Accuracy of EuroSCORE II in patients undergoing minimally invasive mitral valve surgery

Isolated annuloplasty in elderly patients with secondary mitral valve regurgitation: short- and long-term outcomes with a less invasive approach

Background

Long-term outcomes of elderly and frail patients with secondary mitral valve regurgitation (MR) are inconclusive. Especially in patients with co-morbidities such as atherosclerosis who are suffering from heart failure, optimal medical therapy (OMT) is the preferred therapy relative to surgical or percutaneous interventions. It remains challenging to identify the most successful therapy to improve symptoms and increase life expectancy. To reduce surgical trauma for these patients, minimally invasive mitral valve surgery (MIMVS) was developed; this has shown promising medium-term results, but there is still a lack of evidence regarding long-term results. The aim of this investigation was to describe the long-term outcomes of less invasive mitral valve surgery (MVS) in elderly patients.

Methods

In this longitudinal retrospective analysis, 67 patients (aged ≥70 years) with secondary MR who underwent MV repair ± tricuspid valve repair (TVR) were identified. MVS was performed via minithoracotomy (MT) in most cases (n = 54); in patients with contraindications for MIMVS, partial upper sternotomy (PS) was the preferred route for surgical access (n = 13). The appropriate access route was chosen according to the patient's clinical condition and comorbidities. We analyzed reoperation-free long-term survival, combined operative success (lack of residual MR, conversion to MV replacement, or larger thoracic incisions), and perioperative safety (at 30 days: mortality, re-thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation, stroke, myocardial infarction). In a subgroup analysis, we compared long-term survival in MVS patients with and without TVR.

Results

The median age of patients (62.7% female) was 74 years (interquartile range: 72-76 years), with a median EuroSCORE2 of 2.8% (1.5%-4.6%) and N-terminal pro-brain natriuretic peptide plasma levels of 1,434 ng/L (1035-2149 ng/L). The median follow-up period was 5.6 years (2.7-8.5 years). The reoperation-free long-term survival rate up to 10 years was 66.2%. Combined operative success and perioperative safety were achieved in 94% and 76% of patients, respectively. Additional TVR was performed in 56.7% of patients, without any significant difference in survival rates compared to the group without TVR (p = 0.417; HR 1.473, 95% CI 0.578-3.757).

Conclusion

Less invasive MV repair for secondary MR shows excellent operative success and safety in selected patients. Freedom from significant MR and from the need for reoperation indicates long-lasting efficacy. These results should be considered in heart team discussions regarding allocation of patients to surgical mitral procedures.

Minimally invasive mitral valve surgery in high-risk patients: operating outside the boxplot

OBJECTIVES

(i) To establish who is at high risk for mitral surgery. (ii) To assess the performance of minimally invasive mitral valve surgery in high-risk patients by presenting early and late outcomes and compare these with those of the non-high-risk population.

METHODS

We reviewed our database of prospective data of 1873 consecutive patients who underwent minimally invasive mitral surgery from 2003 to 2015. To establish an unbiased definition of risk cut-off, we considered as high-risk the 'outliers of risk' identified using boxplot analysis in relation to EuroSCORE II.

RESULTS

Two hundred and five patients were outliers, with 98 as minor (EuroSCORE II ≥ 6%) and 107 as major outliers (EuroSCORE II ≥ 9%). Outliers accounted for several different comorbidities. Nineteen patients died while in hospital (9.2%); different postoperative complications were observed. Outliers had a significantly lower mean survival time and a higher risk of cardiac-related death than the general population; however, the worst outcomes were observed in major outliers. No statistically significant difference was found with regard to the need for mitral reintervention and the degree of mitral regurgitation at follow-up.

CONCLUSIONS

Boxplot analysis helped to achieve an internal definition of risk cut-off, starting from EuroSCORE II ≥ 6%. Minimally invasive mitral surgery in these outliers of risk was associated with acceptable early and long-term results; however, major outliers with EuroSCORE II ≥ 9% may benefit from catheter-based procedures.