Should a video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery?

BACKGROUND AND AIM OF THE STUDY: Reoperative cardiac surgery carries a greater morbidity and mortality than primary cardiac surgery. The study aim was to compare perioperative outcomes in patients undergoing mitral valve surgery who had already undergone a previous cardiac operation using either a minimally invasive video-assisted (MIVA) mini-thoracotomy or a redo median sternotomy (MS). METHODS: Between January 1996 and June 2003, 71 consecutive patients with prior cardiac surgery underwent mitral valve surgery. Of these operations, 38 were MIVA procedures, performed through a 5-cm right anterior thoracotomy using voice-activated robotic camera control (AESOP 3000). Outcome was compared with results in 33 consecutive patients who underwent a standard redo MS. RESULTS: The MIVA and redo MS cohorts differed in preoperative ejection fraction (46 +/- 2% versus 55 +/- 2%; p = 0.004) and percentage of urgent operations (33 versus 8.3%; p = 0.01). Operative mortality was similar in both groups (5.7% and 5.9% respectively; p = 0.976), as were cardiopulmonary bypass, operating room, and ICU times. Postoperative intubation time was shorter in the MIVA group than in the redo MS group (29.1 +/- 8.9 versus 38.0 +/- 9.9 h; p = 0.008), and blood transfusion requirements were also reduced (2.9 +/- 0.6 versus 5.5 +/- 0.7 units; p = 0.001) respectively. Length of hospital stay was significantly less in the MIVA group (7.1 +/- 1.3 versus 11.2 +/- 1.1 days; p = 0.001). CONCLUSION: Minimally invasive video-assisted mitral valve operations may be performed safely and efficiently in patients with prior cardiac surgery. Demonstrated advantages include fewer red blood cell and blood product transfusions, as well as decreased intubation time and length of hospital stay.

Robotic mitral valve repair: experience with the da Vinci system.

BACKGROUND: As part of a Food and Drug Administration trial, mitral repairs were performed in 38 patients using the robotic da Vinci surgical system (Intuitive Surgical, Inc, Mountain View, CA). Prospectively, we evaluated safety and efficacy in performing both simple and complex mitral repairs. METHODS: Eligible patients had nonischemic moderate to severe mitral insufficiency. Operative techniques included peripheral cardiopulmonary perfusion, a 4- to 5-cm mini-thoracotomy, transthoracic aortic occlusion, and antegrade blood cardioplegia. Transesophageal echocardiograms were done intraoperatively with three-dimensional reconstructions. Successful repairs were defined as mild or less residual regurgitation. RESULTS: Enhanced three-dimensional visualization of mitral leaflets and the subvalvar apparatus allowed safe, dexterous intracardiac tissue manipulation. All patients had successful valve repairs including quadrangular resections, sliding plasties, and edge-to-edge approximations, as well as both chordal transfers and replacements. There were no operative deaths, strokes, or device-related complications. One patient required valve replacement for hemolysis and 1 was reexplored for bleeding. There were no incisional conversions. Both robotic repair and total operating times decreased significantly from 1.9 +/- 0.1 and 5.1 +/- 0.1 hours (mean +/- standard error of the mean) for the first 19 patients to 1.5 +/- 0.1 (p = 0.002) and 4.4 +/- 0.1 hours (p = 0.04) for the last 19 operations, respectively. Total hospital length of stay for patients was 3.8 +/- 0.6 days. Of all patients, 31 (82%) had a 4-day or less length of stay. Seven patients (18%) had stays between 5 and 9 days (6.4 +/- 1.0). CONCLUSIONS: This study shows that the da Vinci surgical system (Intuitive Surgical, Inc) has few limitations in performing complex valve repairs. Articulated wrist-like instruments and three-dimensional visualization enabled precise tissue telemanipulation. Future robotic design advances and adjunctive suture technologies may promote continuing evolution of robotic cardiac operations.

Causes of increased length of hospitalization on a general thoracic surgery service: a prospective observational study.

OBJECTIVE: To characterize medical and nonmedical reasons for delayed discharge on a general thoracic surgery unit. DESIGN: A prospective observational cohort study. SETTING: A university-affiliated tertiary care institution. PATIENTS: Between February 1999 and July 2000, the in-hospital progress of 130 patients who had undergone an elective thoracic surgical procedure was evaluated prospectively. Baseline characteristics (age, sex, comorbid conditions and pulmonary function test results) were documented. MAIN OUTCOME MEASURES: Complications that delayed the time when the patient was medically ready for discharge. The day the patient was deemed fit for discharge (medically required length of stay) was compared with the actual day of discharge (actual length of stay). RESULTS: The 3 most frequent complications that prevented discharge by postoperative day 6 were persistent air leaks, pulmonary infections and atrial fibrillation. The presence of a persistent air leak increased the medically required length of stay by a mean of 13.1 days (95% confidence interval [CI] 11.0-15.2 d), pneumonia by 9.6 days (95% CI 4.96-14.2 d) and atrial fibrillation by 2.4 days (95% CI -2.6 to 7.4 d). The mean medically required length of stay was 6.9 days, and this differed from the mean day on which the patient was actually discharged (7.35 d, p < 0.01), which contributed 44 excess days of hospitalization per 100 patients. The 2 most common causes of this discrepancy were the lack of home support (10.2% of patients) and the unavailability of convalescent facilities (7.1% of patients). Prolonged hospital stay for nonmedical reasons was associated with increased mean age (67.4 v. 60.7 yr, p = 0.05). CONCLUSIONS: Length of hospitalization after elective thoracic surgery may be prolonged for medical or nonmedical reasons. Although complications like persistent air leak and pneumonia have an impact on medically required length of stay, social factors may also significantly delay discharge.