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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 111-115

Outcome of minimal access mitral valve surgery in elderly patients


1 Department of Cardiothoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India; Division of Cardiac Surgery, Yale University Medical Centre, New Haven, CT, USA
2 Division of Cardiac Surgery, Yale University Medical Centre, New Haven, CT, USA

Date of Web Publication12-Sep-2017

Correspondence Address:
Sanjay Kumar
Department of Cardiovascular and Thoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_16_17

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  Abstract 

Background: Mitral valve surgery (MVS) approached through sternotomy can be associated with significant morbidity and mortality in the elderly population. The aim of this study was to review our experience with minimal access MVS (mini-mitral) in patients aged 70 years or older.
Materials and Methods: A total of 44 patients over the age of 70 years had sternal sparing mini-mitral surgery performed by a single surgeon from January 2011 to November 2015.
Results: A total of 44 patients (28 [64%] males and 16 [36%] females), in the age group ranging from 70 to 92 years (mean 79.84 ± 6.52), were included in the study. Comorbidities included hypertension (70.5%; n = 31), peripheral vascular disease (9.1%; n = 4), cerebrovascular disease (11.4%; n = 5), severe chronic obstructive pulmonary disease (2.3%; n = 1), and dialysis-dependent chronic kidney disease (2.3%; n = 1). Five (11.4%) patients had undergone one or more previous cardiac surgery procedures. A total of 33 (75%) patients underwent mitral valve repair, and 11 (25%) underwent replacement with bioprosthesis. Seven (15.9%) required concomitant tricuspid repair and 1 (2.3%) patent foramen ovale closure. Indications for MVS included myxomatous valve (84%; n = 37), ischemic mitral regurgitation (9%; n = 4), and infective endocarditis (7%; n = 3). Eight (18.2%) cases were performed urgently whereas 36 (71.2%) were performed on an elective basis. The median duration of cardiopulmonary bypass and cross-clamp time was 129 and 85 min, respectively. Three (6.8%) had surgery under hypothermic fibrillatory arrest. There were no conversions to median sternotomy and no 30-day mortalities. Postoperative complications included respiratory complications (34%; n = 15), stroke (4.5%; n = 2), acute renal failure (2.3%; n = 1), and reoperation for bleeding (2.3%; n = 1). The median number of hours on mechanical ventilation and hospital stay was 14 h and 7.5 days, respectively.
Conclusion: Mini-mitral surgery is safe and feasible with excellent outcomes in the elderly. In our practice, it is the treatment of choice for MVS in elderly patients over the age of 70 years.

Keywords: Elderly patients, minimal access surgery, mini-thoracotomy, mitral valve


How to cite this article:
Kumar S, Yuh D. Outcome of minimal access mitral valve surgery in elderly patients. Heart India 2017;5:111-5

How to cite this URL:
Kumar S, Yuh D. Outcome of minimal access mitral valve surgery in elderly patients. Heart India [serial online] 2017 [cited 2017 Oct 20];5:111-5. Available from: http://www.heartindia.net/text.asp?2017/5/3/111/214422


  Introduction Top


Advanced age is a major predictor of poor outcome in patients undergoing valve surgery. We hypothesized that elderly patients who underwent minimally invasive valve surgery for aortic or mitral valve disease would do better when compared with those undergoing the standard median sternotomy.[1],[2],[3],[4]

Minimal access mitral valve surgery (mini-MVS) approaches are becoming increasingly common. They are thought to be associated with less perioperative bleeding and postoperative pain, resulting in shorter hospital length of stay (LOS) and faster return to daily activities. However, there are concerns that this approach may have inferior surgical results in elderly patients with resultant increases in morbidity and mortality when compared to conventional MVS. To address this issue in the literature, we undertook a retrospective review and analysis of elderly patients over the age of 70 undergoing right thoracotomy mini-MVS (MT-MVS).


  Materials and Methods Top


We sought approval of Institutional Review Board to conduct this retrospective study. We retrospectively reviewed our institutions' MVS dataset and analyzed patients who underwent MVS using mini-thoracotomy approach. A total of 44 patients were identified and formed the cohort of this study.

