Analysis of clinical outcome and postoperative organ function effects in a propensity‐matched comparison between conventional and minimally invasive mitral valve surgery

Biomarkers of inflammation and coagulation after minimally invasive mitral valve surgery: a prospective comparison to conventional surgery

OBJECTIVES

Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy.

DESIGN

A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored.

RESULTS

The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115-146] vs 79 min [65-112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23-69] vs 61[41-139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400-1040], p = 0.04).

CONCLUSIONS

Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.

A review and meta-analysis of conventional sternotomy versus minimally invasive mitral valve surgery for degenerative mitral valve disease focused on the last decade of evidence

OBJECTIVES

Early meta-analyses comparing minimally invasive mitral valve surgery (MIMVS) with conventional sternotomy (CS) have determined the safety of MIMVS. We performed this review and meta-analysis based on studies from 2014 onwards to examine the differences in outcomes between MIMVS and CS. Specifically, some outcomes of interest included renal failure, new onset atrial fibrillation, mortality, stroke, reoperation for bleeding, blood transfusion and pulmonary infection.

METHODS

A systematic search was performed in six databases for studies comparing MIMVS with CS. Although the initial search identified 821 papers in total, nine studies were suitable for the final analysis. All studies included compared CS with MIMVS. The Mantel - Haenszel statistical method was chosen due the use of inverse variance and random effects. A meta-analysis was performed on the data.

RESULTS

MIMVS had significantly lower odds of renal failure (OR: 0.52; 95% CI 0.37 to 0.73, p < 0.001), new onset atrial fibrillation (OR: 0.78; 95% CI 0.67 to 0.90, p < 0.001), reduced prolonged intubation (OR: 0.50; 95% CI 0.29 to 0.87, p = 0.01) and reduced mortality (OR: 0.58; 95% CI 0.38 to 0.87, p < 0.01). MIMVS had shorter ICU stay (WMD: -0.42; 95% CI -0.59 to -0.24, p < 0.001) and shorter time to discharge (WMD: -2.79; 95% CI -3.86 to -1.71, p < 0.001).

CONCLUSION

In the modern era, MIMVS for degenerative disease is associated with improved short-term outcomes when compared to the CS.

Daptomycin Pharmacokinetics in Blood and Wound Fluid in Critical Ill Patients with Left Ventricle Assist Devices

Daptomycin is a cyclic lipopeptide antibiotic with bactericidal effects against multidrug-resistant Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecalis (VRE). For critically ill patients, especially in the presence of implants, daptomycin is an important therapeutic option. Left ventricle assist devices (LVADs) can be utilized for intensive care patients with end-stage heart failure as a bridge to transplant. We conducted a single-center prospective trial with critically ill adults with LVAD who received prophylactic anti-infective therapy with daptomycin. Our study aimed to evaluate the pharmacokinetics of daptomycin in the blood serum and wound fluids after LVAD implantation. Daptomycin concentration were assessed over three days using high-performance liquid chromatography (HPLC). We detected a high correlation between blood serum and wound fluid daptomycin concentration at 12 h (IC95%: 0.64 to 0.95; r = 0.86; p < 0.001) and 24 h (IC95%: -0.38 to 0.92; r = 0.76; p < 0.001) after antibiotic administration. Our pilot clinical study provides new insights into the pharmacokinetics of daptomycin from the blood into wound fluids of critically ill patients with LVADs.

Longitudinal Outcomes Following Surgical Repair of Primary Mitral Regurgitation

Degenerative mitral valve (MV) disease is the most common cause of organic mitral regurgitation (MR) in developed countries. Surgical mitral valve repair is the gold standard treatment for primary MR. Surgical mitral valve repair is associated with excellent outcomes in terms of survival and freedom from recurrent MR. As well, innovations in surgical repair techniques, including thoracoscopically and robotically assisted approaches, further reduce morbidity. Emerging catheter-based therapies may also provide advantages in select patient groups. Although the outcomes following surgical mitral valve repair are well described in the literature, longitudinal follow-up is heterogenous. Indeed, longitudinal follow-up and long-term data are vital to better advise treatment and counsel patients.