Outcomes of Minimally Invasive Valve Surgery Versus Median Sternotomy in Patients Age 75 Years or Greater

doi:10.1016/j.athoracsur.2010.09.019

The Annals of Thoracic Surgery

Volume 91, Issue 1, January 2011, Pages 79-84

https://doi.org/10.1016/j.athoracsur.2010.09.019 Get rights and content

Background

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.

Methods

We retrospectively reviewed 2,107 consecutive heart operations at our institution and identified 203 patients, age 75 years or greater, who underwent isolated mitral or aortic valve surgery. Outcomes of those who had minimally invasive valve surgery through a right minithoracotomy were compared with those who had a median sternotomy.

Results

Of the 203 patients, 119 (59%) underwent a minimally invasive approach, while 84 (41%) had a median sternotomy. The median postoperative length of stay was 7 days (interquartile range [IQR] 6 to 10) versus 12 days (IQR 9 to 20), p less than 0.001, and intensive care unit length of stay was 52 hours (IQR 44 to 93) versus 119 hours (IQR 57 to 193), p less than 0.001 for minimally invasive and median sternotomy, respectively. In-hospital mortality was 2 (1.7%) versus 8 (9.5%, p = 0.01 and composite postoperative morbidity and mortality occurred in 25 (21%) versus 38 (45.2%), p less than 0.001, in minimally invasive versus median sternotomy, respectively. The difference was driven by the following: a lower incidence of acute renal failure, 1 (0.8%) versus 14 (16.7%), p less than 0.001; prolonged intubation 23 (19.3%) versus 32 (38.1%), p = 0.003; wound infections 1 (0.8%) versus 5 (6%), p = 0.034; and death.

Conclusions

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.

Section snippets

Material and Methods

After obtaining approval from the Institutional Review Board, we retrospectively reviewed a computerized database of 2,107 consecutive heart surgery done at our institution between January 2005 and September 2009. Of these, 854 were coronary artery bypass surgery, 683 involved single valve aortic or mitral surgery, 411 were concomitant valve and bypass surgery, and 144 were multivalve surgery. Of the 683 single valve procedures, 227 were in subjects 75 years of age and greater. Of those that

Results

There were 203 patients at least 75 years of age who underwent isolated valve surgery during the analysis period. Of these, 119 (59%) underwent minimally invasive surgery and 84 (41%) underwent a median sternotomy. The operations were evenly distributed between aortic and mitral valve surgery (Table 2). There were three cases (2.5%) that were initiated minimally invasively but were converted to a median sternotomy; two of them because of heavily calcified aortic roots and the third because of

Comment

When compared with a standard median sternotomy, minimally invasive valve surgery has been shown to reduce morbidity. However, individual studies and meta-analyses of the major trials evaluating minimally invasive valve surgery have failed to demonstrate a reduction in mortality for either mitral or aortic minimally invasive valve surgery [12, 13, 14, 15]. The failure to demonstrate a reduction in mortality may have been due to subject selection, with lower-risk populations such as younger

