Minimally invasive mitral valve surgery

Moving from minimally invasive to totally endoscopic mitral valve surgery: a retrospective review of outcomes

OBJECTIVES

Mitral valve surgery has undergone significant advancements with the emergence of minimally invasive mitral surgery harnessing endoscopic technology to facilitate repair through a right anterior thoracotomy. Further refinement within the field has borne the novel totally endoscopic approach, reducing incision size, and surgical trauma, to 3 cm. While there is evidence to support non-inferiority of minimally invasive techniques compared to a traditional sternotomy, a knowledge gap exists regarding the comparative safety and efficacy between minimally invasive modalities, necessitating.

METHODS

A retrospective review of outcomes following totally endoscopic and minimally invasive mitral valve surgery by right anterior thoracotomy was completed. One hundred eighty-six patients were included, all operations having been performed by a single surgeon, between January 2019 and June 2023. The hypothesis posits that the former offers an equivalence in repair while reducing postoperative pain, bleeding from the wound and enhancing cosmesis.

RESULTS

While low 30-day mortality rates were seen in both cohorts, the totally endoscopic group exhibited lower rates of patients discharged with opiates (16% vs 23%), reduced blood product transfusion requirements (33% vs 43%) and shorter postoperative stays (mean of 9.2 days vs 11.4 days).

CONCLUSIONS

Moving from minimally invasive to totally endoscopic mitral valve surgery has been a positive experience with key patient advantages characterized by smaller incisions and avoidance of rib spreading. In this dataset, improved patient outcomes such as postoperative bleeding, pain, length of hospital stay and cosmesis were observed with all limitations given its fully uncontrolled nature. Validation of these findings warrants a larger study.

Implementing Ultra-Fast-Track Cardiac Anesthesia in Minimally Invasive Cardiac Surgery

OBJECTIVE

To analyze factors influencing the implementation of ultra-fast-track cardiac anesthesia (UFTCA) from the perspectives of preoperative and intraoperative conditions and to compare its postoperative recovery with that of conventional cardiac anesthesia (CGA).

DESIGN

An observational retrospective study SETTING: Electronic medical records data for patients from January 2021 through July 2023 PARTICIPANTS: 967 patients with a documented history of minimally invasive cardiac surgery (MICS) INTERVENTIONS: Review of electronic medical records MEASUREMENTS AND RESULTS: Data for 947 patients, including 439 who received UFTCA and 508 who received CGA, were analyzed retrospectively. Multivariate logistic regression identified independent factors associated with UFTCA implementation. Risk factor analysis showed that age >50 years (odds ratio [OR], 1.924; p = 0.040), history of stroke (OR, 2.290; p = 0.009), and duration of cardiopulmonary bypass (CPB) (OR, 1.013; p < 0.001), intraoperative sufentanil dosage (OR, 1.035; p < .001), and surgeries ending after 8 pm (OR, 2.184; p < 0.001) were negatively correlated with UFTCA implementation. Pectoral muscle fascial plane block (OR, 0.120; p < .001) and dexamethasone (OR, 0.438; p < .001) were positive factors in UFTCA implementation. Compared to the CGA group, the UFTCA group had fewer cases of intensive care unit (ICU) rescue analgesia (77 [17.5%] vs 178 [35%]; p < 0.001), shorter ICU stay (mean, 22.83 ± 20 hours vs 44 ± 43 hours; p < 0.001) and postoperative hospital stay (mean, 8 ± 3 days vs 10 ± 5 d; p < .001), and lower incidence of postoperative delirium (6 [1.4%] vs 28 [5.5%]; p = 0.001) but a higher incidence of postoperative nausea and vomiting (86 [19.6%] vs 62 [12.2%]; p = 0.002). The oxygenation index (OI) was lower at 1 hour postsurgery but higher at 6 hours postsurgery in the UTCA group compared to the CGA group (p < 0.05).

CONCLUSIONS

Seven independent factors were identified for UFTCA implementation in MICS, among which age >50 years, history of stroke, duration of CPB, intraoperative sufentanil dosage, and surgery ending after 8 pm were negative factors and pectoral muscle fascial plane block and dexamethasone use were positive factors. The use of UFTCA in MICS shortened ICU stay and hospital stay, decreased the incidence of delirium, and promoted postoperative pulmonary function.

