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Pahwa S, Kertai MD, Abrams B, Huang J. Length of Hospital Stay as a Performance Metric-Is That a Fair Assessment? Semin Cardiothorac Vasc Anesth 2023; 27:5-7. [PMID: 36786418 DOI: 10.1177/10892532231159723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- Siddharth Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin Abrams
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, 5170University of Louisville, Louisville, KY, USA
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Hashim SW, McMahon SR, Vaitkeviciute IK, Collazo S, Hashim IM, Loya DS, Takata ET, Mather JF, McKay RG. Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:724-733. [PMID: 36106398 DOI: 10.23736/s0021-9509.22.12397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. METHODS We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. RESULTS Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. CONCLUSIONS In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.
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Affiliation(s)
- Sabet W Hashim
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Irena K Vaitkeviciute
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Susan Collazo
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA -
| | - Jeff F Mather
- Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
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3
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Hisatomi K, Miura T, Obase K, Matsumaru I, Nakaji S, Tanigawa A, Taguchi S, Takura M, Nakao Y, Eishi K. Minimally Invasive Valvular Surgery in the Elderly - Safety, Early Recovery, and Long-Term Outcomes. Circ J 2022; 86:1725-1732. [PMID: 36198575 DOI: 10.1253/circj.cj-22-0338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND For elderly people, the benefit of minimally invasive cardiac surgery (MICS) is unclear, so we evaluated the safety, recovery, and long-term survival in elderly MICS patients.Methods and Results: 63 propensity score-matched pairs of 213 consecutive patients (≥70 years old) who underwent mitral and/or tricuspid valve surgery between 2010 and 2020 (121 right mini-thoracotomies vs. 92 full sternotomies) were compared. The primary outcome was safety (composite endpoint of in-hospital death or major complication). Secondary outcomes were early ambulation and discharge to home. There were no differences between the groups for in-hospital death (3.2% vs. 0.0%, P=0.157) and primary outcome (14.3% vs. 17.5%, P=0.617). The rate of early ambulation (73.0% vs. 55.6%, P=0.048) and discharge to home (66.7% vs. 49.2%, P=0.034) were significantly higher in the mini-thoracotomy group. Major complication was an independent negative predictor of early ambulation for mini-thoracotomy but not for a conservative approach. Survival was 87.8±4.4% vs. 86.8±4.7% at 5 years, which was not significantly different. CONCLUSIONS Similar safety but better recovery were observed for mini-thoracotomy, and long-term survival was comparable between groups. Major complication was a negative predictor of early ambulation after mini-thoracotomy. Careful preoperative risk stratification would enhance the benefits of MICS in elderly patients.
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Affiliation(s)
- Kazuki Hisatomi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Takashi Miura
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Kikuko Obase
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Ichiro Matsumaru
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Shun Nakaji
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Akihiko Tanigawa
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Shunsuke Taguchi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Masayuki Takura
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Yuko Nakao
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
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Abri QA, von Ballmoos MCW. Cardiovascular Surgery Procedural Training and Evaluation: Current Status and Future Directions. Methodist Debakey Cardiovasc J 2022; 18:30-38. [PMID: 35734157 PMCID: PMC9165672 DOI: 10.14797/mdcvj.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/18/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Qasim Al Abri
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
- Weill Cornell Medicine, New York, US
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5
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Agnino A, Graniero A, Villari N, Roscitano C, Gerometta P, Albano G, Anselmi A. Evaluation of robotic-assisted mitral surgery in a contemporary experience. J Cardiovasc Med (Hagerstown) 2022; 23:399-405. [PMID: 35645031 DOI: 10.2459/jcm.0000000000001319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To evaluate the safety/effectiveness of a recently established robotic-assisted mitral surgery program. METHODS Cohort study with prospective collection of clinical data of 59 consecutive recipients (May 2019-August 2021) of robotic-assisted (fourth-generation platform, DaVinci X) mitral valve repair for degenerative disease, using a totally endoscopic technique. Patients' selection was based on defined anatomical and clinical criteria. We established a dedicated multidisciplinary protocol to facilitate postoperative fast-tracking, and a systematic in-house clinical and echocardiographic follow-up at 3, 6, and 12 postoperative months. RESULTS All patients (89.8% men, average age 58 ± 12 years) received mitral valve repair; there was no operative mortality, one conversion to sternotomy (1.7%) and one stroke (1.7%). Extubation within the operative theater occurred in 28.8%; average mechanical ventilation time and ICU stay was 2.8 ± 4.1 and 32.5 ± 15.8 h (after exclusion of one outlier, learning-curve period, suffering from perioperative stroke); average postoperative hospital stay was 6.8 ± 3.4 days and 96.6% of patients were discharged home. One patient was transfused (1.7%); there were no other complications. Follow-up revealed stability of the results of mitral repair, with one (1.7%) persistent (>2+/4+) mitral regurgitation, and stability of coaptation height over time. We observed optimal functional results (class I was 98% at 3 months and 96% at 12 months). Quarterly case load consistently increased during the experience. CONCLUSION This initial experience suggests the reliability and clinical safety of a recently established local robotic-assisted mitral surgery. This strategy can facilitate faster postoperative recovery, and its positioning in the therapeutic armamentarium needs to be defined.
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Affiliation(s)
- Alfonso Agnino
- Division of Minimally Invasive and Video-Assisted Cardiac Surgery
| | - Ascanio Graniero
- Division of Minimally Invasive and Video-Assisted Cardiac Surgery
| | - Nicola Villari
- Division of Cardiac Anesthesia, Cliniche HUMANITAS Gavazzeni, Bergamo, Italy
| | - Claudio Roscitano
- Division of Cardiac Anesthesia, Cliniche HUMANITAS Gavazzeni, Bergamo, Italy
| | | | - Giovanni Albano
- Division of Cardiac Anesthesia, Cliniche HUMANITAS Gavazzeni, Bergamo, Italy
| | - Amedeo Anselmi
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital.,Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
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Pirola S, Montisci A, Mastroiacovo G, Jaber EA, Fileccia D, Bonomi A, Pappalardo F, Bisleri G, Polvani G. Right Ventricular Function After Minimally Invasive Mitral Valve Surgery. J Cardiothorac Vasc Anesth 2021; 36:1073-1080. [PMID: 34629238 DOI: 10.1053/j.jvca.2021.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Right ventricular (RV) dysfunction is a significant cause of morbidity and mortality after cardiac surgery. Minimally invasive mitral valve surgery (MIMVS) increasingly is being performed. The authors aim was to evaluate postoperative RV function in patients who underwent MIMVS versus traditional mitral valve surgery. DESIGN Six hundred seventy-five patients who underwent elective isolated mitral valve surgery at Centro Cardiologico Monzino from January 2016 to December 2019 were analyzed. After 1:1 propensity score matching, 60 patients were identified in the MIMVS (study group A) and 58 patients in the median sternotomy (control group B) and compared. SETTING A university-affiliated scientific institute, monocentric. PARTICIPANTS Patients. INTERVENTIONS Mitral valve surgery. MEASUREMENTS AND MAIN RESULTS No in-hospital deaths occurred. Aortic cross-clamp time (102 [87.5-119] v 83 [61-109] minutes, p = 0.0001), cardiopulmonary bypass duration (161.5 [142.5-181] v 105.5 [74-134] minutes, p < 0.0001) and intensive care unit stay (47 [44-72] v 45 [40-47] hours, p = 0.0015) were significantly longer in group A. The tricuspid annular plane systolic excursion was not different between group A and group B neither postoperatively (15 ± 3 v 14 ± 4 mm, p = 0.1) nor at three-month follow-up (18 ± 4 v 15 ± 3 mm, p = 0.3). No differences in peak postoperative lactates, inotropic score, central venous pressure, and pulmonary artery pulsatility index were observed. The length of hospital stay was significantly shorter in the minimally invasive group (ten [eight-13] v 12 [ten-17], p = 0.006). CONCLUSION The authors study showed that the surgical strategy had no significant impact on postoperative RV function after mitral valve surgery.
