Techniques and results of direct-access minimally invasive mitral valve surgery: a paradigm for the future.

OBJECTIVES: Our objective was to determine whether direct-access minimally invasive mitral valve surgery can improve recovery and cost while maintaining the efficacy of conventional surgery. METHODS: Minimally invasive mitral valve operations were performed on 106 patients, 58% male, average age 58.1 years, with good ventricular function. Ninety underwent repair of a regurgitant, myxomatous valve, and 16 underwent mitral valvuloplasty for prematurely calcified mitral stenosis. The valve was approached with standard instruments through a 5- to 8-cm right parasternal incision. Eighty-five had open femoral artery-femoral vein cannulation, but this technique has recently been replaced by direct cannulation of the aorta and percutaneous cannulation of the femoral vein for most patients. RESULTS: There were no operative deaths. The mean mitral regurgitation score (0-4) decreased from 3.7 to 0.7 after the operation. Although ischemic and bypass times were increased, postoperative recovery was accelerated. Ventilatory support time, intensive care unit stay, hospital stay, need for rehabilitation, and return to "normal activities" all improved. Hospital charges, pain medications, and blood transfusions were also reduced. New atrial fibrillation contributed significantly to increased length of stay and charges. There were no deep wound infections. Other complications included re-exploration for bleeding (n = 1), transient ischemic attacks (n = 2), stroke (n = 1), femoral artery injury (n = 5), pseudoaneurysm (n = 2), and antegrade dissection of the ascending aorta (n = 1). Two patients died and 1 required reoperation during a mean follow-up of 8.8 months. CONCLUSIONS: Direct-access minimally invasive mitral valve surgery can accelerate recovery, decrease charges, and decrease pain, while maintaining overall surgical efficacy. It has become our standard approach for isolated primary mitral valve operations.

Minimally invasive aortic valve surgery: technical considerations and results with the parasternal approach.

BACKGROUND: The history of surgery over the last 30 years has moved steadily toward minimally invasive surgery; more recent experience with the gall bladder, arthroscopy, and video-assisted thoracic surgery has confirmed this trend. METHODS: Our experience in minimally invasive valve surgery between July 1996 and October 1997 included 180 patients, 80 with aortic valve replacement and 100 with mitral valve replacement. The 80 aortic valve replacement patients consisted of 46 males and 34 females, with a mean age of 63 years (range 32 to 90 years) and mean New York Heart Association Functional Class 2.5. The etiology of disease was varied: degenerative in 41 patients, congenital in 17, rheumatic in 8, subacute bacterial endocarditis in 6, myxomatous in 4, and structural valve degeneration in 4. RESULTS: There were two (2.5%) operative deaths, both from multisystem organ failure. Only 16 (20%) of the 80 patients experienced new postoperative atrial fibrillation. The mean length of stay in the hospital was 5 days (range 3 to 24 days). Only 18 (23%) of the 78 surviving patients required posthospital rehabilitation, and there were no late deaths. Morbidity included cerebrovascular accident in 1 patient (1.2%), sternal infection in 1 (1.2%), groin infection in 1 (1.2%), and bleeding requiring reoperation in 1 (1.2%). CONCLUSIONS: Minimally invasive cardiac valve surgery is extremely effective and has become our current technique of choice in every mitral and aortic valve patient who does not have coronary artery disease because it reduces the length of hospital stay and cost, requires fewer blood transfusions, and stimulates less atrial fibrillation.

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.

OBJECTIVE: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. SUMMARY BACKGROUND DATA: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. METHODS: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. RESULTS: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. CONCLUSIONS: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.

Reducing costs and length of stay and improving efficiency and quality of care in cardiac surgery.

BACKGROUND: The present era of health care places major emphasis on significantly reducing cost and resource utilization while maintaining quality of care and patient satisfaction. Clinicians are being challenged to achieve this within the framework of a patient subset that is increasing in severity of disease and risk-adjusted mortality. The Brigham and Women's Cardiac Surgical Services Management Group was formed in 1987 to help accomplish these goals. METHODS: The principles we have followed involve protocols and people. The multidisciplinary group includes the chiefs of cardiac surgery and anesthesia, chief residents, physician assistants, perfusionists, intensive care unit nursing personnel, and case managers. Weekly meetings address every aspect of problems arising in the cardiac surgical service; separate weekly morbidity and mortality conferences are held. The Care Coordination Team establishes and monitors clinical pathways and recommends ways of improving all aspects of the service through a process of daily review on an individual patient basis. RESULTS: The volume of cardiac surgery at Brigham and Women's Hospital has increased steadily. The length of stay overall has decreased about 15%, and similarly, cost and total charges have also decreased. In addition, patient satisfaction has increased to a level of about 95%. CONCLUSIONS: The goals of cost-containment with improved patient care and outcome are possible through the collaborative efforts of representatives of all the personnel involved in cardiac care, as well as leadership by the surgical faculty.

Choosing a revascularization strategy for your patient with CAD. Consider both the clinical presentation and the urgency of the situation.

For patients with less severe coronary artery disease, particularly one- or two-vessel disease, initial therapy may be with either thrombolytics or angioplasty. In those with more extensive disease (three-vessel or left main artery disease or proximal left anterior descending artery stenosis), bypass grafting can significantly reduce mortality. However, a patient's risk profile markedly influences outcome regardless of the procedure performed. Because angioplasty achieves incomplete revascularization, patients may need repeated angiography or revascularization, or they may have recurrent angina. If bypass graft disease is prevented, surgery may be effective for up to 20 years.

Noninvasive assessment of valvular heart disease: surgery without catheterization.

Forty-one patients underwent valve surgery at our institution based solely on clinical, M-mode echocardiographic, phonocardiographic, and external pulse recording findings without preoperative cardiac catheterization. Patients with clinical evidence of coronary artery disease were excluded from the study. Preoperatively, 83% of the patients were New York Heart Association functional class III or IV. In all patients, the noninvasive evaluation was considered sufficiently diagnostic of the nature and severity of valvular heart disease to allow surgery without preoperative catheterization. In 23 of 41 cases (group 1), cardiac catheterization was not performed due to the patients' unstable hemodynamic condition at the time surgery was being considered. In the remaining 18 patients (group 2), the probability of obtaining data at catheterization that would significantly affect management decisions was thought to be low, thus not justifying the cost and potential morbidity of this procedure. In all cases, the noninvasive diagnosis was corroborated at operation; there were no unexpected findings nor deaths related to incomplete or incorrect diagnoses. Over a followup period of 4.5 +/- 1.4 years, no patient experienced signs or symptoms of ischemic heart disease. In selected patients without anginal chest pain syndromes, appropriate and successful valve surgery may be performed on the basis of combined clinical and noninvasive evaluation without the need for cardiac catheterization.