Survival Analysis of Minimally Invasive Mitral Valve Surgery Versus Conventional Median Sternotomy in the United States

BACKGROUND

Minimally invasive mitral valve surgery (MiMVS), particularly via right mini-thoracotomy, has gained popularity as an alternative to median sternotomy, potentially reducing surgical trauma and recovery time. However, recent data on its surgical outcomes remain limited. To provide updated insights while minimizing selection bias, we analyzed elective patients undergoing mitral valve surgery, comparing MiMVS and sternotomy in terms of survival, operative times, and perioperative complications.

METHODS

We conducted a single-center retrospective cohort study that included patients who underwent mitral valve surgery between 2015 and 2024. Patients were stratified into MiMVS or sternotomy groups. Kaplan-Meier survival curves and log-rank tests assessed survival, while propensity score matching (PSM) minimized selection bias.

RESULTS

Among 422 patients (319 MiMVS, 103 sternotomy), the MiMVS group had a shorter hospital stay (5.0 vs. 8.0 days, p < 0.01) and lower postoperative bleeding (3.9% vs. 9%). Median cross-clamp and cardiopulmonary bypass (CPB) times were shorter in MiMVS (76 vs. 94 min, p < 0.01; and 114 vs. 140 min, p < 0.01, respectively). Survival analysis showed no significant difference between groups (log-rank p = 0.07) after PSM. The adjusted hazard ratio for mortality in MiMVS versus sternotomy was 0.30 (95% CI: 0.08-1.12, p = 0.07). However, mitral replacement was associated with a significantly higher mortality risk than mitral repair (HR 5.22, 95% CI: 1.26-21.61, p = 0.04). In-hospital mortality was comparable (1.9% for sternotomy vs. 0.6% for MiMVS, p = 0.25). Reoperation rates at five and 10 years were lower in MiMVS (1.7% vs. 2.1% at five years and 1.7% vs. 3.2% at 10 years).

CONCLUSIONS

While MiMVS offers advantages such as shorter hospital stays and lower postoperative bleeding rates, no statistically significant difference in overall survival was found compared to sternotomy. However, a trend toward improved survival with MiMVS was observed. Notably, mitral valve replacement was associated with a significantly higher mortality risk than mitral repair, emphasizing the importance of prioritizing repair whenever feasible.

Contemporary Review of Minimally Invasive Mitral Valve Surgery: Current Considerations and Innovations

Minimally invasive mitral valve surgery (MIMVS) has become a well-established alternative to traditional median sternotomy at high-volume surgical centers. Advancements in surgical instruments have led to further refinement of MIMVS. However, MIMVS remains limited to select patients in select settings. In this review, we provide a brief overview of the evolution of MIMVS, as well as a technical description of the most relevant aspects of minimally invasive mitral valve surgery.

Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques

Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved.

A qualitative improvement program for minimally invasive mitral surgery: technical advancements ameliorate outcome and operative times

OBJECTIVES

Minimally invasive mitral valve surgery (MIMVS) has evolved over the last 2 decades. The aim of the study was to identify the impact of era and technical improvements on perioperative outcome after MIMVS.

METHODS

A tota of 1000 patients (mean age: 60.8 ± 12.7 years, 60.3% male) underwent video-assisted or totally endoscopic MIMVS between 2001 and 2020 in a single institution. Three technical modalities were introduced during the observed period: (i) 3D visualization, (ii) use of premeasured artificial chordae (PTFE loops) and (iii) preoperative CT scans. Comparisons were made before and after the introduction of technical improvements.

RESULTS

A total of 741 patients underwent isolated mitral valve (MV) procedure, whereas 259 received concomitant procedures. These consisted of tricuspid valve repair (208), left atrium ablation (145) and persistent foramen ovale or atrial septum defect (ASD) closure (172). The aetiology was degenerative in 738 (73.8%) patients and functional in 101 patients (10.1%). A total of 900 patients received MV repair (90%), and 100 patients (10%) underwent MV replacement. Perioperative survival was 99.1%, and periprocedural success 93.5% with a periprocedural safety of 96.3%. Improvement in periprocedural safety attributed to the lower rates of postoperative low output (P = 0.025) and less reoperations for bleeding (P < 0.001). 3D visualization improved cross-clamp (P = 0.001) but not cardiopulmonary bypass times. The use of loops and preoperative CT scan both had no impact on periprocedural success or safety but improved cardiopulmonary bypass and cross-clamp times (both P < 0.001).

CONCLUSIONS

Increased surgical experience improves safety in MIMVS. Technical improvements are related to increased operative success and decreased operative times in patients undergoing MIMVS.