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Affiliation(s)
- Sergio Pirola
- Department of Cardiac Surgery, Centro Cardiologico Monzino, Milan, Italy
| | - Andrea Montisci
- Division of Cardiothoracic Intensive Care, ASST Spedali Civili, Brescia, Italy.
| | - Giorgio Mastroiacovo
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Emad Al Jaber
- Department of Cardiac Surgery, Centro Cardiologico Monzino, Milan, Italy
| | - Daniele Fileccia
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Alice Bonomi
- Department of Statistics, Centro Cardiologico Monzino, Milan, Italy
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St. Micheal's Hospital, University of Toronto, Toronto (ON), Canada
| | - Gianluca Polvani
- Department of Cardiac Surgery, Centro Cardiologico Monzino, Milan, Italy; Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
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Pojar M, Karalko M, Dergel M, Vojacek J. Minimally invasive or sternotomy approach in mitral valve surgery: a propensity-matched comparison. J Cardiothorac Surg 2021; 16:228. [PMID: 34376231 PMCID: PMC8353832 DOI: 10.1186/s13019-021-01578-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
Objectives Conventional mitral valve surgery through median sternotomy improves long-term survival with acceptable morbidity and mortality. However, less-invasive approaches to mitral valve surgery are now increasingly employed. Whether minimally invasive mitral valve surgery is superior to conventional surgery is uncertain. Methods A retrospective analysis of patients who underwent mitral valve surgery via minithoracotomy or median sternotomy between 2012 and 2018. A propensity score-matched analysis was generated to eliminate differences in relevant preoperative risk factors between the two groups. Results Data from 525 patients were evaluated, 189 underwent minithoracotomy and 336 underwent median sternotomy. The 30 day mortality was similar between the minithoracotomy and conventional surgery groups (1 and 3%, respectively; p = 0.25). No differences were seen in the incidence of stroke (p = 1.00), surgical site infections (p = 0.09), or myocardial infarction (p = 0.23), or in total hospital cost (p = 0.48). However, the minimally invasive approach was associated with fewer patients receiving transfusions (59% versus 76% in the conventional group; p = 0.001) or requiring reoperation for bleeding (3% versus 9%, respectively; p = 0.03). There were no significant differences in 5 year survival between the minithoracotomy and conventional surgery groups (93% versus 86%, respectively; p = 0.21) and freedom from mitral valve reoperation (95% versus 94%, respectively; p = 0.79). Conclusions In patients undergoing mitral valve surgery, a minimally invasive approach is feasible, safe, and reproducible with excellent short-term outcomes; mid-term outcomes and efficacy were also seen to be comparable to conventional sternotomy.
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Affiliation(s)
- Marek Pojar
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Charles University, Sokolska 581, 500 05, Hradec Kralove, Czech Republic.
| | - Mikita Karalko
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Charles University, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Martin Dergel
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Charles University, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Charles University, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
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8
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Liu J, Wei P, Liu Y, Ma J, Wu H, Tan T, Chen Z, Chen J, Huang H, Guo H. Trends in redo mitral procedure for treating mitral bioprostheses failure: a single center's experience. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1306. [PMID: 34532443 PMCID: PMC8422140 DOI: 10.21037/atm-21-3118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/07/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Transcatheter mitral valve-in-valve implantation (TM-VIV) has emerged as a viable and attractive alternative to surgical mitral valve replacement (SMVR). This study aimed to review a single-center experience with redo mitral procedure for mitral bioprostheses failure over an 8-year period. In addition, it compared procedural safety and early outcomes of various approaches. METHODS Between January 2013 and January 2021, 79 consecutive patients who underwent redo procedure for mitral bioprostheses failure in our institution were retrospectively reviewed. SMVR and transapical TM-VIV were performed in 54 and 25 patients, respectively. In the SMVR group, 12 patients underwent totally thoracoscopic redo mitral valve replacement (MVR). RESULTS The annual volume of procedures grew continuously during the study period, with the use of totally thoracoscopic redo MVR increasing from 0% in 2012 to 20% in 2019. In 2020, 84.2% of total procedures were performed via the transcatheter approach. Patients in the TM-VIV group were significantly older and had higher scores on the European System for Cardiac Operative Risk Evaluation II (EuroScore II) and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) (P<0.01). The in-hospital mortality for the SMVR group and TM-VIV group was 3.7% (2 patients) and 0, respectively. Compared to the SMVR group, TM-VIV was associated with shorter ventilation time, intensive care unit stay, and postoperative in-hospital stay, and there was less need for blood transfusion. In the subgroup analysis, no significant difference was detected among most perioperative outcomes between the totally thoracoscopy approach group and the TM-VIV group. CONCLUSIONS There is an increasing number of patients demanding surgical treatments for mitral bioprostheses failure. TM-VIV is playing a significant role due to its scope of application and excellent outcomes.
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Affiliation(s)
- Jian Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Peijian Wei
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Yanjun Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Jiexu Ma
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Hongxiang Wu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Zhao Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Huanlei Huang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
| | - Huiming Guo
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, China
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Bonatti J, Crailsheim I, Grabenwöger M, Winkler B. Minimally Invasive and Robotic Mitral Valve Surgery: Methods and Outcomes in a 20-Year Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:317-326. [PMID: 34315268 DOI: 10.1177/15569845211012389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the mid- to late-1990s the cardiac surgery community began to apply limited incisions in mitral valve surgery. Ministernotomies and right-sided minithoracotomies were placed instead of the classic midline sternotomy. Adjunct technology such as videoscopy, advanced peripheral cannulation techniques, procedure specific long shafted surgical instruments, as well as surgical robots became available, and the procedures were refined in a stepwise fashion. In 2021, minimally invasive mitral valve repair is routine at many centers around the globe. We reviewed a total of 50 consecutive patient series published on the topic between 1999 and 2019. Three main versions of minimally invasive mitral valve surgery were applied in 20,539 patients. The surgical methods, their specific results, and the cumulative outcome of less invasive mitral valve surgery published over more than 20 years are reported and an integrated view on what less invasive mitral valve surgery can offer is presented.
