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

Mitral Repair With Complete Rings or Posterior Bands in Barlow Disease: Long-term Results

BACKGROUND

Complete rings or posterior bands are both commonly used during mitral valve repair, but which one ensures the best long-term outcome in patients with Barlow disease is a topic of debate. This study evaluated whether the type of annuloplasty device affects the long-term durability of the repair.

METHODS

We selected 296 consecutive patients with severe mitral regurgitation due to Barlow disease who underwent edge-to-edge mitral repair at our institution between 2004 and 2013. For the edge-to-edge repair, a complete semirigid ring was used in 151 patients, whereas a posterior flexible band was used in 145 patients. The clinical and echocardiographic outcomes of both groups were compared at long-term follow-up.

RESULTS

At 14 years, the overall survival was 87.3% ± 2.79% in the ring group and 94.1% ± 2.30% in the band group (P = .056). The incidence of mitral valve reintervention was 4.9% ± 1.95% in the ring group and 5.5% ± 2.53% in the band group (P = .371) at 14 years. The incidence of recurrence of mitral regurgitation ≥3+ and ≥2+ was 8.3% ± 2.64% in the ring group and 8.7% ± 3.07% in the band group (P = .991) and 26.5% ± 4.23% in the ring group and 17.4% ± 3.26% in the band group (P = .697), respectively. Mitral regurgitation ≥1+ at discharge was the only independent predictor of reoperation and recurrence of mitral regurgitation ≥3+ in the long-term.

CONCLUSIONS

In patients with Barlow disease undergoing edge-to-edge mitral valve repair, the type of annuloplasty device does not influence the long-term results. Achieving an optimal immediate result remains the key to maintain the stability of the repair at long-term.

Mitral Valve Repair Versus Replacement in The Elderly

The disadvantages of mitral valve replacement with a bioprosthesis in the long-term may not play an important role if the shorter life expectancy of older patients is taken into account. This study aims to evaluate whether mitral valve replacement in the elderly is associated with similar outcome compared to repair in the short- and long-term. All patients aged 70 years and older undergoing minimally invasive mitral valve surgery were studied retrospectively. Primary outcome was 30-day complication rate, secondary outcome was long-term survival and freedom from re-operation. 223 Patients underwent surgery (124 replacement and 99 repair) with a mean age of 76.4 ± 4.2 years. 30-Day complication rate (replacement 73.4% versus repair 67.7%; p=.433), 30-day mortality (replacement 4.0% versus repair 1.0%; p=.332) and 30-day stroke rate (replacement 0.0% versus repair 1.0%; p=.910) were similar in both groups. Multivariable cox regression revealed higher age, diabetes and left ventricular dysfunction as predictors for reduced long-term survival, while a valve replacement was no predictor for reduced survival. Sub analysis of patients with degenerative disease showed no difference in long-term survival after propensity weighting (HR 1.4; 95%CI 0.84 - 2.50; p=.282). The current study reveals that mitral valve repair and replacement in the elderly can be achieved with good short- and long-term results. Long-term survival was dependent on patient related risk factors and not on the type of operation (replacement versus repair).

A Propensity Score Analysis of Early and Long-Term Outcomes of Retrograde Arterial Perfusion for Endoscopic and Minimally Invasive Heart Valve Surgery in Both Young and Elderly Patients

(1) Background: Minimal invasive cardiac surgery via right anterolateral thoracotomy for heart valve surgery and other intracardiac procedures proven to have lower postoperative complications. We aim to compare the neurological complications and post-operative outcomes in two cohort groups as well as survival rates up to 5 years postoperatively; (2) Methodology: Retrospective observational study for patients who had minimally invasive cardiac valve surgery with retrograde femoral arterial perfusion between 2007 and 2021 (n = 596) and the categorized patients into two groups based on their age (≥70 years old and below 70). Propensity match analysis was conducted. The primary endpoint consisted of major postoperative complications and the secondary endpoint was the long-term survival rate. (3) Results: There was no difference between the two groups in terms of postoperative outcomes. Patients ≥ 70 years old had no increased risk for neurological complications (p = 0.75) compared with those below 70 years old. The mortality rate was also not significant between the two groups (p = 0.37) as well as the crude survival rates. (4) Conclusions: The use of retrograde femoral arterial perfusion in elderly patients is not associated with increased risk compared to the younger patients’ group for a spectrum of primary cardiac valve procedures. Hence, minimally invasive approaches could be offered to elderly patients who might benefit from it.

