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Right arrow Minimally invasive surgery
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J Thorac Cardiovasc Surg 2009;137:70-75
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Early and late outcomes in minimally invasive mitral valve repair: An eleven-year experience in 707 patients

R. Scott McClure, MD, SMa,b, Lawrence H. Cohn, MDa,*, Esther Wiegerincka, Gregory S. Couper, MDa, Sary F. Aranki, MDa, R. Morton Bolman, III, MDa, Michael J. Davidson, MDa, Frederick Y. Chen, MDa

a Brigham and Women's Hospital, Division of Cardiac Surgery, Boston, Mass
b Harvard School of Public Health, Department of Epidemiology, Boston, Mass

Received for publication June 24, 2008; revisions received August 21, 2008; accepted for publication August 27, 2008.

* Address for reprints: Lawrence H. Cohn, MD, Brigham and Women's Hospital, 75 Francis Street, Boston MA, 02115. (Email: lcohn{at}partners.org).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Objective: This study analyzes a single institution experience with minimally invasive mitral valve repair and evaluates long-term surgical outcomes of morbidity, mortality, and rates of reoperation. Late follow-up of mitral regurgitation and left ventricular function were also assessed.

Methods: Between August 1996 and October 2007, minimally invasive mitral valve repair was performed in 713 patients (mean follow-up 5.7 years). Excluding 6 repairs with robotic assistance, an perspective analysis of the remaining 707 patients was carried forth. Mean age was 57 ± 13 years. Mean preoperative ejection fraction was 60% ± 10%. Surgical access was through a lower ministernotomy (74%), right parasternal incision (24%), right thoracotomy (1.4%), or upper ministernotomy (0.7%). Exposure of the mitral valve was through the left atrium in 58% of the cases and transeptal in 42%. A ring annuloplasty was incorporated into 680 (96%) of 707 repairs. The Kaplan–Meier and Student t test for paired samples were used for statistical analysis.

Results: There were 3 (0.4%) operative deaths. Perioperative morbidity included new-onset atrial fibrillation (20%), reoperation for bleeding (2%), stroke (1.9%), permanent pacemaker implantation (1.7%), deep sternal wound infection (0.7%), and aortic dissection (0.4%). Median hospital stay was 5 days. Only 31% of patients required blood transfusion during the hospital course. There were 49 (6.9%) late deaths and 34 (4.8%) failed repairs necessitating reoperation. At 11.2 years, survival was 83% (95% confidence intervals, 76.5–88.1); freedom from reoperation was 92% (95% confidence intervals, 86.2–94.9). Nine (1.3%) patients were lost to follow-up. A total of 2369 patient-years of echocardiography time were obtained in 544 patients (mean 4.36 years, range 0.47–11.09). Mean grade of mitral regurgitation decreased from 3.80 to 1.42 (P < .0001) Mean left ventricular ejection fraction decreased from 60.7% to 56.3% (P < .0001). Combined risk of death, reoperation, and recurrence of moderately severe to severe mitral regurgitation was 7.7% (43/555).

Conclusion: Minimally invasive mitral valve repair is safe, with low perioperative morbidity, low rates of recurrent mitral regurgitation, and low rates of reoperation and death at late follow-up.

Abbreviations and Acronyms CI = confidence intervals; MR = mitral regurgitation; MVP = mitral valve repair; MVR = mitral valve replacement


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 


Formula

Earn CME credits at http://cme.ctsnetjournals.org

 

Minimally invasive mitral valve surgery has been proven a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality.1,2Go Efforts to minimize surgical trauma, hasten patient recovery, increase patient satisfaction, and reduce cost, without compromise to surgical repair or replacement techniques, continue to be the rationale for minimally invasive procedures. This study reviews a single institution's 11-year experience with minimally invasive mitral valve repair (MVP), assessing morbidity, mortality, rates of reoperation, and repair durability via follow-up echocardiography, in an effort to better quantify long-term outcomes with these techniques.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
From August 1996 to October 2007, 2181 patients underwent isolated mitral valve surgery (defined as mitral valve surgery without coronary artery bypass grafting). There were 1512 MVPs and 669 mitral valve replacements (MVRs). A minimally invasive approach was used in 780 (36%) patients. Minimally invasive MVR and MVP were performed in 67 (67/669, 10%) and 713 (713/1512, 47%) patients, respectively. Patient selection was predicated by surgeon preference. Absolute contraindications to undergoing minimally invasive mitral valve surgery were surgically significant coronary artery disease, atrial fibrillation deemed amenable to surgical maze treatment, chest wall deformities, and morbid obesity. Excluding 6 patients who had MVP with robotic assistance, a cohort of 707 patients underwent isolated minimally invasive MVP and is the basis of this review.