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Affiliation(s)
- Johannes Bonatti
- 553088 Department of Cardiac and Vascular Surgery, Vienna Health Network - Clinic Floridsdorf, Austria.,Karl Landsteiner Institute of Cardiovascular Surgical Research, Vienna, Austria
| | - Ingo Crailsheim
- 553088 Department of Cardiac and Vascular Surgery, Vienna Health Network - Clinic Floridsdorf, Austria.,Karl Landsteiner Institute of Cardiovascular Surgical Research, Vienna, Austria
| | - Martin Grabenwöger
- 553088 Department of Cardiac and Vascular Surgery, Vienna Health Network - Clinic Floridsdorf, Austria.,Karl Landsteiner Institute of Cardiovascular Surgical Research, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Bernhard Winkler
- 553088 Department of Cardiac and Vascular Surgery, Vienna Health Network - Clinic Floridsdorf, Austria.,Karl Landsteiner Institute of Cardiovascular Surgical Research, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Austria
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10
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Bowdish ME, Elsayed RS, Tatum JM, Cohen RG, Mack WJ, Abt B, Yin V, Barr ML, Starnes VA. Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease. J Card Surg 2021; 36:2636-2643. [PMID: 33908645 DOI: 10.1111/jocs.15586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 03/26/2021] [Accepted: 04/03/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Debate continues in regard to the optimal surgical approach to the mitral valve for degenerative disease. METHODS Between February 2004 and July 2015, 363 patients underwent mitral valve repair for degenerative mitral valve disease via either sternotomy (sternotomy, n = 109) or small right anterior thoracotomy (minimally invasive, n = 259). Survival, need for mitral valve reoperation, and progression of mitral regurgitation more than two grades were compared between cohorts using time-based statistical methods and inverse probability weighting. RESULTS Survival at 1, 5, and 10 years were 99.2, 98.3, and 96.8 for the sternotomy group and 98.1, 94.9, and 94.9 for the minimally invasive group (hazard ratio: 0.39, 95% confidence interval [CI] 0.11-1.30, p = .14). The cumulative incidence of need for mitral valve reoperation with death as a competing outcome at 1, 3, and 5 years were 2.7%, 2.7%, and 2.7% in the sternotomy cohort and 1.5%, 3.3%, and 4.1% for the minimally invasive group (subhazard ratio (SHR) 1.17, 95% CI: 0.33-4.20, p = .81). Cumulative incidence of progression of mitral regurgitation more than two grades with death as a competing outcome at 1, 3, and 5 years were 5.5%, 14.4%, and 44.5% for the sternotomy cohort and 4.2%, 9.7%, and 20.5% for the minimally invasive cohort (SHR: 0.67, 95% CI: 0.28-1.63, p = .38). Inverse probability weighted time-based analyses based on preoperative cohort assignment also demonstrated equivalent outcomes between surgical approaches. CONCLUSIONS Minimally invasive and sternotomy mitral valve repair in patients with degenerative mitral valve disease is associated with equivalent survival and repair durability.
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Affiliation(s)
- Michael E Bowdish
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA.,Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Ramsey S Elsayed
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - James M Tatum
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Robbin G Cohen
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Brittany Abt
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Victoria Yin
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Mark L Barr
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Vaughn A Starnes
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
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11
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McBride K, Steffens D, Stanislaus C, Solomon M, Anderson T, Thanigasalam R, Leslie S, Bannon PG. Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload. BMC Health Serv Res 2021; 21:108. [PMID: 33522941 PMCID: PMC7849115 DOI: 10.1186/s12913-021-06105-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Background A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. Methods A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. Results Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. Conclusions There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06105-z.
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Affiliation(s)
- Kate McBride
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia. .,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Christina Stanislaus
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
| | - Michael Solomon
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Teresa Anderson
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ruban Thanigasalam
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Scott Leslie
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul G Bannon
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,The Baird Institute, Sydney, New South Wales, Australia
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12
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Perin G, Shaw M, Toolan C, Palmer K, Al-Rawi O, Modi P. Cost Analysis of Minimally Invasive Mitral Valve Surgery in the UK National Health Service. Ann Thorac Surg 2020; 112:124-131. [PMID: 33068544 DOI: 10.1016/j.athoracsur.2020.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/04/2020] [Accepted: 08/06/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND In the UK National Health Service, finite resources make the adoption of minimally invasive (MI) mitral valve surgery challenging unless greater operative costs (vs sternotomy [ST]) are balanced by postoperative savings. This study examined whether the cost analysis now became unfavorable. METHODS All patients (n = 380) undergoing isolated mitral valve surgery with or without a maze procedure over a 3-year period by either MI or ST approaches were included. Propensity matching (2 cohorts, 1:1 matched;, n = 75 per group) and multivariable regression were used to assess for the effect on cost. Cost data were prospectively collected from Service Line Reporting and reported in Sterling (£) as median (interquartile range [IQR]). RESULTS Matched data revealed that total hospital costs were equivalent (MI vs ST, £16,672 [IQR, £15,044, £20,611] vs £15,875 [IQR, £12,281, £20,687]; P .33). Three of 15 costing pools were significantly different: operative costs were higher for the MI group (MI vs ST, £7458 [IQR, £6738, £8286] vs £5596 iIQR, £4204, £6992]; P < .001), whereas ward costs (boarding, nursing) (MI vs ST, £1464 [IQR, £1146, £1864] vs £1733 [IQR, £1403, £2445] P = .006) and pharmacy services (MI vs ST, £187 [IQR, £140, £239] vs £244 [IQR, £179, £375] P < .001) were lower for the MI group. Hospital stay was shorter in the MI group (MI vs ST, 6 days [IQR, 5, 8 days] vs 8 days [IQR, 6, 11 days]; P < .001). Multivariable regression produced similar findings. CONCLUSIONS There was no difference in overall hospital cost between MI and ST mitral valve surgery: higher operative costs of MI surgery were offset by lower postoperative costs, with a 2-day shorter hospital stay.
