Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes

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.

Minithoracotomy and Beating Heart Strategy for Mitral Surgery in Secondary Mitral Regurgitation

BACKGROUND

In patients with secondary mitral regurgitation (MR) associated with low ejection fraction or previous heart surgery, minimally invasive mitral valve surgery without aortic cross-clamp (MIMVS-WAC) has shown promising results. We report our experience for this strategy in our centers.

METHODS

Between August 2011 and April 2017, 46 patients (mean age 69 ± 11 years, 76% males) received MIMVS-WAC. Indications for this technique were prior coronary bypass surgery (26%), severe or recent left ventricular (LV) dysfunction (30%), or both (39%). The mean EuroSCORE II was 12 ± 10.

RESULTS

For each procedure, we conducted right minithoracotomy and hypothermic cardiopulmonary bypass (CPB) after peripheral cannulation. Mean CPB time was 159 ± 39 minutes. A mitral valve replacement (MVR) was performed in 23 cases (50%), an annuloplasty in 22 cases (48%), and a prosthesis pannus removal in 1 case (2%). Mean hospital length of stay was 12 ± 5.4 days. We report no sternotomy conversions, six reoperations for bleeding, and three deaths at 30 days. Transfusion was requested in 62% (mean infusion 2 ± 2.4 packed red blood cells). The postoperative echocardiography showed an LV function preservation in 69% of cases and a reduction of pulmonary arterial pressure in 73% of cases. Four additional deaths occurred in the long-term follow-up (mean 637 ± 381 days, median 593 days). No mitral reoperation was required, with a MR ≤ 2 in 90% of patients.

CONCLUSION

In high-risk patients, the MIMVS-WAC is a safe technique. It avoids hard dissections while ensuring excellent preservation of cardiac function.