Fifteen-Year Experience With Minimally Invasive Approach for Reoperations Involving the Mitral Valve

Study Questions:

What is the success rate for a minimally invasive approach for reoperations involving the mitral valve?

Methods:

Between June 1996 and April 2010, the investigators performed right minithoracotomy for reoperations involving the mitral valve on 167 patients, 85 (51%) of these since 2006. Seventy-one percent had undergone previous coronary artery bypass grafting and 38% a previous valve procedure. Fibrillatory arrest was used in 77%, and aortic clamping and root cardioplegia in 23%. Nineteen procedures were performed with robotic assistance.

Results:

Mitral repair frequency increased during each 5-year interval of the investigators’ experience (1996–2000, 43%; 2001–2005, 53%; 2006–2010, 72%; p = 0.019), including 80% of native mitral valves without stenosis. Concomitant procedure frequency, most commonly atrial fibrillation ablation, also increased during each 5-year interval (0%, 21%, 48%; p < 0.0001). Thirty-day mortality was 3.0% (5/167), 0% since 2005. There were no conversions to sternotomy or aortic dissections. Stroke, in 2.4% (4/167), was statistically unrelated to fibrillatory arrest. Increased New York Heart Association functional class (odds ratio, 5.6; 95% confidence interval, 1.1-27.8; p = 0.037) was the only independent predictor of mortality in multivariable analysis.

Conclusions:

The authors concluded that their experience confirmed the effectiveness of minimally invasive right thoracotomy to treat mitral pathology while avoiding reoperative sternotomy risk.

Perspective:

This single-center 15-year experience demonstrates the utility of minimally invasive right thoracotomy to effectively address mitral valve pathology in reoperative patients while avoiding the risk of a repeat sternal reentry. This series confirms both fibrillatory and cardioplegic arrest to be useful preservation strategies, and minimally invasive right thoracotomy appears to be the preferred approach to correct mitral regurgitation in the reoperative setting. Given the single-center nature of the study and lack of a defined reference group, the benefits of the technique need independent validation at other major surgical centers.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Thoracotomy, Reoperation, Robotics, Atrial Fibrillation, Coronary Artery Bypass, Mitral Valve


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