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Affiliation(s)
- Giordano Perin
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiothoracic Anaesthesia, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom
| | - Matthew Shaw
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiothoracic Anaesthesia, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom
| | - Caroline Toolan
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiothoracic Anaesthesia, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom
| | - Kenneth Palmer
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiothoracic Anaesthesia, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom
| | - Omar Al-Rawi
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiothoracic Anaesthesia, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom
| | - Paul Modi
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom; Department of Cardiothoracic Anaesthesia, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, United Kingdom.
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13
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Minimally invasive and transcatheter approaches for mitral valve surgery. Indian J Thorac Cardiovasc Surg 2020; 36:492-501. [PMID: 33061160 DOI: 10.1007/s12055-019-00901-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/22/2019] [Accepted: 11/07/2019] [Indexed: 10/24/2022] Open
Abstract
Mitral valve surgery has evolved through the ages, in response to prevalent epidemiology of mitral pathologies. In the modern era, advances in technology has allowed physicians to help a wider spectrum on increasingly sicker patients. This review summarises these advances and its associated evidence base for safety and efficacy.
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14
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Weyl A, Chantalat E, Daniel G, Bordier B, Chaynes P, Doumerc N, Malavaud B, Vaysse C, Roumiguié M. Transvaginal minimally invasive approach: An update on safety from an anatomical, anatomopathological and clinical point of view. J Gynecol Obstet Hum Reprod 2020; 50:101941. [PMID: 33045446 DOI: 10.1016/j.jogoh.2020.101941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The aim of this work was to analyze the transvaginal approach in minimally invasive surgery in terms of anatomical, histopathological and functional characteristics, to show the safety of this surgical approach. METHODS Anatomical study was first conducted by dissection on fresh cadavers of adult women in order to measure the distance between the vaginal incision and the ureters, rectum and hypogastric nerves. In parallel, an anatomopathological study detailed and compared the macroscopic and histological characteristics of the anterior and posterior surfaces of vaginal samples obtained from cadavers and patients in the context of a hysterectomy for benign pathology. Finally, patients who underwent a transvaginal approach nephrectomy or transplantation were retrospectively enrolled for a clinical examination and an evaluation of their sexuality. RESULTS The anatomical study conducted on seventeen cadavers showed that the posterior vaginal fornix was remote from the major structures of the pelvis such as rectum, ureters, hypogastric plexus, which allowed a safe incision. Mechanical tests further demonstrated that the posterior vaginal fornix was more extensible than the anterior and histological features showed no major vascular or nervous structures. Ten patients were included in the retrospective clinical study. Long-term follow up showed no negative impact on the texture of the vagina or satisfaction from sexual intercourse. CONCLUSIONS Anatomical, histological and functional data supported that transvaginal approach by posterior vagina fornix incision is a minimally invasive surgery that can be performed safely and effectively by a skilled surgeon in cases with a specific surgical indication for this approach.
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Affiliation(s)
- Ariane Weyl
- Department of Gynecologic Surgery, University Hospital of Toulouse Rangueil, 1 Avenue du Professeur Jean Poulhès, 31400, Toulouse, France; Department of Anatomy, Université Paul Sabatier Toulouse III, 133 route de Narbonne, 31400, Toulouse, France.
| | - Elodie Chantalat
- Department of Gynecologic Surgery, University Hospital of Toulouse Rangueil, 1 Avenue du Professeur Jean Poulhès, 31400, Toulouse, France; Department of Anatomy, Université Paul Sabatier Toulouse III, 133 route de Narbonne, 31400, Toulouse, France
| | - Gwendoline Daniel
- Department of Anatomopathology, Institut Universitaire du cancer de Toulouse Oncopole, 1 av Irene Joliot-Curie, 31100, Toulouse, France
| | - Benoît Bordier
- Department of Urology, Clinique Pasteur, 45 avenue de Lombez, 31300, Toulouse, France
| | - Patrick Chaynes
- Department of Anatomy, Université Paul Sabatier Toulouse III, 133 route de Narbonne, 31400, Toulouse, France
| | - Nicolas Doumerc
- Department of Urology, University Hospital of Toulouse Rangueil, 1 Avenue du Professeur Jean Poulhès, 31400, Toulouse, France
| | - Bernard Malavaud
- Department of Urology, University Hospital of Toulouse Rangueil, 1 Avenue du Professeur Jean Poulhès, 31400, Toulouse, France; Department of Anatomy, Université Paul Sabatier Toulouse III, 133 route de Narbonne, 31400, Toulouse, France
| | - Charlotte Vaysse
- Department of Gynecologic Surgery, University Hospital of Toulouse Rangueil, 1 Avenue du Professeur Jean Poulhès, 31400, Toulouse, France
| | - Mathieu Roumiguié
- Department of Urology, University Hospital of Toulouse Rangueil, 1 Avenue du Professeur Jean Poulhès, 31400, Toulouse, France; Department of Anatomy, Université Paul Sabatier Toulouse III, 133 route de Narbonne, 31400, Toulouse, France
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15
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Missault S, Causenbroeck JV, Vandewiele K, Czapla J, Philipsen T, François K, Bové T. Analysis of clinical outcome and postoperative organ function effects in a propensity‐matched comparison between conventional and minimally invasive mitral valve surgery. J Card Surg 2020; 35:3276-3285. [DOI: 10.1111/jocs.15010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/18/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sophie Missault
- Department of Cardiac Surgery University Hospital of Ghent Ghent Belgium
| | | | | | - Jens Czapla
- Department of Cardiac Surgery University Hospital of Ghent Ghent Belgium
| | - Tine Philipsen
- Department of Cardiac Surgery University Hospital of Ghent Ghent Belgium
| | - Katrien François
- Department of Cardiac Surgery University Hospital of Ghent Ghent Belgium
| | - Thierry Bové
- Department of Cardiac Surgery University Hospital of Ghent Ghent Belgium
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16
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Less Invasive Mitral Surgery Versus Conventional Sternotomy Stratified by Mitral Pathology. Ann Thorac Surg 2020; 111:819-827. [PMID: 32717233 DOI: 10.1016/j.athoracsur.2020.05.145] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Our objective was to compare national mitral repair rates and outcomes after less invasive mitral surgery (LIMS) vs conventional sternotomy across the spectrum of mitral pathologies and repair techniques. METHODS Patients undergoing isolated primary mitral valve surgery in The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2014 to December 2018 were evaluated. Propensity score models were constructed nonparsimoniously, and prediction models used to compute adjusted effects of surgical approach. Hypothesis tests were adjusted for propensity score with inverse-probability weighting. RESULTS A total of 41,082 patients met inclusion criteria; comprising 10,238 (24.9%) LIMS and 30,844 (75.1%) conventional sternotomy, with increased LIMS adoption annually. Surgeons reporting LIMS cases had higher annual median mitral case volumes than those who did not (23 vs 8, P < .001). Groups were well-balanced after propensity adjustment including mitral pathology. Propensity score-adjusted outcomes showed increased procedural volume (odds ratio 1.030 [95% confidence interval: 1.028-1.031]) and LIMS (odds ratio 2.139 [95% confidence interval 2.032-2.251]) were independently associated with higher mitral repair rates. Propensity-adjusted outcomes included reduced stroke (P < .001), atrial fibrillation (P < .001), pacemaker (P < .001), renal failure (P < .001), and length of stay (P < .001) for LIMS vs sternotomy, without differences in mortality. Operative volume influenced outcomes in both groups. CONCLUSIONS LIMS was associated with higher mitral repair rates, and lower morbidity. Further studies regarding the impact of surgeon volume on choice of operative approach are necessary.
