5. [DOI: 10.1093/icvts/ivu235] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Murzi M, Miceli A, Di Stefano G, Cerillo AG, Kallushi E, Farneti P, Solinas M, Glauber M. Enhancing quality control and performance monitoring in thoracic aortic surgery: a 10-year single institutional experience. Eur J Cardiothorac Surg 2014; 47:608-15. [PMID: 24948415 DOI: 10.1093/ejcts/ezu249] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of the present study was to monitor performance and learning effects for thoracic aortic surgery. In addition, we evaluated the volume-outcome relationship of patients undergoing surgery of the thoracic aorta, comparing the results of two higher-volume surgeons (HVSs) with six lower volume surgeons. METHODS A total of 867 thoracic aortic procedures (elective cases n = 753 and Type A acute dissection n = 114) were performed from 2003 to 2013 by eight surgeons (range 28-238 procedures) at our institution. Departmental and individual performance was monitored using control charts, with a predetermined acceptable failure rate of 10%. Perioperative death or one or more of four adverse events constituted failure. Moreover, results of two higher-volume operators (n = 460; 53%) were compared with those of six lower-volume operators (n = 407; 47%). RESULTS The incidence rate of in-hospital mortality for elective cases was 2% and for Type A dissection repair 9.6%. Institutional control charts revealed that the surgical process was under control for all the study periods apart from small periods of worse than expected performance which were congruent with new surgeons joining the programme. The predominant surgical failure was reoperation for bleeding. There were differences between surgeons with regard to the learning curves and performance. No significant differences were observed between high- and low-volume surgeons in terms of mortality and morbidity for elective cases. However, high-volume surgeons presented a trend suggesting a higher mortality rate in Type A aortic dissection repair (17.1 vs 6.3%; P = 0.09). CONCLUSIONS Thoracic aortic surgery can be performed with similar results by high- and low-volume surgeon. Control charts can facilitate learning effects and performance monitoring. Implementation of continuous departmental and individual performance monitoring is practicable.
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Affiliation(s)
- Michele Murzi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Antonio Miceli
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Gioia Di Stefano
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Alfredo G Cerillo
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Enkel Kallushi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Pierandrea Farneti
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Mattia Glauber
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
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Sood A, Ghani KR, Ahlawat R, Modi P, Abaza R, Jeong W, Sammon JD, Diaz M, Kher V, Menon M, Bhandari M. Application of the statistical process control method for prospective patient safety monitoring during the learning phase: robotic kidney transplantation with regional hypothermia (IDEAL phase 2a-b). Eur Urol 2014; 66:371-8. [PMID: 24631408 DOI: 10.1016/j.eururo.2014.02.055] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 02/24/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Traditional evaluation of the learning curve (LC) of an operation has been retrospective. Furthermore, LC analysis does not permit patient safety monitoring. OBJECTIVES To prospectively monitor patient safety during the learning phase of robotic kidney transplantation (RKT) and determine when it could be considered learned using the techniques of statistical process control (SPC). DESIGN, SETTING AND PARTICIPANTS From January through May 2013, 41 patients with end-stage renal disease underwent RKT with regional hypothermia at one of two tertiary referral centers adopting RKT. Transplant recipients were classified into three groups based on the robotic training and kidney transplant experience of the surgeons: group 1, robot trained with limited kidney transplant experience (n=7); group 2, robot trained and kidney transplant experienced (n=20); and group 3, kidney transplant experienced with limited robot training (n=14). INTERVENTION We employed prospective monitoring using SPC techniques, including cumulative summation (CUSUM) and Shewhart control charts, to perform LC analysis and patient safety monitoring, respectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcomes assessed included post-transplant graft function and measures of surgical process (anastomotic and ischemic times). CUSUM and Shewhart control charts are time trend analytic techniques that allow comparative assessment of outcomes following a new intervention (RKT) relative to those achieved with established techniques (open kidney transplant; target value) in a prospective fashion. RESULTS AND LIMITATIONS CUSUM analysis revealed an initial learning phase for group 3, whereas groups 1 and 2 had no to minimal learning time. The learning phase for group 3 varied depending on the parameter assessed. Shewhart control charts demonstrated no compromise in functional outcomes for groups 1 and 2. Graft function was compromised in one patient in group 3 (p<0.05) secondary to reasons unrelated to RKT. In multivariable analysis, robot training was significantly associated with improved task-completion times (p<0.01). Graft function was not adversely affected by either the lack of robotic training (p=0.22) or kidney transplant experience (p=0.72). CONCLUSIONS The LC and patient safety of a new surgical technique can be assessed prospectively using CUSUM and Shewhart control chart analytic techniques. These methods allow determination of the duration of mentorship and identification of adverse events in a timely manner. A new operation can be considered learned when outcomes achieved with the new intervention are at par with outcomes following established techniques. PATIENT SUMMARY Statistical process control techniques allowed for robust, objective, and prospective monitoring of robotic kidney transplantation and can similarly be applied to other new interventions during the introduction and adoption phase.