Sustained results of robotic mitral repair in a lower volume center with extensive minimally invasive mitral repair experience

The literature for robotic mitral repair is dominated by a small number of large volume institutions, and intermediate-term outcomes out to 5 years are rare. Whether and under what circumstances a lower volume institution could obtain durable outcomes is not known. A retrospective review was performed on all 133 patients undergoing robotically assisted mitral repair from 2011 to 2019 at a single institution. Mean volume of robotic mitral repair was 16 ± 7 cases per year, while mean institutional total volume of mitral repair was 116 ± 16 cases per year. Mean age was 58 ± 12 years, 77% were men, and mitral etiology was prolapse in 90%. Comorbidity was infrequent with atrial fibrillation in 20% and moderate tricuspid regurgitation in 14%. Central aortic cannulation was used in 97% with concurrent tricuspid operation in 5% and concurrent maze in 14%. Median clamp time, pump time, and length of stay were 146 min, 265 min, and 5 days, respectively, but none improved with experience. There were no deaths or stroke. At 5 years, the cumulative incidence of moderate mitral regurgitation was 18 ± 6% (prolapse patients 11 ± 5%), severe regurgitation 4 ± 3%, and mitral replacement 9 ± 5% (prolapse patients 5 ± 3%). 5-year survival was 96 ± 3%. At centers with significant mitral repair volume, a volume of 16 robotic mitral cases/year can yield good clinical outcomes durable out to 5 years. A case volume of 16 cases per year was not sufficient to improve pump time or length of stay over time.

Robotic versus port-access mitral repair: A propensity score analysis

BACKGROUND

Port-access (PORT) and robotic (ROBO) mitral repair are well established, but differences in patient selection and outcomes are not well documented.

METHODS

A retrospective analysis was performed on 129 ROBO and 628 PORT mitral repairs at one institution. ROBO patients had 4 cm nonrib spreading incisions with robotic assistance, while PORT patients had 6-8 cm rib spreading incisions with thoracoscopic assistance. Propensity score analysis matched patients for differences in baseline characteristics.

RESULTS

Unmatched ROBO patients were younger (58 ± 11 vs. 61 ± 13, p = .05), had a higher percentage of males (77% vs. 63%, p = .003) and had less NYHA Class 3-4 symptoms (11% vs. 21%, p < .01), less atrial fibrillation (19% vs. 29%, p = .02) and less tricuspid regurgitation (14% vs. 24%, p = .01). Propensity score analysis of matched patients showed that pump time (275 ± 57 vs. 207 ± 55, p < .0001) and clamp time (152 ± 38 vs. 130 ± 34, p < .0001) were longer for ROBO patients. However, length of stay, postoperative morbidity, and 5-year survival (97 ± 1% vs. 96 ± 3%, p = .7) were not different. For matched patients with degenerative valve disease, 5-year incidence of mitral reoperation (3 ± 2% vs. 1 ± 1%), severe mitral regurgitation (MR) (6 ± 4% vs. 1 ± 1%), or ≥2 + MR (12 ± 5% vs. 12 ± 4%), were not significantly different between ROBO versus PORT approaches. Predictors of recurrent moderate MR were connective tissue disease, functional etiology, and non-White race, but not surgical approach.

CONCLUSIONS

In this first comparison out to 5 years, robotic versus port-access approach to mitral repair had longer pump and clamp times. Perioperative morbidity, 5-year survival, and 5-year repair durability were otherwise similar.

Minimally invasive mitral valve surgery: a systematic safety analysis

Objective

Minimally invasive surgery is increasingly adopted as an alternative to conventional sternotomy for mitral valve pathology in many centres worldwide. A systematic safety analysis based on a comprehensive list of pre-specified 30-day complications defined by the Mitral Valve Academic Consortium (MVARC) criteria is lacking. The aim of the current study was to systematically analyse the safety of minimally invasive mitral valve surgery in our centre based on the MVARC definitions.

Methods

All consecutive patients undergoing minimally invasive mitral valve surgery through right mini-thoracotomy in our institution within 10 years were studied retrospectively. The primary outcome was a composite of 30-day major complications based on MVARC definitions.

Results

745 patients underwent minimally invasive mitral valve surgery (507 repair, 238 replacement), with a mean age of 62.9±12.3 years. The repair was successful in 95.8%. Overall 30-day mortality was 1.2% and stroke rate 0.3%. Freedom from any 30-day major complications was 87.2%, and independent predictors were left ventricular ejection fraction <50% (OR 1.78; 95% CI 1.02 to 3.02) and estimated glomerular filtration rate <60 mL/min/1.73 m² (OR 1.98; 95% CI 1.17 to 3.26).

Conclusions

Minimally invasive mitral valve surgery is a safe technique and is associated with low 30-day mortality and stroke rate.