Minimally Invasive Versus Sternotomy Approach for Mitral Valve Surgery in Patients Greater Than 70 Years Old: A Propensity-Matched Comparison

Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany.
The Annals of thoracic surgery (Impact Factor: 3.85). 02/2011; 91(2):401-5. DOI: 10.1016/j.athoracsur.2010.08.006
Source: PubMed


The goal of this study was to compare the outcome after mitral valve surgery through either standard sternotomy or right lateral minithoracotomy in elderly patients with higher perioperative risk.
All 1,027 elderly patients (>70 years) who received isolated mitral valve surgery (± tricuspid valve repair) between August 1999 and July 2009 were analyzed for outcome differences due to surgical approach using propensity score matching. The etiology of mitral valve disease was degenerative (83%), endocarditis (6%), rheumatic (10%), and acute ischemic (<1%). Isolated stenosis was rare (3%); most patients had mitral valve regurgitation (72%) or combined mitral valve disease (25%).
The minimally invasive approach led to longer duration of surgery (186 ± 61 vs 169 ± 59 minutes, p = 0.01), cardiopulmonary bypass time (142 ± 54 vs 102 ± 45 minutes, p = 0.0001), and cross-clamp time (74 ± 44 vs 64 ± 28 minutes, p = 0.015). There were no differences between the matched groups in 30-day mortality (7.7% vs 6.3%, p = 0.82), combined major adverse cardiac and cerebrovascular events (11.2% vs 12.6%, p = 0.86), or other postoperative outcome. Only the number of postoperative arrhythmias and pacemaker implants was higher in the sternotomy group (65.7% vs 50.3%, p = 0.023 and 18.9% vs 10.5%, p = 0.059). Long-term survival was 66% ± 5.6% vs 56 ± 5.5% at 5 years and 35% ± 12% vs 40% ± 7.9% at 8 years, and did not show significant differences.
Minimally invasive mitral valve surgery through a right lateral minithoracotomy is at least as good and safe as the standard sternotomy approach in elderly patients.

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    • "In 1998, Mohr developed a video-assisting port access technology to reduce CPB and cross-clamp times which allowed a better visualization of the valve [3]. Since then, MIMVS has been performed through a wide variety of approaches (hemisternotomy, parasternal incision, mini-thoracotomy , total endoscopically and robotically) with favourable long-term outcomes even in elderly and redo patients when compared with sternotomy despite longer bypass and cross-clamp times [4] [5] [6] [7] [8] [9]. However, minimally invasive cardiac surgery is always accompanied by a learning curve. "
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    ABSTRACT: Since the 1990s, minimally invasive cardiac surgery has gained wide acceptance due to patient and economic demand. The advantages are less trauma, less bleeding, less wound infections, less pain and faster recovery. Many studies showed that the outcomes are comparable with those of conventional sternotomy. Right lateral mini-thoracotomy evolved into a routine and safe access in specialized centres for minimally invasive mitral valve surgery. The 6-cm incision is performed over the fifth intercostal space in the inframammary groove. With a double-lumen tube, the right lung is deflated before entering the pleural cavity. A soft tissue retractor is used to minimize rib spreading. The stab incisions for the endoscopic camera and the transthoracic clamp are performed in the right anterior and posterior axillary line in the third intercostal space. Surgery on the mitral valve is performed in a standard fashion under a direct vision with video assistance. One chest tube is inserted. The intercostal space is adapted with braided sutures to prevent lung herniation. Ropivacaine is used for local infiltration. The pectoral muscle, subcutaneous tissue and skin are adapted with running sutures. Complications of a right lateral mini-thoracotomy are rare (conversion to sternotomy, rethoracotomy, phrenic nerve palsy, wound infection and thoracic wall hernia) and well manageable.
    Multimedia Manual of Cardiothoracic Surgery 10/2015; 2015. DOI:10.1093/mmcts/mmv031
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    • "The number of elderly patients referred for elective cardiac surgery is growing constantly [1]. These patients are considered to be at increased risk for perioperative mortality and morbidity, although several studies have shown good outcomes for this patient population [2] [3] [4] [5]. Besides a higher number of comorbidities, the phenotype of frailty is largely represented in elderly patients with cardiovascular disease [6]. "
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    ABSTRACT: Assessment of perioperative risk of elderly patients in cardiac surgery is difficult, and most of the common risk scores show over- or underestimation. Two frailty scores, the comprehensive assessment of frailty (CAF) score and the Frailty predicts death One yeaR after CArdiac Surgery Test (FORECAST), were developed as additional tools to estimate the preoperative mortality risk, taking into consideration the frailty status of elderly patients. Four hundred and fifty patients who were referred for elective cardiac surgery were included. All the patients were assessed with the CAF test and the FORECAST. Thirty-day and 1-year mortality were evaluated by telephone interview. Univariate and bivariate logistic regression were performed to test the predictive power of the tests on mortality. Correlation of the scores with age was calculated with Spearman ranks. Three commensurate groups were built for each of the frailty scores and the outcome was compared between the groups. All analyses were performed for Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE) accordingly. A total of 227 male and 223 female patients were included. Thirty-day mortality was 6.1%, and 1-year mortality was 13.3%. Logistic regression showed that both scores are able to predict 30-day as well as 1-year mortality. Bivariate logistic regression showed that both frailty scores give relevant additional information to the STS and EuroSCORE for the prediction of 1-year mortality. The frailty scores were only weakly correlated with age in contrast to STS and EuroSCORE and therefore can be used as indicator of the biological age of patients besides the numerical age. Survival up to 1 year was relevantly reduced in the group of patients with the higher frailty scores. CAF and FORECAST are additional tools to evaluate elderly patients adequately before elective cardiac surgery, and showed an association with short- and mid-term mortality independently of age.
    Interactive Cardiovascular and Thoracic Surgery 02/2014; 18(5). DOI:10.1093/icvts/ivu006 · 1.16 Impact Factor
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    ABSTRACT: Robotic cardiac surgery utilizes the most advanced surgical technology to offer patients a minimally invasive alternative to open surgery in the treatment of a broad range of cardiac pathologies. Although robotics may offer substantial benefits to physicians, patients and healthcare institutions, there are important barriers to its adoption that includes inadequate funding, competition from alternate therapies and challenges in training. There is a growing body of evidence to demonstrate the efficacy of robotic cardiac surgery. Technological innovations are improving patient safety and expanding the indications for robotic cardiac surgery beyond the treatment of mitral valve and coronary artery disease. Robotic cardiac surgery is rapidly becoming a feasible, safe and effective option for the definitive treatment of cardiac disease in the context of 21st century challenges to healthcare provision such as diabetes, obesity and an aging population.
    Future Cardiology 07/2011; 7(4):511-22. DOI:10.2217/fca.11.40
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