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17
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Han JJ, Smood B, Atluri P. Commentary: Transitioning to Minimally Invasive Mitral Valve Repair-Navigating the Gauntlet. Semin Thorac Cardiovasc Surg 2020; 32:838-839. [PMID: 32610191 DOI: 10.1053/j.semtcvs.2020.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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18
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Huang Y, Wittwer ED, Dearani JA, Schaff HV. The impact of surgical incision on hospital stay in patients extubated in the operating room after cardiac surgery. JTCVS Tech 2020; 1:62-64. [PMID: 34317716 PMCID: PMC8288618 DOI: 10.1016/j.xjtc.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/07/2019] [Accepted: 12/13/2019] [Indexed: 11/30/2022] Open
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19
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Goldman S. Commentary: Case of the missing message. JTCVS Tech 2020; 1:67-68. [PMID: 34317718 PMCID: PMC8288808 DOI: 10.1016/j.xjtc.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Scott Goldman
- Address for reprints: Scott Goldman, MD, Department of Surgery, Lankenau Medical, 280 Lankenau MSB, 100 Lancaster Ave, Wynnewood, PA.
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20
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Percy E, Hirji SA, Yazdchi F, McGurk S, Kiehm S, Cook R, Kaneko T, Shekar P, Pelletier MP. Long-Term Outcomes of Right Minithoracotomy Versus Hemisternotomy for Mitral Valve Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:74-80. [PMID: 31957524 DOI: 10.1177/1556984519891966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Minimally invasive mitral valve repair has been increasingly adopted. Right minithoracotomy (RT) and lower hemisternotomy (HS) have each been associated with improved short-term outcomes; however, these approaches have not been directly compared to each other. The aim of this study was to compare long-term survival and durability of 2 minimally invasive approaches to mitral repair. METHODS We retrospectively identified all isolated mitral repairs performed via RT or HS between October 1997 and June 2018; 100 RT cases and 719 HS cases were included. Outcomes of interest were postoperative complications, long-term survival, and freedom from mitral reoperation. A Cox proportional hazard model was used to compare RT and HS to a reference cohort of full-sternotomy cases. Total observation time was 9,901 patient-years and mean follow-up time was 12.2 years. RESULTS Mean age was 58±12 years in the RT group and 56±13 years in the HS group (P = 0.2). The RT group had longer bypass (143 minutes vs. 112 minutes; P < 0.001) and cross-clamp times (99 minutes vs. 78 minutes; P < 0.001) compared with the HS group. There were no differences in operative mortality or 30-day outcomes. Survival at 5, 10, and 15 years was 99% (96-100), 92% (85-100), and 69% (30-100) in the RT group and 98% (97-99), 92% (90-94), and 89% (86-92) for HS (P < 0.9). There were no differences in risk-adjusted survival between RT, HS and full sternotomy. No long-term mitral reoperations occurred in the RT group and 8 (1%) occurred in the HS group (P < 0.50). CONCLUSIONS Minimally invasive mitral valve repair can be performed safely through RT or HS with excellent survival and durability at 15 years.
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Affiliation(s)
- Edward Percy
- 8166 Division of Cardiovascular Surgery, University of British Columbia, Vancouver, BC, Canada.,1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer A Hirji
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Farhang Yazdchi
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Siobhan McGurk
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Spencer Kiehm
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Cook
- 8166 Division of Cardiovascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Tsuyoshi Kaneko
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prem Shekar
- 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc P Pelletier
- 114516 Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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21
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Williams RD, Foley NM, Vyas R, Huang S, Kertai MD, Balsara KR, Petracek MR, Shah AS, Absi TS. Predictors of Stroke After Minimally Invasive Mitral Valve Surgery Without the Cross-Clamp. Semin Thorac Cardiovasc Surg 2020; 32:47-56. [DOI: 10.1053/j.semtcvs.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 11/11/2022]
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22
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Shcherbatyuk KV, Komarov RN, Pidanov OY. [Right thoracotomy approach for minimally invasive mitral valve surgery]. Khirurgiia (Mosk) 2019:121-125. [PMID: 31825352 DOI: 10.17116/hirurgia2019121121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Minimally invasive approach in mitral valve surgery has been applied since the late 1990s. Considerable experience of mini-thoracotomy in cardiac surgery has been gained over this period. Stages of the development of minimally invasive cardiac surgery are reviewed in the article. Features of mitral valve surgery through right-sided mini-thoracotomy are discussed. Surgical outcomes of these procedures are reported considering data of various cardiac surgery centers. Moreover, the authors determined indications and limitations of this technique.
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Affiliation(s)
- K V Shcherbatyuk
- Clinical Hospital of the Presidential Administration, Moscow, Russia
| | - R N Komarov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - O Yu Pidanov
- Sechenov First Moscow State Medical University, Moscow, Russia
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23
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Minimally Invasive Surgical Options with Valvular Heart Disease. Crit Care Nurs Clin North Am 2019; 31:257-265. [DOI: 10.1016/j.cnc.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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24
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Kamada K, Kitahara H, Koichi Y, Wakabayashi N, Ise H, Tanaka C, Nakanishi S, Ishikawa N, Kamiya H. Delayed thoracic wall bleeding after minimally invasive mitral valve repair. J Surg Case Rep 2019; 2019:rjz187. [PMID: 31214324 PMCID: PMC6565816 DOI: 10.1093/jscr/rjz187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 05/24/2019] [Indexed: 11/13/2022] Open
Abstract
The first case of late thoracic wall bleeding after minimally invasive mitral valve repair treated by endovascular therapy is reported. A 55-year-old woman underwent mitral valve repair and tricuspid annuloplasty through a mini-thoracotomy approach. Her postoperative course was uneventful until she had anemia one week after the surgery. Contrast-enhanced computed tomography showed right hemothorax due to bleeding from a branch of the right lateral thoracic artery. Endovascular coil embolization and gelatin sponge injection were performed. The patient was discharged without any complications on postoperative day 20.
