Interact CardioVasc Thorac Surg 2008;7:678-683. doi:10.1510/icvts.2008.180182
© 2008 European Association of Cardio-Thoracic Surgery
Best evidence topic - Valves |
Is a port-access mitral valve repair superior to the sternotomy approach in accelerating postoperative recovery?
Lydia Richardsona,*,
Michael Richardsonb and
Steven Hunterc
a Medical Student, Brighton and Sussex Medical School, Brighton, East Sussex, UK
b General Practitioner, Hadleigh House Surgery, The Kirkway, Broadstone, Dorset, UK
c Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Received 18 March 2008;
received in revised form 27 March 2008;
accepted 31 March 2008
*Corresponding author. Tel./fax: +44 7894 559594.
E-mail address: l.e.richardson{at}bsms.ac.uk (L. Richardson).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether port-access mitral valve repair reduces the recovery period of patients compared to the conventional sternotomy approach. Using the reported search, 778 papers were identified. Thirteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The 13 papers demonstrated that patients who undergo minimally invasive mitral valve repair have a shorter ICU and total hospital stay than those who undergo the sternotomy approach. Results vary but mean hospital stays range from 5.6 to 13 days in port-access groups compared to 6.25–15 days in sternotomy groups. Other advantages over the sternotomy approach were reduced postoperative bleeding and pain, shorter time to extubation and a quicker return to daily activities. However, it is consistently reported that operative time is longer, with the increase in bypass time being around 30 min. We conclude that in several cohort studies minimally invasive mitral valve repair is reported to result in a shorter ICU and hospital stay, reduced postoperative bleeding and pain and a shorter time to resuming normal activities. This is at the expense of longer bypass and operative times.
Key Words: Minimally invasive mitral valve repair; Sternotomy; Hospital/ICU stay
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1. Introduction
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A best evidence topic was constructed according to a structured protocol, described in the ICVTS [1].
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2. Clinical scenario
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You are a general practitioner who suffered from two episodes of paroxysmal atrial fibrillation. Having heard a pansystolic murmur on self-examination, you see a cardiologist who demonstrates moderate mitral regurgitation from a prolapsing P2 segment. You are aware of port-access mitral valve repair as an alternative to sternotomy but elect to search for the evidence that this approach is both safe and superior to the more conventional approach prior to being referred for surgery.
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3. Three-part question
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In [patients requiring mitral valve repair] does [minimally invasive mitral valve repair] compared to [conventional repair] safely improve [clinical outcomes]?
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4. Search strategy
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Medline 1950 to March 2008 using OVID Interface. [exp mitral valve prolapse/OR exp mitral valve insufficiency/OR exp heart valve prosthesis implantation/OR mitral repair.mp] AND [exp surgical procedures/OR exp minimally invasive/OR exp port-access/OR exp heartport]. Embase 1980 to March 2008. [exp mitral valve prolapse/OR exp mitral valve insufficiency] AND [exp minimally invasive/OR exp port access]. Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials register searched on 1st March 2008 using search terms ‘minimally invasive’ and ‘mitral valve repair’. References of resulting papers were also reviewed.
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5. Search outcome
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Four hundred and forty-five papers were found in Medline, 332 abstracts from Embase and one paper from the Cochrane controlled trials register. From these studies 13 represented the best evidence on the topic (Table 1). We included seven cohort studies [2–8], four of which were comparative and three that studied the peri- and post-operative outcomes of minimally invasive mitral valve surgery alone, four comparative case-control studies [9–12] and two prospective randomised studies [13, 14].
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6. Comments
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One of the two prospective randomised trials included only mitral valve repair operations, however, they recruited a small patient population [13], therefore, further larger randomised trials are needed to consolidate their findings. The remaining studies are all uncontrolled comparative studies with their obvious limitations.
In nine studies [3, 4, 7 –13], a minimally invasive approach was compared to the sternotomy approach. In all these studies, the mean ICU stay was shorter in patients who underwent minimally invasive mitral valve surgery ranging from 10 h [13] to 2.1 days [3], compared to sternotomy patients which ranged from 1.6 [13] to 3.9 days [3]. In six of the comparative studies, the total hospital stay was shorter in the minimally invasive patient group ranging from 5.6 [4] to 13 days [10], compared to sternotomy patients ranging from 6.25 [12] to 15 days [10]. As the patient groups in the majority of studies were small, these results were not statistically significant, however, they suggest that patients undergoing minimally invasive mitral valve repair will leave hospital earlier than sternotomy patients.
Other advantages of minimally invasive surgery were a shorter time to extubation with a difference of 18 h [3], a statistically significant faster return to normal activity of 4 vs. 9 weeks [7], a reduction in pain medication post-operatively [8] and a reduction in postoperative bleeding with a difference ranging from 449 [14] to 670 ml [11] between minimally invasive and sternotomy patients. Two studies did not compare to sternotomy, however, they did observe low mortality rates of 1.1% [5] and no peri-vascular leak on 3-month follow-up [6].
Two of the comparative studies [3, 9] compared the sternotomy to robotic-assisted (da Vinci) minimally invasive surgery. Additionally, procedure variability was present; De Vaumas et al. [10] and Aklog et al. [4] performed a relatively long 8–10 cm incision with excision of the 3rd and 4th costal cartilages, while Yamada et al. [8] performed a mini-sternotomy. The difference in relative invasiveness of the surgeons may account for the ranges in results attained.
Casselman et al. [2] performed a retrospective study of 187 patients who underwent endoscopic mitral valve repair and distributed a patient satisfaction questionnaire at follow-up. It showed that 93.5% of patients experienced minimal pain and 33.7% had returned to routine/work activity within 4 weeks, with another 26.6% within 8 weeks.
A peri-operative outcome observed in seven of the nine comparative studies [3, 7–9, 13] was a longer time on bypass (min) in the minimally invasive group of 165.5 compared to 130.6 for sternotomy patients.
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7. Clinical bottom line
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Minimally invasive mitral valve repair shortens hospital and ICU stay compared to the sternotomy approach. Other postoperative benefits include less postoperative bleeding probably due to the avoidance of sternotomy, shorter time to extubation, less postoperative pain, shorter period of returning to normal activities and low hospital mortality. As the bypass period and anaesthetic set-up are longer, the operative time is longer than sternotomy.
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References
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Abstract
1. Introduction