Interact CardioVasc Thorac Surg 2009;9:327-332. doi:10.1510/icvts.2009.203448
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Valves |
Is a minimally invasive approach for re-operative mitral valve surgery superior to standard resternotomy?
Michele Murzi*,
Marco Solinas and
Mattia Glauber
Department of Adult Cardiac Surgery, G. Pasquinucci Heart Hospital, Massa, Italy
Received 21 January 2009;
received in revised form 24 April 2009;
accepted 29 April 2009
*Corresponding author. Tel./fax: +393395380428.
E-mail address: michelem{at}ifc.cnr.it (M. Murzi).
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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 ‘Is a minimally invasive approach superior to standard sternotomy for re-operative mitral valve surgery?’. Altogether 48 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that minimally invasive mitral valve re-operation can be performed with an operative mortality similar to standard sternotomy approach but with a higher patient satisfaction. Less postoperative bleeding, reduced need for blood transfusion and absence of sternal wound infection are the main advantages of this technique. Mean hospital stays and ventilation time appear to be reduced with this approach.
Key Words: Review; Mitral valve surgery; Re-operation; Minimally invasive cardiac surgery
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients undergoing re-operative mitral valve surgery] is [a minimally invasive approach] superior to [standard median sternotomy] in terms of [morbidity and mortality]?
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3. Clinical scenario
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You are seeing a 65-year-old gentleman in clinic who has severe mitral valve regurgitation with a P2 prolapse, good left ventricular function and NYHA grade III shortness of breath. Thirteen years ago he underwent CABGx2 for left main stem disease, and his angiogram shows that his grafts are patent. You are discussing the risks and benefits of re-operative sternotomy, when he mentions that he has looked on the internet and wondered if it would be worth being referred to a surgeon who offers port-access mitral valve repair as he has heard that he would get better quicker. You agree to see him again and resolve to look up the comparative results of these two techniques before referring him on.
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4. Search strategy
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Medline 1950 to March 2009 using Pubmed interface: [exp Heart Valve Prosthesis Implantation/OR mitral valve surgery.mp. OR mitral repair.mp. OR mitral replacement.mp. OR mitral valve repair.mp. OR mitral valve replacement.mp] AND [re-operat$.mp OR re-operat$.mp.] AND port access.mp OR mini thoracotom$.mp OR endoscopic. mp.
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5. Search outcome
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Forty-eight papers were found using the reported search. From these nine papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
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6. Results
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In 2006, Sharony et al. [2] reviewed a large consecutive cohort of patients undergoing re-operative valve surgery (161 through a minimally invasive approach and 337 through a median resternotomy). They showed a comparable hospital mortality, CPB and aortic clamp time between the two groups. In addition, they demonstrated fewer wound complications, less blood transfusion requirements and shorter hospital stays for the minimally invasive group. They also demonstrated a slightly favorable mid-term outcome with the minithoracotomy approach. However, it is important to note that the median sternotomy group had a high incidence of congestive heart failure, renal disease and urgent operation.
Burfeind et al. [3] showed that patients undergoing re-operative mitral valve surgery through a right minithoracotomy approach had lower mortality and less blood transfusion than via resternotomy or an anterolateral thoracotomy. They also revealed that the incidence of mediastinitis can be avoided with a minithoracotomy approach. However, longer CPB and aortic clamp time were observed in the minimally invasive group (port-access 208±76 min, thoracotomy 158±56 min, sternotomy 157±53 min).
Bolotin et al. [4] compared a minimally invasive group of 38 patients with 33 patients who underwent standard resternotomy. The authors demonstrated no differences in terms of hospital mortality, clinical outcome and CPB time. However, they showed a shorter intubation time and less blood transfusion requirements in the minithoracotomy group. In these patients, they also demonstrated a reduction in hospital stay but not of the ICU stays.
Vleissis et al. [5] operated on 22 consecutive patients via a minithoracotomy approach over a 1-year period. Their results showed an absence of hospital mortality and deep wound infection. They also demonstrated a strong patient satisfaction with this approach.
Casselman et al. [6] reported a series of 80 patients undergoing endoscopic re-operative mitral valve surgery through a very small thoracotomy, without rib-spreading. They reported an in-hospital mortality of 3.8% over an expected mortality of 16±14%. In their follow-up they demonstrated a 4-year survival rate of 85.6% with just one late re-operation at five years. Of interest is the fact that 99% of the patients preferred the endoscopic approach over the previous sternotomy operation.