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Affiliation(s)
- Keisuke Kamada
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroto Kitahara
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yuta Koichi
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Naohiro Wakabayashi
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hayato Ise
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Chiharu Tanaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Sentaro Nakanishi
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
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25
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Coyan G, Wei LM, Althouse A, Roberts HG, Schauble D, Murashita T, Cook CC, Rankin JS, Badhwar V. Robotic mitral valve operations by experienced surgeons are cost-neutral and durable at 1 year. J Thorac Cardiovasc Surg 2018; 156:1040-1047. [DOI: 10.1016/j.jtcvs.2018.03.147] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 02/12/2018] [Accepted: 03/02/2018] [Indexed: 11/29/2022]
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26
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Nakamura Y, Emmanuel S, Shikata F, Shirai C, Ito Y, Kuroda M. Pressure difference between radial and femoral artery pressure in minimally invasive cardiac surgery using retrograde perfusion. Int J Artif Organs 2018; 41:635-643. [DOI: 10.1177/0391398818784791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To investigate whether radial artery pressure is a reliable surrogate measure of central arterial pressure as approximated by femoral artery pressure in minimally invasive cardiac surgery with retrograde perfusion via femoral cannulation. Method: Fifty-two consecutive patients undergoing minimally invasive cardiac surgery were prospectively included in this study. Cardiopulmonary bypass was established via a femoral artery cannulation and femoral vein. Radial and femoral arterial pressures were recorded continuously, and the pressure differential between them was calculated for both systolic and mean arterial pressures. The agreement between measurements from the two arteries was compared using Bland–Altman plots. An interval of 95% limits of agreement of less than 20 mm Hg was set as satisfactory agreement. Results: Average age was 65 ± 14 years. With respect to systolic arterial pressure, 28 patients (54%) had a peak pressure differential between radial and femoral arteries ⩾20 mm Hg. With respect to mean arterial pressure, only five patients (9%) had a peak pressure differential ⩾20 mm Hg. The pressure differential changed with time. Pressure differential in systolic arterial pressure was 5 ± 8 mm Hg until aortic declamping, then increased to a peak of 23 ± 16 mm Hg when cardiopulmonary bypass was turned off. The femoral systolic arterial pressures were significantly greater than radial systolic arterial pressures from time of aortic declamping to 20 min after cardiopulmonary bypass. The Bland–Altman plots revealed large biases and poor agreement in this period. Conclusion: Radial and femoral systolic artery pressure readings can differ significantly in minimally invasive cardiac surgery with retrograde perfusion. Intraoperative arterial pressure management based solely on radial systolic arterial pressure readings should be avoided.
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Affiliation(s)
- Yoshitsugu Nakamura
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Sam Emmanuel
- Department of Cardiothoracic Surgery, St Vincent’s Hospital Sydney, Sydney, NSW, Australia
| | - Fumiaki Shikata
- Department of Cardiothoracic Surgery, St Vincent’s Hospital Sydney, Sydney, NSW, Australia
| | - Chihiro Shirai
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Yujiro Ito
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Miho Kuroda
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
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27
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Chen CW, Atluri P. Robotic mitral valve surgery: Additive benefits without additive cost. J Thorac Cardiovasc Surg 2018; 156:1038-1039. [PMID: 29941165 DOI: 10.1016/j.jtcvs.2018.05.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Carol W Chen
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa.
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28
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Zhou T, Li J, Lai H, Zhu K, Sun Y, Ding W, Hong T, Wang C. Benefits of Early Surgery on Clinical Outcomes After Degenerative Mitral Valve Repair. Ann Thorac Surg 2018; 106:1063-1070. [PMID: 29883645 DOI: 10.1016/j.athoracsur.2018.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/10/2018] [Accepted: 05/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to evaluate the clinical trends of mitral valve repair for degenerative mitral regurgitation and the benefit of early surgical intervention on repair durability in a high-volume center. METHODS From January 2003 to December 2015, 1,903 consecutive patients with severe degenerative mitral regurgitation underwent mitral valve repair at our institution. The timing of surgical intervention was evaluated by guideline-related indications including symptoms, atrial fibrillation, left ventricular dysfunction, and pulmonary hypertension. Clinical outcomes and risk factors for recurrent mitral regurgitation were analyzed. RESULTS Over 13 years from 2003 to 2015, trends of preoperative characteristics demonstrated that the proportion of asymptomatic patients substantially increased. The 8-year overall survival, freedom from reoperation for mitral valve, and freedom from recurrent mitral regurgitation were 96%, 96%, and 85%, respectively. Ejection fraction less than 60%, left ventricular end-diastolic dimension greater than 60 mm, isolated anterior leaflet lesion, and intraoperative mild residual mitral regurgitation were independent predictive factors for recurrent mitral regurgitation. The incidence of recurrent mitral regurgitation was significantly lower in the early intervention group (3% versus 18%, p < 0.01). In subgroup analysis of asymptomatic patients, the incidence of recurrent mitral regurgitation was significantly lower in patients without guideline-related indications (3% versus 31%, p < 0.0001). CONCLUSIONS Early surgical intervention for severe degenerative mitral regurgitation before symptoms, atrial fibrillation, and ventricular dysfunction are associated with excellent clinical outcomes. Besides complexity of leaflet lesion and repair quality, surgical timing also significantly affects repair durability. Early surgical intervention should therefore be recommended to reduce recurrent mitral regurgitation.
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Affiliation(s)
- Tianyu Zhou
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun Li
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Zhu
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongxin Sun
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenjun Ding
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Hong
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiac Surgery and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.
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Mkalaluh S, Szczechowicz M, Dib B, Sabashnikov A, Szabo G, Karck M, Weymann A. Early and long-term results of minimally invasive mitral valve surgery through a right mini-thoracotomy approach: a retrospective propensity-score matched analysis. PeerJ 2018; 6:e4810. [PMID: 29868261 PMCID: PMC5978402 DOI: 10.7717/peerj.4810] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 04/30/2018] [Indexed: 11/30/2022] Open
Abstract
Background Minimally invasive mitral valve surgery (MVS) via right mini-thoracotomy has recently attracted a lot of attention. Minimally invasive MVS shows postoperative results that are comparable to those of conventional MVS through the median sternotomy as per various earlier studies. Methods Between 2000 and 2016, a total of 669 isolated mitral valve procedures for isolated mitral valve regurgitation were performed. A propensity score-matched analysis was generated for the elimination of the differences in relevant preoperative risk factors between the cohorts and included 227 patient pairs. Only degenerative mitral valve regurgitation was included. The aim of our study was to examine if the minimally MVS is superior to the conventional approach through sternotomy based on a retrospective propensity-matched analysis. The primary endpoints were early mortality and long-term survival. The secondary endpoints included postoperative complications. Results The in-hospital mortality rate was significantly higher within the conventional sternotomy cohort (3.1%, n = 7 vs 0.4%, n = 1 for the minimally invasive cohort; p = 0.032). The incidence of stroke and exploration for bleeding was comparable. In contrast, the necessity for dialysis was significantly lower in the minimally invasive cohort (p = 0.044). Postoperative pain was not significantly lower in the minimally invasive MVS cohort (p = 0.862). While patients who underwent minimally invasive MVS experienced longer bypass and cross-clamp times, their lengths of stay in the intensive care unit and in the hospital, did not differ from the conventionally operated collective (p = 0.779 and p = 0.516), respectively. The mitral valve repair rate of 81.1% in the minimally invasive cohort was significantly superior to that of the conventional approach, which was 46.3% (p < 0.0001). The one-, five-, and 10-year survival rates were significantly higher in the minimally invasive cohort compared to the conventional approach (96%, 90%, and 84% vs. 89%, 85%, and 70%; log rank p = 0.004). Conclusion Despite prolonged cardiopulmonary bypass and cross-clamping times, the minimally invasive MVS may be considered a safe approach that is equivalent to standard median sternotomy with lower early mortality and superior long-term survival.
