Minimally invasive mitral valve surgery utilizing heart port technology.

OBJECTIVE: To determine operative outcomes of right mini-thoracotomy mitral valve surgery utilizing port access technology in first-time and reoperative cardiac surgery patients. METHODS: From 2002 to 2011, 881 patients underwent minimally invasive mitral valve surgery. Of these, 154 patients had previous cardiac operations via sternotomy (Group 1), of which 18 (12%) had two previous operations. Seven hundred and twenty-seven patients had no previous cardiac operations (Group 2). RESULTS: Patient demographics were similar in both groups. In Group 1, 76 (49%) patients had previous coronary artery bypass grafting, 13 (8%) had previous aortic valve surgery, and 57 (37%) had previous mitral valve surgery. Preoperative echo findings for Groups 1 and 2 included severe mitral regurgitation (MR) (88%, n = 135; 94%, n = 687), mitral stenosis (MS) (4%, n = 6; 2%, n = 12), MS + MR (8%, n = 13; 4%, n = 28), and ejection fraction (48%, 56%). Operative procedures in Groups 1 and 2 were MV repair (54%, n = 84; 89%, n = 645) and MV replacement (46%, n = 70; 11%, n = 82). Circulatory management techniques for Groups 1 and 2 included endoballoon (75%, n = 116; 79%, n = 576), Chitwood clamp (8%, n = 12; 20%, n = 147), and fibrillatory arrest (17%, n = 30; 0.5%, n = 4). Perioperative outcomes were: stroke: 2.5%, 1.6%; reoperation for bleeding: 5%, 6%; valvular reoperation rate: 0.6%, 2%; aortic dissection: 2.5%, 1%; and wound infection: 0%, 0%. Transfusion requirement was 49% (n = 76) and 31% (n = 232), respectively. Median hospital stay was seven and seven days, respectively. On postoperative echocardiography, 98% (n = 151) and 99% (n = 718) of patients had zero or trace MR (1+) with 100% freedom from MR > 2+. In-hospital mortality was 3% (n = 5) and 1% (n = 8). CONCLUSIONS: Operative outcomes with minimally invasive mitral valve surgery utilizing port access technology can be performed safely. Stroke rate was higher in the reoperative cases (p = NS) although similar to reports evaluating redo sternotomy in mitral valve cases.

Minimally Invasive Port Access Approach for Reoperations on the Mitral Valve.

BACKGROUND: In patients requiring a second-time or more operation on the mitral valve (MV), we assessed whether the outcomes of the minimally invasive port access approach (port access group) were equivalent to those of the traditional redo sternotomy approach (redo sternotomy group). METHODS: In a retrospective review (1998-2011), 409 patients had previous MV operations requiring a second-time or more MV reintervention. Of those, 67 patients had the port access approach, and 342 had the redo sternotomy approach. Of the latter, 220 met the inclusion criteria because emergencies, patients with endocarditis, and those requiring concomitant procedures involving aortic valve and aorta were excluded. RESULTS: New York Heart Association class 2 or above, age, atrial fibrillation, and surgical indications were similar in both groups. The port access group had more patients with previous MV repair (78% [n = 52] vs 41% [n = 90], p < 0.01) than with MV replacement (19% [n = 13) vs 53% [n = 116], p < 0.01). Concomitant procedures were similar (20% [n = 14] vs 27% [n = 59], p = 0.4). The MV re-repair rates were similar (19% [n = 10] vs 22% [n = 20], p = 1). The cardiopulmonary bypass times (153 ± 42 minutes vs 172 ± 83 minutes, p = 0.07) and aortic cross-clamping times (104 ± 38 minutes versus 130 ± 71 minutes, p < 0.01) were lower in the port access group. Mortality was lower in the port access group, although not significantly (3.0% [n = 2] vs 6.0% [n = 13], p = 0.5). The rates of postoperative stroke were similar (3.0% [n = 2] vs 3.2% [n = 7], p = 1). On postoperative echocardiography, freedom from mitral regurgitation >2+ was 100% in the port access group and 99% in the redo sternotomy group. The mean hospital length of stay was 11 ± 15 days versus 14 ± 12 days (p = 0.07). CONCLUSIONS: The port access approach can be safely adopted for reoperations on the MV without compromising postoperative mortality or MV function.

The progression of a transcatheter aortic valve program: a decision analysis of more than 680 patient referrals.

BACKGROUND: A ground-breaking, US Food and Drug Administration clinical trial for the treatment of critical aortic stenosis commenced at our institution in November 2007 with our first transcatheter aortic valve repair (TAVR). This novel procedure created a new treatment option for high-risk patients with aortic stenosis. Although the pivotal trial completed enrollment in 2009, continued access was implemented by the Food and Drug Administration in response to an unprecedented demand for this new procedure by patients and physicians. This is an overview of one site's management strategy for patient referrals. METHODS: Patients underwent evaluation with a comprehensive assessment in a multidisciplinary transcatheter aortic valve clinic. All screened patients were classified as either traditional open surgical candidates or nonsurgical candidates. Major exclusions for open procedures included low Society of Thoracic Surgeons score, coronary artery disease, and other valvular disease. Major exclusions of nonsurgical candidates resulted from physician discretion or multiple comorbidities such as renal failure, significant liver or lung disease, and progressive cancer. A third group of patients was excluded because of inadequate femoral access. RESULTS: From November 2007 to November 2010, 681 patients were referred for evaluation, including 578 screened patients and 103 patients whose evaluation was pending. During the screening process, 82 patients died (12%). Among 343 patients who did not qualify for enrollment (50%), 108 received open surgical intervention and 235 were nonsurgical candidates; 35 of these patients underwent balloon aortic valvuloplasty. A total of 153 patients were enrolled in the TAVR trial. CONCLUSIONS: With the availability of a novel treatment option for aortic stenosis in high-risk patients, institutions offering these alternative methods will be forced to reevaluate patient management. A careful strategy that includes multidisciplinary evaluation is crucial in order to have a successful transcatheter aortic valve program.