The study of Walther et al. [7] is an update article of a their previous series. The authors reported 97 patients operated on over a decade. They demonstrated a lower hospital mortality in comparison with their institutional registry data. However, they did not report any operative and postoperative data.
In 2002, Trehan et al. [8] reported 32 patients (prevalently rheumatic; 28 patients) operated on through a right minithoracotomy for redo mitral valve surgery. The authors reported no in-hospital mortality, no re-exploration for bleeding and no neurological complications. At follow-up (mean 18.4±9.2 months) no late death occurred.
Onnasch et al. [9] compared a series of 39 patients operated on by a minimally invasive approach and 25 patients, retrospectively selected, operated on by a redo-sternotomy. The authors did not find significant difference in operative time, CPB time and cross-clamp time between the two groups. The only data which differed significantly were the times of preparation which were lower in the minimally invasive group (43±8 vs. 57±20; P<0.05). Hospital mortality in the minimally invasive group was 5.1%. Unfortunately the authors did not provide any data on the resternotomy group in terms of hospital mortality, complications and follow-up.
Seeburger et al. recently reported the largest series of minimally invasive re-operative mitral valve surgery [10]. Over a period of 9 years, the authors operated on 181 patients via a right minithoracotomy. Thirty-day mortality was 6.6%. Myocardial protection was assured by aortic cross-clamp in 31 patients (17.1%), hypothermic ventricular fibrillation in 140 patients (77.3%) and by beating heart technique with CPB in 10 patients (5.5%). Conversion to sternotomy was necessary in three patients (1.7%). Strokes happened in seven patients and early re-operation (<30 days) was performed in six patients (3.3%). The authors do not give any follow-up.
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7. Clinical bottom line
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Minimally invasive mitral valve re-operation can be performed with an operative mortality similar to standard sternotomy approach. Less postoperative bleeding, low need for blood transfusion and absence of sternal wound infection are the main advantages of this technique. Mean hospital stays and ventilation time appear to be reduced with this approach.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–409.[Abstract/Free Full Text]
- Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ursomanno P, Ribakove GH, Galloway AC, Colvin SB. Minimally invasive reoperative isolated valve surgery: early and mid-term results. J Card Surg 2006;21:240–244.[CrossRef][Medline]
- Burfeind WR, Glower DD, Davis RD, Landolfo KP, Lowe JE, Wolfe WG. Mitral surgery after prior cardiac operation: port-access versus sternotomy or thoracotomy. Ann Thorac Surg 2002;74:1323–1325.[CrossRef]
- Bolotin G, Kypson AP, Reade CC, Chu VF, Freund WL, Nifong LW, Chitwood WR. Should a video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery? J Heart Valve Dis 2004;13:155–158.[Medline]
- Vleissis A, Bolling SF. Mini-reoperative mitral valve surgery. J Cardiac Surg 1998;13:468–470.[CrossRef][Medline]
- Casselman F, La Meir M, Jeanmart H, Mazzarro E, Coddens J, Van Praet F, Wellens F, Vermeulen Y, Vanermen H. Endoscopic mitral and tricuspid valve surgery after previous cardiac surgery. Circulation 2007;116:270–275.
- Walther T, Falk V, Mohr FW. Minimally invasive surgery for valve disease. Curr Prob Cardiol 2006;31:399–437.[CrossRef][Medline]
- Trehan N, Mishra YK, Mathew SG, Sharma KK, Shrivastava S, Metha Y. Redo mitral valve surgery using the port-access system. Asian Cardiovasc Thorac Ann 2002;10:215–218.[Abstract/Free Full Text]
- Onnasch JF, Schneiderr F, Falk V, Walther T, Gummert J, Mohr FW. Minimally invasive approach for redo mitral valve surgery.
- Seeburger J, Borger MA, Falk V, Passage J, Walther T, Doll N, Mohr FW. Minimally invasive mitral valve surgery after previous sternotomy: experience in 181 patients. Ann Thorac Surg 2009;87:709–714.[Abstract/Free Full Text]
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Abstract
1. Introduction