Current trends in mitral valve surgery: A multicenter national comparison between full-sternotomy and minimally-invasive approach

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Highlights

  • Minimally invasive approach in mitral valve surgery has been increasingly adopted.

  • In a large national cohort, the approach is preferred for repairs and replacements.

  • The approach appears safe with low mortality rates and few major complications.

  • Cardiopulmonary bypass and cross-clamp time became shorter in recent years.

  • Minimally invasive mitral valve surgery may be considered standard technique.

Abstract

Background

Mitral valve surgery (MVS) is evolving. Compared to standard sternotomy (S-MVS), minimally invasive method (Mini-MVS) has been increasingly adopted in the last years with encouraging results for both repairs and replacements. We evaluated trends of surgical approaches and operative outcomes in a multicenter study involving 10 cardiac surgical centers in Italy.

Methods

Patients who received isolated mitral valve surgery, including only a concomitant tricuspid valve repair, from January 2011 up to December 2017. Minimally invasive approach (right anterior mini-thoracotomy) and standard sternotomy was performed in 2602 and 1947 patients, respectively. Stratifying by surgery, 1493 patients per group were paired using a propensity matching procedure.

Results

The minimally invasive approach has been progressively more frequent over the years (from 27.5% in 2011 to 71.7% in 2017). Compared to S-MVS, Mini-MVS patients were younger with less preoperative comorbidities and less frequently operated for valve replacement or in association with tricuspid repair. The 30-day mortality was lower in the Mini-MVS (overall 1.2% vs 2.7%; p < 0.001) as well as the incidence of most postoperative complications. Subjects paired by propensity score had similar 30-day mortality (1.9% vs 1.8%, p = 0.786) but lower blood transfusion and permanent pace-maker insertion. Cardiopulmonary bypass and cross-clamp time, initially longer in the Mini-MVS patients, became shorter in recent years for the minimally invasive approach.

Conclusions

In a large multi-institutional recent cohort, minimally invasive mitral valve surgery has drastically increased being the preferred technique and appears to be safe with procedural duration shorter than the beginning.

Introduction

Treatment of heart diseases is rapidly evolving with a tendency to offer minimally invasive or transcatheter interventions rather than standard full sternotomy operations that have been successfully utilized in the past decades. Management of mitral valve disease is no different: the use of new transcatheter mitral repair or prosthesis techniques is in sight for the future [1,2] and minimally invasive techniques to perform standardized surgical operations are increasingly utilized. Surgery through right mini-thoracotomy approach has established itself as an optimal option to treat pathologies affecting atrio-ventricular valves [3,4]. Experienced and specifically trained surgeons can achieve excellent results as those obtained with standard sternotomy, with many studies reporting better pain control, faster recovery and a shorter hospital stay as compared to conventional surgery [5]. Despite encouraging results and excellent reports from leading institutions and surgeons, minimally invasive is not yet considered a standard of care nor mentioned as the technique of choice in guidelines. It is still many surgeons' belief that minimally invasive cardiac surgery is not safe, prolongs intervention time and can be performed only by a selected minority of very skilled surgeons. The aim of the present study is to evaluate trends of surgical approaches, operative outcomes and variations in operation times in a multicenter large cohort of patients undergone mitral valve surgery either with standard full sternotomy (S-MVS) or minimally invasive approach (Mini-MVS).

Section snippets

Methods

Data from 10 Italian cardiac centers sharing the same clinical and administrative database were analyzed from January 2011 up to December 2017. In all centers cardiology and cardiac surgery divisions are unified in a single department sharing the same clinical and administrative organization. All patients who received mitral valve surgery through a standard sternotomy or minimally invasive approach (right anterior mini-thoracotomy) were considered for the analysis. Excluded from the analysis

Results

During the study period, 4549 patients underwent mitral valve surgery in 10 hospitals. In 1947 cases a full sternotomy was performed while in 2602 a minimally invasive approach was chosen. Utilization of Mini-MVS has increased over the years becoming the most practiced approach (Fig. 1). The overall number of procedures performed per year increased from 454 in 2011 up to 776 in 2017. During the study period all but one center performed >40 mitral procedures per year. One center performed a mean

Discussion

Minimally invasive mitral valve approach is now an established procedure, we demonstrate in a large, multi-center population that with adequate training and team commitment the majority of mitral valve procedures can be performed safely with a minimally invasive approach. However its adoption remains hectic among cardiac centers and some concerns still exist in terms of safety. Also, it requires a steep learning curve, thus conventional sternotomy continues to be the standard practice in many

Conclusions

This multi-center propensity score matched study contributes to demonstrate that minimally invasive approach is as safe as conventional sternotomy, exhibiting low mortality and morbidity. Moreover it is associated with some better immediate postoperative outcomes compared to standard sternotomy, such as lower incidence of blood transfusion and pacemaker implant. The adoption of minimally invasive approach has increased dramatically in the course of our observation and the time of the operations

Declaration of competing interest

None declared.

References (17)

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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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