Current trends in mitral valve surgery: A multicenter national comparison between full-sternotomy and minimally-invasive approach
Introduction
Treatment of heart diseases is rapidly evolving with a tendency to offer minimally invasive or transcatheter interventions rather than standard full sternotomy operations that have been successfully utilized in the past decades. Management of mitral valve disease is no different: the use of new transcatheter mitral repair or prosthesis techniques is in sight for the future [1,2] and minimally invasive techniques to perform standardized surgical operations are increasingly utilized. Surgery through right mini-thoracotomy approach has established itself as an optimal option to treat pathologies affecting atrio-ventricular valves [3,4]. Experienced and specifically trained surgeons can achieve excellent results as those obtained with standard sternotomy, with many studies reporting better pain control, faster recovery and a shorter hospital stay as compared to conventional surgery [5]. Despite encouraging results and excellent reports from leading institutions and surgeons, minimally invasive is not yet considered a standard of care nor mentioned as the technique of choice in guidelines. It is still many surgeons' belief that minimally invasive cardiac surgery is not safe, prolongs intervention time and can be performed only by a selected minority of very skilled surgeons. The aim of the present study is to evaluate trends of surgical approaches, operative outcomes and variations in operation times in a multicenter large cohort of patients undergone mitral valve surgery either with standard full sternotomy (S-MVS) or minimally invasive approach (Mini-MVS).
Section snippets
Methods
Data from 10 Italian cardiac centers sharing the same clinical and administrative database were analyzed from January 2011 up to December 2017. In all centers cardiology and cardiac surgery divisions are unified in a single department sharing the same clinical and administrative organization. All patients who received mitral valve surgery through a standard sternotomy or minimally invasive approach (right anterior mini-thoracotomy) were considered for the analysis. Excluded from the analysis
Results
During the study period, 4549 patients underwent mitral valve surgery in 10 hospitals. In 1947 cases a full sternotomy was performed while in 2602 a minimally invasive approach was chosen. Utilization of Mini-MVS has increased over the years becoming the most practiced approach (Fig. 1). The overall number of procedures performed per year increased from 454 in 2011 up to 776 in 2017. During the study period all but one center performed >40 mitral procedures per year. One center performed a mean
Discussion
Minimally invasive mitral valve approach is now an established procedure, we demonstrate in a large, multi-center population that with adequate training and team commitment the majority of mitral valve procedures can be performed safely with a minimally invasive approach. However its adoption remains hectic among cardiac centers and some concerns still exist in terms of safety. Also, it requires a steep learning curve, thus conventional sternotomy continues to be the standard practice in many
Conclusions
This multi-center propensity score matched study contributes to demonstrate that minimally invasive approach is as safe as conventional sternotomy, exhibiting low mortality and morbidity. Moreover it is associated with some better immediate postoperative outcomes compared to standard sternotomy, such as lower incidence of blood transfusion and pacemaker implant. The adoption of minimally invasive approach has increased dramatically in the course of our observation and the time of the operations
Declaration of competing interest
None declared.
References (17)
- et al.
Initial feasibility study of a new transcatheter mitral prosthesis: the first 100 patients
J. Am. Coll. Cardiol.
(2019) - et al.
Isolated mitral valve surgery: the Society of Thoracic Surgeons adult cardiac surgery database analysis
Ann. Thorac. Surg.
(2018) - et al.
Results of mitral valve repair for Barlow disease (bileaflet prolapse) via right minithoracotomy versus conventional median sternotomy: a randomized trial
J. Thorac. Cardiovasc. Surg.
(2011) - et al.
Right minithoracotomy versus median sternotomy for mitral valve surgery: a propensity matched study
Ann. Thorac. Surg.
(2015) - et al.
Thoracoscopic versus open mitral valve repair: a propensity score analysis of early outcomes
Ann. Thorac. Surg.
(2009) - et al.
Early mortality following percutaneous coronary intervention and cardiac surgery: correlations within providers and operators
Int. J. Cardiol.
(2017) - et al.
Transcatheter mitral-valve repair in patients with heart failure
N. Engl. J. Med.
(2018) - et al.
Mitral valve surgery can now routinely be performed endoscopically
Circulation
(2003)
Cited by (44)
Enhanced recovery after cardiac surgery: The next step towards optimized care
2023, International Journal of CardiologyTime Trends of Cardiovascular Disease in the General Population and Inflammatory Arthritis
2023, Rheumatic Disease Clinics of North AmericaCitation Excerpt :Still, recent data from a multicenter study in the United States suggest no change in the incidence rate but more frequent diagnostics of the atrial fibrillation.64 Over the years, there has been a significant increase in pacemaker implantation as well as cardiac valve surgery due to technical and surgical progress.65–69 In patients with spondarthritis, and in patients with PsA with axial disease, conduction abnormalities and aortic insufficiency are suggested to be related to the rheumatic disease per se and possibly influenced by the disease activity of the rheumatic disease,70,71 with a possible association of the conduction disorders to human leukocyte antigen B27 (HLAB27).72
Enhanced recovery after cardiac surgery under CPB or off-pump 2021
2022, Anesthesie et ReanimationGuidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump
2022, Anaesthesia Critical Care and Pain MedicineCitation Excerpt :One hundred forty-five studies were reviewed, out of which 17 were selected. Among the selected studies, nine (3 randomised controlled trials (RCTs), 4 meta-analyses, 1 observational study with propensity score matching, and 1 observational study) pertained to aortic valve replacement [149–157], six (1 RCT, 5 observational studies with propensity-score matching) addressed mitral valve replacement [158–163], and 2 were observational studies with propensity score matching that involved patients undergoing coronary artery bypass grafting (CABG) [164,165]. Regarding aortic valve replacement, the studies [149–156] compared patients with full sternotomy to those with mini-sternotomy and/or antero-lateral thoracotomy, sometimes mixing both.
Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study
2022, Journal of Clinical AnesthesiaCitation Excerpt :Minimally invasive cardiac surgery with anterolateral thoracotomy has been proposed with the aim to improve aesthetics and enhance functional recovery. While the benefits of the minimally invasive approach are well documented [1,20–23], there are scattered data in the literature on its impact on APP and PPP [10,24–34]. At our institution, patients undergoing elective cardiac surgical procedures both with anterolateral thoracotomy and sternotomy, are considered for our fast-track program that includes early extubation in a post-anesthesia care unit (PACU) without admission to the intensive care unit. [35,36].
- 1
This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.