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Affiliation(s)
- Akshay Sood
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
| | - Khurshid R Ghani
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Rajesh Ahlawat
- Kidney and Urology Institute, Medanta-The Medicity, Gurgaon, India
| | - Pranjal Modi
- Department of Urology, H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Ronney Abaza
- Department of Urology, Ohio State University, Columbus, OH, USA
| | - Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Jesse D Sammon
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Mireya Diaz
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Vijay Kher
- Kidney and Urology Institute, Medanta-The Medicity, Gurgaon, India
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
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Glauber M, Murzi M, Solinas M. Central aortic cannulation for minimally invasive mitral valve surgery through right minithoracotomy. Ann Cardiothorac Surg 2013; 2:839-40. [PMID: 24349992 DOI: 10.3978/j.issn.2225-319x.2013.11.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 11/04/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Mattia Glauber
- Fondazione Toscana Gabriele Monasterio, Ospedale del Cuore, Massa, Italy
| | - Michele Murzi
- Fondazione Toscana Gabriele Monasterio, Ospedale del Cuore, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana Gabriele Monasterio, Ospedale del Cuore, Massa, Italy
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Perier P, Hohenberger W, Lakew F, Batz G, Diegeler A. Rate of repair in minimally invasive mitral valve surgery. Ann Cardiothorac Surg 2013; 2:751-7. [PMID: 24349977 DOI: 10.3978/j.issn.2225-319x.2013.10.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 10/25/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND Valve repair has been shown to be the method of choice in the treatment of patients with severe mitral valve regurgitation. Minimally invasive surgery has raised skepticism regarding the rate of repair especially for supposedly complex lesions, when anterior leaflet involvement or bileaflet prolapse is present. We sought to review our experience of all our patients presenting with degenerative mitral valve regurgitation and operated on minimally invasively. METHOD From September 2006 to December 2012, 842 patients (mean age 56.12±11.62 years old) with degenerative mitral valve regurgitation and anterior leaflet (n=82, 9.7%), posterior leaflet (n=688, 81.7%) and bileaflet (n=72, 8.6%) prolapses were operated on using a minimally invasive approach. RESULTS 836 patients had a valve repair (99.3%) and received a concomitant ring annuloplasty (mean size, 33.7; range, 28-40). Six patients (0.7%) underwent valve replacement. Two patients had a re-repair due to MR progression or infective endocarditis. Thirty-day mortality was 0.2% (two patients). There were 60 major adverse events (MAE) (7.1%). CONCLUSIONS A minimally invasive approach allows repair of almost all degenerative valves with good short-term outcomes in a tertiary referral center, when using proven and efficient surgical techniques.
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Affiliation(s)
- Patrick Perier
- Herz und Gefäß Klinik, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany
| | | | - Fitsum Lakew
- Herz und Gefäß Klinik, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany
| | - Gerhard Batz
- Herz und Gefäß Klinik, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany
| | - Anno Diegeler
- Herz und Gefäß Klinik, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany
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Glauber M, Murzi M, Cerillo AG. Is proctoring mandatory when starting a TAVI program? Ann Cardiothorac Surg 2013; 1:190-3. [PMID: 23977493 DOI: 10.3978/j.issn.2225-319x.2012.07.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 07/11/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Mattia Glauber
- Adult Cardiac Surgery Department, G. Pasquinucci Heart Hospital, Fondazione Toscana Gabriele Monasterio, Via Aurelia Sud 54100, Massa, Italy
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Murzi M, Cerillo AG, Miceli A, Bevilacqua S, Kallushi E, Farneti P, Solinas M, Glauber M. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg 2013; 43:e167-72. [DOI: 10.1093/ejcts/ezt043] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cerillo AG, Murzi M, Glauber M, Berti S. Quality control and the learning curve of transcatheter aortic valve implantation. JACC Cardiovasc Interv 2012; 5:456; author reply 456-7. [PMID: 22516410 DOI: 10.1016/j.jcin.2012.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 02/04/2012] [Indexed: 10/28/2022]
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