Minimally invasive mitral valve surgery: Does it make a difference?

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Abstract

Minimally invasive mitral valve surgery (MIMVS) has emerged as an alternative approach to conventional sternotomy to perform mitral valve repair and replacement with equivalent results. This strategy was developed to decrease surgical trauma by minimizing the size of incisions and permits excellent exposure of the mitral valve thereby avoiding conventional full sternotomy. The purpose of this review is to provide a critical, objective, balanced, and evidence-based analysis of the literature to understand advantages, potential scope, and the utility of these minimally invasive approaches to the mitral valve in modern cardiac care.

Introduction

Mitral valve repair is a safe, effective, and reproducible operation that has been shown to improve the survival of patients with severe degenerative mitral valve regurgitation (MR). The performance of early surgical MR correction has recently been confirmed to be associated with long-term improvements in life expectancy and freedom from heart failure; even many years following operation [1]. Less-invasive techniques to perform mitral valve repair have evolved to both facilitate expeditious referral and patient acceptance of early mitral valve repair [2], [3].

Minimally invasive mitral valve surgery (MIMVS) does not refer to a single procedure but rather therapeutic strategies in general that aim to decrease the surgical trauma by minimizing the size of incisions and modifying the approach to the mitral valve to avoid a conventional full sternotomy. Historically, right parasternal as well as transsternal incisions were described as MIMVS approaches. Currently, partial upper sternotomy, partial lower sternotomy, right anterolateral thoracotomy with direct vision, and right lateral mini-thoracotomy with or without videoscopic assistance (including robotics) are the most frequently MIMVS approaches. A recent study [4] from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) demonstrated an increase in the proportion of MIMVS from 10% in 2004 to 20% in 2008 (Fig. 1).

More recently, robot-assisted MIMVS has become the least invasive approach to mitral valve surgery. With robot-assisted MIMVS, mitral valve surgery is performed through 1–2-cm ports allowing a totally endoscopic mitral valve repair procedure without thoracotomy or significant rib spreading. In many centers where non-sternotomy approaches are routine, MIMVS provides equivalent or superior results to those achieved via conventional operations in terms of in-hospital mortality, stroke rates, repairability index of the mitral valve, and long-term durability of the mitral valve repair while conveying advantages of shorter hospital stay, faster recovery/return to preoperative level of activities, less blood transfusion, favorable cosmesis, and elimination of sternotomy-related morbidities such as deep sternal wound infection and sternal dehiscence.

Many retrospective series have reported excellent short- and long-term results with MIMVS. Several propensity matched studies have also compared MIMVS to conventional mitral valve surgery (CMVS) performed through full sternotomy and have confirmed equivalent results. The purpose of this review is to provide a critical, objective, balanced, and evidence-based analysis of the literature of MIMVS compared to CMVS to understand advantages, potential scope, and the utility of these approaches in modern cardiac care.

Section snippets

History of minimally invasive mitral valve surgery

In the mid-1990s, MIMVS emerged as an alternative approach to conventional sternotomy with acceptable results. Cosgrove and Cohen described the right vertical parasternal incision approach to the mitral valve [5], [6]. This approach usually involves resection of the third and fourth intercostal cartilages and ligation of the right mammary artery. The adoption of this approach was limited as it was associated with occasional chest wall instability and lung herniation and is rarely used

MIMVS short-term outcomes

Large randomized studies that compare MIMVS and CMVS have not been performed. One small randomized trial compared MIMVS with CMVS. Speziale et al. [22] randomized 70 patients with Barlow׳s mitral valve disease (bileaflet prolapse) to CMVS or MIMVS using right mini-thoracotomy approach with peripheral cannulation, external aortic clamping, and surgery under direct vision. Mortality and stroke were comparable in both groups. Operative and cardiopulmonary bypass times were longer in the MIMVS

Does MIMVS increase the risk of perioperative stroke?