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Affiliation(s)
- Sabreen Mkalaluh
- Department of Cardiac Surgery, Heart and Marfan Center-University of Heidelberg, Heidelberg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, Heart and Marfan Center-University of Heidelberg, Heidelberg, Germany
| | - Bashar Dib
- Department of Cardiac Surgery, Heart and Marfan Center-University of Heidelberg, Heidelberg, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Gabor Szabo
- Department of Cardiac Surgery, Heart and Marfan Center-University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center-University of Heidelberg, Heidelberg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, Heart and Marfan Center-University of Heidelberg, Heidelberg, Germany
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Badhwar V. The assessment of cost effectiveness and the effectiveness of cost assessment in cardiothoracic surgery. J Thorac Cardiovasc Surg 2018; 156:608-609. [PMID: 29764683 DOI: 10.1016/j.jtcvs.2018.04.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 04/16/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
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Han JJ, Atluri P. The invisible hands conducting minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg 2018; 156:617-618. [PMID: 29754797 DOI: 10.1016/j.jtcvs.2018.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/11/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa.
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Minimally invasive mitral valve surgery is associated with excellent resource utilization, cost, and outcomes. J Thorac Cardiovasc Surg 2018; 156:611-616.e3. [PMID: 29709359 DOI: 10.1016/j.jtcvs.2018.03.108] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 03/12/2018] [Accepted: 03/25/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Minimally invasive mitral valve surgery (mini-MVR) has numerous associated benefits. However, many studies fail to include greater-risk patients. We hypothesized that a minimally invasive approach in a representative cohort provides excellent outcomes with reduced resource utilization. METHODS Mitral valve surgical records from 2011 to 2016 were paired with institutional financial records. Patients were stratified by approach and propensity-score matched to balance preoperative difference. The primary outcomes of interest were resource utilization including cost, discharge to a facility, and readmission. RESULTS A total of 478 patients underwent mitral surgery (21% mini-MVR) and were balanced after matching (n = 74 per group), with 18% of patients having nondegenerative mitral disease. Outcomes were excellent with similar rates of major morbidity (9.5% mini-MVR vs 10.8% conventional, P = .78). Mini-MVR cases had lower rates of transfusion (11% vs 27%, P = .01) and shorter ventilator times (3.7 vs 6.0 hours, P < .0001). Mean total hospital cost was equivalent ($49,703 vs $54,970, P = .235) with mini-MVR having lower ancillary ($1645 vs $2652, P = .001) and blood costs ($383 vs $1058, P = .001). These savings were offset by longer surgical times (291 vs 234 minutes, P < .0001) with greater surgical ($7645 vs $7293, P = .0001) and implant costs ($1148 vs $748, P = .03). Rates of discharge to a facility (9.6% vs 16.2%) and readmission (9.6% vs 4.1%) were not statistically different. CONCLUSIONS In a real-world cohort, mini-MVR continues to demonstrate excellent results with a favorable resource utilization profile. Greater surgical and implant costs with mini-MVR are offset by decreased transfusions and ancillary needs leading to equivalent overall hospital cost.
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Ferket BS, Oxman JM, Iribarne A, Gelijns AC, Moskowitz AJ. Cost-effectiveness analysis in cardiac surgery: A review of its concepts and methodologies. J Thorac Cardiovasc Surg 2018; 155:1671-1681.e11. [PMID: 29338858 PMCID: PMC6497446 DOI: 10.1016/j.jtcvs.2017.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 10/31/2017] [Accepted: 11/09/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jonathan M Oxman
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, One Medical Center Drive, Lebanon, NH
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
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Tatum JM, Bowdish ME, Mack WJ, Quinn AM, Cohen RG, Hackmann AE, Barr ML, Starnes VA. Outcomes after mitral valve repair: A single-center 16-year experience. J Thorac Cardiovasc Surg 2017; 154:822-830.e2. [PMID: 28283230 DOI: 10.1016/j.jtcvs.2017.01.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 12/18/2016] [Accepted: 01/08/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate outcomes after mitral valve repair. METHODS Between May 1999 and June 2015, 446 patients underwent mitral valve repair. Isolated mitral valve annuloplasty was excluded. A total of 398 (89%) had degenerative valve disease. Mean follow-up was 5.5 ± 3.8 years. Postoperative echocardiograms were obtained in 334 patients (75%) at a mean of 24.3 ± 13.7 months. RESULTS Survival was 97%, 96%, 95%, and 94% at 1, 3, 5, and 10 years. Risk factor analysis showed age >60 years and nondegenerative etiology predict death (hazard ratio, 2.91; 95% confidence interval, 1.06-8.02, P = .038; and hazard ratio, 1.87; 95% confidence interval, 1.16-3.02, P = .010, respectively). Considering competing risks due to mortality, the cumulative incidence of reoperation was 2.8%, 4.2%, 5.1%, and 9.6% at 1, 3, 5, and 10 years. Competing risk proportional hazard survival regression identified nondegenerative etiology and previous cardiac surgery as predictors of reoperation, and posterior repair was protective (all P < .05). Cumulative incidence of progression of mitral regurgitation (2 or more grades) with mortality as a competing risk was 4.7%, 10.5%, 21.0%, and 35.8% at 1, 3, 5, and 10 years. Patients with previous sternotomy, repair or coronary artery bypass grafting, and concurrent tricuspid valve procedure or isolated anterior leaflet repair were more likely to develop progression of mitral regurgitation (all P < .05), and posterior leaflet repair was protective (P = .038). On multivariate analysis diabetes, previous coronary artery bypass grafting and concurrent tricuspid valve intervention predicted MR progression. CONCLUSIONS Mitral valve repair has excellent outcomes. Our results demonstrate failures appear to occur less in those who undergo posterior leaflet repair.
