Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison.
ABSTRACT 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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ABSTRACT: Objective To update the current evidence of mitral valve surgery through a lateral minithoracotomy versus median sternotomy. Methods We performed a comprehensive literature research regarding studies comparing mitral valve surgery through a right lateral minithoracotomy (MIVS) and median sternotomy in MEDLINE, EMBASE, Cochrane Central, CTSnet and Google Scholar for the most recent literature up to April 2013. From the studies found in the literature we performed a systematic review and meta-analysis. Results More than 20’000 patients out of 45 studies were included in this study. Stroke rate and all-cause mortality up to 30 days was similar in both groups. The length of stay in the ICU, respirator dependence and hospital stay were significantly shorter in the MIVS-group. Furthermore, blood drainage volume and blood transfusions were decreased in the MIVS-group. On the contrary, cardiopulmonary bypass time, cross clamp time and procedure length were longer in the MIVS-group. Postoperative new atrial fibrillation was less in the MIVS-group. Aortic dissections occurred more in the MIVS-group. The rate of reexplorations and postoperative renal failure was similar in both groups. Conclusions MIVS and conventional mitral valve surgery show a similar perioperative outcome. Mitral valve surgery via a right lateral minithoracotomy seems to be favorable in regards of resource related outcome.Journal of Thoracic and Cardiovascular Surgery 02/2014; Epub ahead of print. · 3.53 Impact Factor
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ABSTRACT: Mitral valve operations are increasingly performed through minimally invasive approaches such as the right anterior minithoracotomy. To facilitate exposure with this technique, a diaphragmatic suture may be implemented. We describe a liver laceration caused by the diaphragmatic suture in minithoracotomy mitral repair and its successful nonoperative management with arterial embolization.Journal of Cardiac Surgery 04/2014; · 1.35 Impact Factor
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ABSTRACT: Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".Heart Lung & Circulation 04/2014; · 1.25 Impact Factor