The potential risk of perioperative stroke using historic peripheral cannulation and perfusion techniques during MIMVS was raised by Gammie et al. [4]. Their study included 28,143 patients from the STS database. The adjusted rate of permanent stroke was higher with MIMVS, 1.87% vs 1.17% (adjusted OR = 1.96, 95% confidence interval: 1.46–2.63, P < .0001). The risk of stroke was particularly high in patients undergoing MIMVS with fibrillatory arrest or beating heart technique without cross clamp

Transthoracic cross clamping vs endoaortic balloon occlusion

Two methods are currently used for aortic occlusion and cardioplegia delivery during MIMVS. The most common method is by use of transthoracic aortic cross clamp, which is inserted directly through the right chest wall. Cardioplegia is then delivered in the aortic root through a cardioplegia catheter inserted in the aortic root proximal to the aortic cross clamp. The second method is through use of “Port-Access” technology; this involves insertion of endoaortic balloon through the femoral

Benefits of MIMVS surgery over CMVS

In the previous sections, we have demonstrated that MIMVS has equivalent outcomes to CMVS in terms of mortality, perioperative stroke, and major cardiac, renal, and pulmonary complications. However, MIMVS also has several reproducible and proven advantages over CMVS. There is consistent evidence from large propensity score analyses and metaanalyses that MIMVS is associated with significantly lower chest tube drainage volume, blood product transfusions, duration of ventilation, intensive care

Risks associated with Minimally invasive mitral valve surgery

Although MIMVS is associated with important benefits compared to CMVS, there are certain complications that are more likely to be encountered with MIMVS if appropriate attention is not directed toward their avoidance. The metaanalysis by Cheng et al. [30] reported slightly increased rates of iatrogenic aortic dissection/injury (0.2% vs 0%), groin infection (2% vs 0%), and phrenic nerve palsy (3% vs 0%) with MIMVS. While the metaanalysis by Sündermann et al. [29] showed slightly higher rate of

Intermediate- and long-term outcomes with MIMVS

Results from high-volume centers demonstrate equivalent long-term survival and durability of mitral valve repair using the minimally invasive approach. Goldstone et al. [24] reported a 99% repair rate in patients with myxomatous mitral valve disease using a MIMVS approach. The use of minimally invasive approach did not significantly increase the likelihood of a failed repair in their experience. In fact, patients undergoing minimally invasive mitral repair were more likely to have no residual

Should complex MV repair be routinely performed using a MIMVS approach?

Anyanwu and Adams [42] ask us to ponder the theoretical concern that routine use of MIMVS in patients with complex mitral valve disease may compromise safe and durable mitral valve repair. A report from the STS ACSD revealed that the median number of MIMVS performed in centers in the United States was only three cases per year (Fig. 4), and the median number of robot-assisted MIMVS was three cases per year in centers performing these operations (Fig. 5). Previous reports have demonstrated a

Is MIMVS associated with cost saving?

As we have demonstrated above, MIMVS is associated with a significant reduction in hospital length of stay and resource utilization. Therefore, it is presumed that MIMVS should be a cost-effective intervention. Although numerous studies have compared clinical MIMVS with CMVS, only few of these studies performed a true cost analysis. Iribarne et al. [33] compared total hospital cost with MIMVS vs CMVS in 847 patients underwent isolated mitral valve surgery (2003–2008). Propensity matching on 22

Transcatheter mitral valve repair

Multiple transcatheter mitral valve repair approaches have been investigated, but transcatheter edge-to-edge repair using MitraClip device has undergone more extensive and rigorous investigations in human compared to other approaches. This device was designed to mimic the edge-to-edge surgical technique that relies on the approximation of the middle scallops of the anterior and posterior leaflets of the mitral valve creating a double orifice valve. The MitraClip is inserted peripherally through

Limitations

Critical appraisal of the literature comparing MIMVS and CMVS should be undertaken with several important points in mind. First, almost all retrospective studies that have compared MIMVS to CMVS showed significant differences in baseline risk profiles between the two groups, at times, with the higher-risk patients in the CMVS cohort. While propensity score analyses were performed by several groups to account for these differences, selection bias and confounding cannot be eliminated completely

Conclusion

This critical review of contemporary evidence suggests that MIMVS has equivalent and excellent short-, and mid-term outcomes, with low risks of mortality, stroke and other complications when performed by appropriately trained teams. MIMVS is associated with diminished bleeding, blood transfusion, ventilation time, intensive care unit stay, hospital length of stay, postoperative pain scores, sternal complications, and offers more rapid resumption of normal activity. MIMVS is also associated with

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    The authors have indicated there are no conflicts of interest.

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