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Affiliation(s)
- James M Tatum
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Michael E Bowdish
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Adrienne M Quinn
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Robbin G Cohen
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Amy E Hackmann
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Mark L Barr
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Vaughn A Starnes
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
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Nagendran J, Catrip J, Losenno KL, Adams C, Kiaii B, Chu MW. Minimally invasive mitral repair surgery: why does controversy still persist? Expert Rev Cardiovasc Ther 2016; 15:15-24. [DOI: 10.1080/14779072.2017.1266936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Jorge Catrip
- Department of Cardiovascular Surgery, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Katie L. Losenno
- Division of Cardiac Surgery, Department of Surgery, Lawson Health Research Institute, Western University, London, Canada
| | - Corey Adams
- Division of Cardiac Surgery, Department of Surgery, Health Science Center, Memorial University, St. John’s, Canada
| | - Bob Kiaii
- Division of Cardiac Surgery, Department of Surgery, Lawson Health Research Institute, Western University, London, Canada
| | - Michael W.A. Chu
- Division of Cardiac Surgery, Department of Surgery, Lawson Health Research Institute, Western University, London, Canada
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De Palo M, Guida P, Mastro F, Nanna D, Quagliara TAP, Rociola R, Lionetti G, Paparella D. Myocardial protection during minimally invasive cardiac surgery through right mini-thoracotomy. Perfusion 2016; 32:245-252. [PMID: 28327076 DOI: 10.1177/0267659116679249] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myocardial damage is an independent predictor of adverse outcome following cardiac surgery and myocardial protection is one of the key factors to achieve successful outcomes. Cardioplegia with Custodiol is currently the most used cardioplegia during minimally invasive cardiac surgery (MICS). Different randomized controlled trials compared blood and Custodiol cardioplegia in the context of traditional cardiac surgery. No data are available for MICS. AIM The aim of this study was to compare the efficacy of cold blood versus Custodiol cardioplegia during MICS. METHOD We retrospectively evaluated 90 patients undergoing MICS through a right mini-thoracotomy in a three-year period. Myocardial protection was performed using cold blood (44 patients, CBC group) or Custodiol (46 patients, Custodiol group) cardioplegia, based on surgeon preference and complexity of surgery. RESULTS The primary outcomes were post-operative cardiac troponin I (cTnI) and creatine kinase MB (CKMB) serum release and the incidence of Low Cardiac Output Syndrome (LCOS). Aortic cross-clamp and cardiopulmonary bypass times were higher in the Custodiol group. No difference was observed in myocardial injury enzyme release (peak cTnI value was 18±46 ng/ml in CBC and 21±37 ng/ml in Custodiol; p=0.245). No differences were observed for mortality, LCOS, atrial or ventricular arrhythmias onset, transfusions, mechanical ventilation time duration, intensive care unit and total hospital stay. CONCLUSIONS Custodiol and cold blood cardioplegic solutions seem to assure similar myocardial protection in patients undergoing cardiac surgery through a right mini-thoracotomy approach.
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Affiliation(s)
- Micaela De Palo
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Pietro Guida
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Florinda Mastro
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Daniela Nanna
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Teresa A P Quagliara
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Ruggiero Rociola
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Giosuè Lionetti
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Domenico Paparella
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
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Matache R, Dumitrescu M, Bobocea A, Cordoș I. Median sternotomy - gold standard incision for cardiac surgeons. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2016. [DOI: 10.25083/2559.5555.11.3340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Sternotomy is the gold standard incision for cardiac surgeons but it is also used in thoracic surgery especially for mediastinal, tracheal and main stem bronchus surgery. The surgical technique is well established and identification of the correct anatomic landmarks, midline tissue preparation, osteotomy and bleeding control are important steps of the procedure. Correct sternal closure is vital for avoiding short- and long-term morbidity and mortality. The two sternal halves have to be well approximated to facilitate healing of the bone and to avoid instability, which is a risk factor for wound infection. New suture materials and techniques would be expected to be developed to further improve the patients evolution, in respect to both immediate postoperative period and long-term morbidity and mortality.
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Downs EA, Johnston LE, LaPar DJ, Ghanta RK, Kron IL, Speir AM, Fonner CE, Kern JA, Ailawadi G. Minimally Invasive Mitral Valve Surgery Provides Excellent Outcomes Without Increased Cost: A Multi-Institutional Analysis. Ann Thorac Surg 2016; 102:14-21. [PMID: 27041453 DOI: 10.1016/j.athoracsur.2016.01.084] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Minimally invasive mitral valve surgery (mini-MVR) has grown in popularity. Although single centers have reported excellent outcomes, data on real-world outcomes and costs of mini-MVR are limited. Moreover, mini-MVR has been criticized as adding additional cost without clear benefit. We hypothesized that mini-MVR provides superior outcomes with incremental increased costs in a multi-institutional cohort. METHODS Records for patients undergoing mitral valve surgical procedures with or without atrial ablation from 2011 to 2014 were extracted from a multi-institutional, regional Society of Thoracic Surgeons database and stratified according to right chest approach/minimally invasive or conventional sternotomy. Patients undergoing coronary artery bypass grafting or other concomitant procedures were excluded. Patients undergoing isolated mitral surgical procedure were propensity matched according to factors, including age, comorbidities, and preoperative laboratory values; clinical outcomes and cost differences were assessed by approach. RESULTS A total of 1,304 patients underwent mitral operations, including 425 (32.6%) by minimally invasive approach. In the propensity-matched analysis (n = 355 per group), patients undergoing mini-MVR had similar rates of mortality, stroke, and other complications compared with conventional MVR. Meanwhile, patients with mini-MVR experienced shorter intensive care unit and hospital lengths of stay and fewer transfusions. Importantly, total hospital costs were no different between the two matched groups. CONCLUSIONS Compared with conventional sternotomy, mini-MVR in the "real world" demonstrated no differences in rates of major morbidity, but it was associated with shorter length of stay and fewer transfusions. Contrary to our hypothesis, mini-MVR can be performed with similar total hospital costs as conventional sternotomy. In summary, minimally invasive mitral surgical procedure in select patients can provide superior outcomes without increased cost.
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Affiliation(s)
- Emily A Downs
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Lily E Johnston
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Damien J LaPar
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Ravi K Ghanta
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Irving L Kron
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Alan M Speir
- Cardiovascular and Thoracic Associates, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Clifford E Fonner
- Virginia Cardiac Surgery Quality Initiative, Charlottesville, Virginia
| | - John A Kern
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
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Vassileva CM. Minimally invasive mitral repair: The cost is the same, but what is the price? J Thorac Cardiovasc Surg 2016; 151:389-90. [DOI: 10.1016/j.jtcvs.2015.09.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 11/15/2022]
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