Forty-four patients over the age of 70 years had sternal sparing mini-mitral surgery performed by a single surgeon from January 2011 to November 2015. The heart was directly accessed through right mini-thoracotomy, and cardiopulmonary bypass (CPB) was established by femoral arterial and femoral and right internal jugular venous cannulation. One patient had robotic assistance [Figure 1]. Following the initiation of CPB left atrium (LA) is dissected in the interatrial groove. Pleural cavity is insufflated with the CO2 and heart is arrested with antegrade or retrograde cardioplegia or cross clamp/fibrillatory arrest [Figure 2]. The LA is opened and retracted with the help of LA retractor. The mitral valve apparatus was examined for the feasibility of repair. If possible, the valve was repaired or else replaced using bioprosthetic valve-preserving the subvalvular apparatus [Figure 3].
Figure 1: (a and b) The usual instruments and anesthetic preparation for minithoracotomy patients

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Figure 2: (a-d) The site of incision, commencement of cardiopulmonary bypass

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Figure 3: (a-d) The CO2insufflation, opening of left atrium, exposure of mitral valve and size of thoracotomy incision at the end of procedure

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Patient demographics included age, gender, race, body surface area, body mass index, previous sternotomy, days in hospital before left ventricular assist device implantation, preoperative creatinine, liver function tests, and associated comorbidities, for example, hypertension (HTN), diabetes mellitus, chronic renal insufficiency (CRI), dialysis, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD). CRI was defined as glomerular filtration rate <60 ml/min/m 2.

Operative characteristics analyzed were CPB and aortic cross-clamp time. Outcome variables were complications; postoperative survival at 1 month, 6 months, and 1 year; Intensive Care Unit (ICU) and overall LOS; readmission rates; and cause of death.

Postoperative complications included re-exploration for bleeding, dialysis, ventilator-dependent respiratory failure (VDRF), tracheostomy, hemorrhagic or ischemic stroke, and gastrointestinal bleeding. VDRF was defined as the inability to wean from the ventilator for at least 1 week [Table 1].
Table 1: The compilation of demographics, comorbidities, operative details, postoperative complications (n=44)

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Statistical analysis

Patient demographics, operative characteristics, postoperative complications, and hemodynamic data were analyzed. Continuous variables were reported as median or mean, standard deviation, minimum, and maximum and were compared using two-sided two-sample t-tests. Alternatively, Wilcoxon rank-sum tests were used if normality could not be assumed.

Categorical variables were reported as count and percentage and were compared using Chi-square tests. Alternatively, Fisher's exact tests were used if expected cell counts were not sufficiently large. Survival at 30 days, 180 days, and 360 days were assessed.

Tests were considered statistically significant at P < 0.05. All analyses were performed using SAS 9.2 (Statistical Analysis System version 9 (SAS 9) - SAS Institute for advanced analytics, North Carolina State University).


  Results Top


A total of 44 patients (28 [64%] males and 16 [36%] females), in the age group, ranging from 70 to 92 years (mean 79.84 ± 6.52) were included in the study. Their comorbidities included HTN (70.5%; n = 31), PVD (9.1%; n = 4), cerebrovascular disease (11.4%; n = 5), severe COPD (2.3%; n = 1), and dialysis-dependent CRI (2.3%; n = 1). Five (11.4%) patients had undergone one or more previous cardiac surgery procedures.

A total of 33 (75%) patients underwent mitral valve repair and 11 (25%) underwent replacement with bioprosthesis. Seven (15.9%) required concomitant tricuspid repair and 1 (2.3%) patent foramen ovale closure. Indications for MVS included myxomatous valve (84%; n = 37), ischemic mitral regurgitation (9%; n = 4), and infective endocarditis (7%; n = 3). Eight (18.2%) cases were performed urgently whereas 36 (71.2%) were performed on an elective basis. The median duration of CPB and cross-clamp time was 129 and 85 min, respectively. Three (6.8%) had surgery under hypothermic fibrillatory arrest. There were no conversions to median sternotomy and no 30-day mortalities.