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Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).
We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.
Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.
A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.
Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery
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The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types.
A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures.
Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures.
Endoscopic AVR can safely address concomitant valve diseases.
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Citation Excerpt :
A meta-analysis of 7 observational studies of high-risk patients demonstrated that despite longer operative times, minimally invasive patients had lower postoperative blood transfusion and AFib rates, with similar repair and early mortality rates.14 Furthermore, groups have found MIMVS offers similar short-term mortality, with decreased complications in patients with obesity,15 chronic obstructive pulmonary disease,16 and advanced age.17 Our study adds to this collective knowledge of the role of MIMVS in high-risk populations by elucidating the outcomes of MIMVS in PH patients.
Compared with conventional full sternotomy (FS) approaches, minimally invasive mitral valve surgery (MIMVS) offers improved cosmesis, decreased pain and bleeding, and faster recovery without compromising repair or survival rates. However, little is known about outcomes in patients with pulmonary hypertension (PH), an independent risk factor for morbidity and mortality.
Retrospective review was performed between 2002 and 2019 for all adult patients undergoing isolated mitral valve surgery. Patients with PH (mean pulmonary artery pressure ≥25 mm Hg) were stratified by FS or MIMVS, and nearest-neighbor propensity score matching was performed to adjust for differences in baseline characteristics.
Overall, 591 operations (317 MIMVS, 274 FS) met inclusion criteria during the study period. Nearest-neighbor propensity matching generated 112 well-matched pairs. Cardiopulmonary bypass (137 vs 89.5 minutes, P < .001), cross-clamp (102 vs 63 minutes, P < .001), and total operative times (241 vs 178.5 minutes, P < .001) were longer for the MIMVS group. Postoperatively, MIMVS was associated with shorter initial ventilator times (6 vs 9.6 hours, P < .001) and hospital lengths of stay (7 vs 8 days, P = .049), as well as blood product usage rates (26.8% vs 41.1%, P = .03). Survival at 30 days (0.0% vs 2.7%, P = .12) and 10 years (log-rank, P = .661) were similar between groups.
MIMVS is safe in patients with PH and provides traditional benefits of minimally invasive surgery, including shorter initial ventilator times and hospital length of stay, without compromising on long-term survival.
Commentary: The Role of Less-Invasive Mitral Valve Surgery When the Mitral Annulus Is Calcified: When Less Is More
2022, Seminars in Thoracic and Cardiovascular Surgery
Robotic Approach to Mitral Valve Surgery in Septo-Octogenarians
2020, Seminars in Thoracic and Cardiovascular Surgery
Advanced age confers higher Society of Thoracic Surgeons (STS) predicted risks of mortality and longer hospital lengths of stay (LOS) in patients undergoing mitral valve surgery; some consider it a contraindication to robotic-assisted approaches. We analyzed the feasibility and safety of totally endoscopic robotic mitral valve surgery (TERMS) in patients ≥70 years. From 5/11 to 4/18, 570 consecutive patients underwent TERMS by the same 2-surgeon team utilizing the da Vinci Xi Surgical System. Differences in patient demographics, intraoperative variables, and outcomes were analyzed between septo-octogenarian (patients ≥70 years) and younger patients (<70 years). Patients requiring left ventricle patch reconstruction following mitral annular calcification resection were excluded. For those patients with STS predicted risk scores (n = 439), our outcomes were compared to those STS predictions. Patients ≥70 comprised 25% of our TERMS cohort. Patients ≥70 had higher rates of preoperative atrial fibrillation and congestive heart failure, and significantly higher STS predicted risks of mortality. Patients ≥70 had greater incidence of concomitant cryoablation, hybrid percutaneous coronary intervention, and tricuspid repair. Patients ≥70 did not have longer cardiopulmonary bypass or aortic occlusion times. Thirty-day mortality was similar between groups (P = 0.151). Median LOS was 1 day longer for patients ≥70, 4 vs 3 days (P < 0.001). Short LOS (<6 days) was achieved in 72% of patients ≥70, markedly outperforming the STS predicted rates (36%). Advanced age is not a limiting factor for robotic mitral valve surgery in most patients. TERMS in patients ≥70 years matched STS benchmark performance outcomes and provided excellent recovery as evidenced by the short LOS (<6 days) experienced by the majority of septo-octogenarian patients.

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Original articleAdult cardiacOutcomes of Minimally Invasive Valve Surgery Versus Median Sternotomy in Patients Age 75 Years or Greater

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Lancet

Am J Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

Aging: a subject that must be at the top of world agendas: the aging of populations demands major changes across society and health care

BMJ

The risk of the development of aortic stenosis in patients with “benign” aortic valve thickening

Arch Intern Med

Cardiac surgery in octogenarians: peri-operative outcome and long-term results

Eur Heart J

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

Ann Surg

Current approaches to minimally invasive aortic valve surgery

Curr Opin Cardiol

One thousand minimally invasive valve operations: early and late results

Ann Surg

Minimal access aortic valve replacement: effects on morbidity and resource utilization

Ann Thorac Surg

Impact of minimal access valve surgery on clinical outcomes: current best available evidence

J Card Surg

Original article
Adult cardiac
Outcomes of Minimally Invasive Valve Surgery Versus Median Sternotomy in Patients Age 75 Years or Greater