The postoperative complications included respiratory complications (34%; n = 15), stroke (4.5%; n = 2), acute renal failure (2.3%; n = 1), and reoperation for bleeding (2.3%; n = 1). There were no postoperative wound infections or myocardial infarctions. The median number of hours on mechanical ventilation and hospital stay was 14 h and 7.5 days, respectively [Table 1]. Eighteen (41%) patients required a blood transfusion with a median of 1 unit.


  Discussion Top


The mitral valve has been traditionally approached through a median sternotomy. However, significant advances in surgical optics, instrumentation, tissue telemanipulation, and perfusion technology have allowed for MVS to be performed using progressively smaller incisions including the minithoracotomy and hemisternotomy. Due to reports of excellent results, minimally invasive MVS has become a standard of care at certain specialized centers worldwide.[1],[2],[3],[5]

Two studies have looked at the application of minimally invasive (MI) techniques specifically to elderly patients. 111 patients undergoing MI valve surgery who were at least 70-year-old were compared 259 patients having a sternotomy.[3],[6],[7] The MI group had a significantly lower incidence of sepsis and wound complications, required less frozen plasma transfusions, and had a shorter length of hospital stay. They concluded that this approach can be used safely in operations on the elderly population with excellent results. In a recent report, 123 cases of MI mitral valve repair in patients aged 70 years and older with 1.6% operative mortality as well as the 5-year actuarial survival of 87% and 5-year freedom from reoperation of 93%.[6],[7],[8],[9],[10]

Current evidence suggests that mini-MVS maybe associated with decreased bleeding, blood product transfusion, atrial fibrillation, sternal wound infection, scar dissatisfaction, ventilation time, ICU stay, hospital LOS, and reduced time to return to normal activity, without detected adverse impact on the long-term need for valvular reintervention and survival beyond 1 year. Does a more rapid recovery translate into a shorter stay in hospital and therefore reduced costs? Eight studies reported less time in hospital with an MI approach.[2],[4],[11],[12],[13],[14] Chitwood, Cohn, and Cosgrove equated this to a 34%, 20%, and 7% cost saving, respectively.[2],[8],[11],[12],[13],[15] Moreover, these patients had fewer requirements for posthospital rehabilitation, which is a significant advantage in terms of health-care savings with 91% being discharged home compared to 67% with a conventional approach.[13],[15]

However, these potential benefits for mini-MVS may come with an increased risk of stroke, aortic dissection or aortic injury, phrenic nerve palsy, groin infections/complications, and increased cross-clamp, cardiopulmonary bypass, and procedure time. Available evidence is largely limited to retrospective comparisons of small cohorts comparing mini-MVS versus conv-MVS that provide only short-term outcomes.

Limitation of minimitral procedure

Clearly, there is a learning curve for the surgeon as well as the anesthetists, perfusionists, and nursing teams. A high mortality (9.8%) in early port access cases have been reported, partially procedure-related with two of 51 patients suffering an aortic dissection.[2],[3],[5] After simplification of the surgical procedure, the mortality decreased to 3%. Vanermen demonstrated that ICU and hospital stays decrease with increasing experience.[2],[11],[12],[13]

There are potential vascular risks with femoral cannulation, especially with the larger port access femoral cannula. Groin seromas can be problematic but are kept to a minimum by dissection only of the anterior surface of the vessels as well as clipping lymphatics. When the pericardium is opened too posteriorly, phrenic nerve palsy has been reported and can be avoided by placing the pericardiotomy at least 3 cm anterior to it. Excess tension by pericardial retraction sutures should be avoided. Although some have suggested that a small anterior thoracotomy is associated with equal or greater postoperative pain,[2],[4] there is good evidence as detailed above that it actually reduces postoperative discomfort and enhances recovery.[7],[10],[13]

Limitations of our study include a retrospective, single-institutional analysis, an observational, nonrandomized study subject to limitations inherent to any retrospective study. Statistical tests may have been insufficiently powered due to our relatively small sample size. The duration of follow-up was relatively short. There is the potential of inaccuracy of data retrieved retrospectively from medical records. A single institutional study leads to selection bias. Given these limitations, randomized controlled trials with adequate power and duration of follow-up to measure clinically relevant outcomes are recommended to determine the balance of benefits and risks.


  Conclusion Top


Over the last decade, there has been a transformation in the way cardiac surgeons, cardiologists, and patients decide the approach to cardiac therapies. Less invasive procedures are demanded, but at the same time proven safety, efficacy, and durability are expected. There is no prior level one evidence to justify switching to minimally invasive MVS. All the reviewed evidence demonstrates that minimally invasive MVS is associated with equal mortality and neurological events despite longer cardiopulmonary bypass and aortic cross-clamp times. However, there is less morbidity in terms of reduced need for reoperation for bleeding, a trend towards shorter hospital stay, less pain, and faster return to preoperative function levels than conventional sternotomy-based surgery. This would be expected to translate into the improved utilization of limited health-care resources.

MT-MVS does not result in increased morbidity and mortality or procedural duration and may decrease hospital LOS. Our results suggest that MT-MVS is a safe and potentially beneficial approach to the surgical management of mitral valve disease. However, current evidence is underpowered and larger, more methodologically rigorous randomized trials are required.

Minimally invasive surgery for isolated valve lesions in elderly patients yields a lower morbidity and mortality when compared with median sternotomy and should be considered when such individuals require valve surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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Minol JP, Akhyari P, Boeken U, Kamiya H, Weinreich T, Sixt S, et al. Single-centre experience of mitral valve surgery via right lateral mini-thoracotomy in octogenarians. Interact Cardiovasc Thorac Surg 2016;22:287-90.  Back to cited text no. 3
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Sündermann SH, Czerny M, Falk V. Open vs. minimally invasive mitral valve surgery: Surgical technique, indications and results. Cardiovasc Eng Technol 2015;6:160-6.  Back to cited text no. 4
    
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Glauber M, Miceli A, Canarutto D, Lio A, Murzi M, Gilmanov D, et al. Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients. J Cardiothorac Surg 2015;10:181.  Back to cited text no. 5
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Lamelas J, Sarria A, Santana O, Pineda AM, Lamas GA. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg 2011;91:79-84.  Back to cited text no. 6
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Iribarne A, Easterwood R, Russo MJ, Chan EY, Smith CR, Argenziano M. Comparative effectiveness of minimally invasive versus traditional sternotomy mitral valve surgery in elderly patients. J Thorac Cardiovasc Surg 2012;143 4 Suppl:S86-90.  Back to cited text no. 7
    
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Moscarelli M, Fattouch K, Casula R, Speziale G, Lancellotti P, Athanasiou T. What is the role of minimally invasive mitral valve surgery in high-risk patients? A meta-analysis of observational studies. Ann Thorac Surg 2016;101:981-9.  Back to cited text no. 8
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Mihos CG, Santana O, Lamas GA, Lamelas J. Incidence of postoperative atrial fibrillation in patients undergoing minimally invasive versus median sternotomy valve surgery. J Thorac Cardiovasc Surg 2013;146:1436-41.  Back to cited text no. 9
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Biancari F, Schifano P, Pighi M, Vasques F, Juvonen T, Vinco G. Pooled estimates of immediate and late outcome of mitral valve surgery in octogenarians: A meta-analysis and meta-regression. J Cardiothorac Vasc Anesth 2013;27:213-9.  Back to cited text no. 10
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Sündermann SH, Sromicki J, Rodriguez Cetina Biefer H, Seifert B, Holubec T, Falk V, et al. Mitral valve surgery: Right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2014;148:1989-95.e4.  Back to cited text no. 12
    
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Modi P, Hassan A, Chitwood WR Jr. Minimally invasive mitral valve surgery: A systematic review and meta-analysis. Eur J Cardiothorac Surg 2008;34:943-52.  Back to cited text no. 13
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Westhofen S, Conradi L, Deuse T, Detter C, Vettorazzi E, Treede H, et al. Amatched pairs analysis of non-rib-spreading, fully endoscopic, mini-incision technique versus conventional mini-thoracotomy for mitral valve repair. Eur J Cardiothorac Surg 2016;50:1181-7.  Back to cited text no. 14
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