After receiving approval from the Institutional Review Board of Partners Healthcare, we reviewed prospectively entered data from the database of the Brigham Cardiac Valve Center, collecting all prevalent preoperative, intraoperative, and postoperative outcome data for the cohort of interest. In addition, all operative notes and discharge summaries were reviewed to cross-reference the database, input data that was missing from the database, and to collect supplementary surgical procedural data. Data extraction from operative notes and discharge summaries was focused on key variables: preoperative ejection fraction, grade of mitral regurgitation (MR), valve pathology, reparative techniques, and intraoperative and postoperative complications. Follow-up vital status was obtained from the US Social Security Death Index.3Go Long-term echocardiographic data (defined as ≥ 6 months) missing from the database were collected through direct contact with cardiology and primary care offices. In the instance where the referring cardiologist or primary care physician had lost contact with the patient, patients were contacted directly.

The main end points of interest were perioperative complications, 30-day mortality, recurrence of MR, reoperation rates, and overall survival. All statistical data were analyzed with Stata 10.0 for Windows software (Stata Corporation, College Stage, Tex). Statistical data were expressed as a percentage mean ± 1 standard deviation or via 95% confidence intervals (CI). Survival analysis and time-to-event analysis for rates of reoperation were assessed by the Kaplan–Meier method. Patient's grade of residual or recurrent MR and left ventricular ejection fraction were compared with baseline preoperative measurements by the Student t test for paired samples.

Patient characteristics at baseline are listed in Table 1 . The mean age was 57 years. More than 60% of patients were male. Mean preoperative left ventricular ejection fraction was 60% and mean New York Heart Association functional class was 2.0. Mitral valve pathology was regurgitant in 691 (98%) patients and mixed (regurgitant and stenotic) in 16 (2%) patients. Myxomatous degenerative disease was the predominant pathologic condition, witnessed in 88% of the cohort. Other conditions such as rheumatic, endocarditic, ischemic, calcific, and dilatative cardiomyopathy were also treated. Preoperative chronic atrial fibrillation was noted in 143 (20%) patients.


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  		Table 1 Preoperative baseline characteristics (n = 707)
 
Surgical access for minimally invasive MVP has been modified over time at our institution, with the current approach of lower ministernotomy being the standard since late 2001. These techniques have previously been described.1,4Go In brief, a 6- to 8-cm skin incision over the lower sternum was performed distal to the manubriosternal junction and extending distal to a level 2 fingerbreadths proximal to the xiphoid. With a sternal saw, a hemisternotomy was performed from the base of the xiphoid process to the second intercostoal space. The hemisternotomy was then extended to the right second intercostal space with an oscillating saw. Cardiopulmonary bypass was initiated predominantly through direct cannulation of the ascending aorta and percutaneous cannulation of the inferior vena cava via the femoral vein assisted by transesophageal echocardiography. Undersized (16F–24F) vacuum-assisted cannulas improved surgical exposure while maintaining venous drainage. Drainage of the superior vena cava was usually by small cannula insertion directly into the superior vena cava. Cardioplegia was used in all patients; 620 had antegrade and 87 had both antegrade and retrograde routes. With improved instrumentation, from November 2001 onward, a left atrial incision via Sondergaard's groove5Go became the preferred approach for mitral valve exposure. The right atrial transseptal approach was used only if predicated by tricuspid valve disease, atrial septal defect, or an oversized right atrium. Before November 2001 the right atrial transseptal approach was used almost exclusively. Intracardiac air was removed by cardiac filling and active aortic root suction under transesophageal echocardiographic guidance. A complete list of all operative techniques used is listed in Table 2 .


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  		Table 2 Operative techniques (n = 707)
 
MVP techniques are listed in Table 3 . Posterior leaflet resection and sliding or modified sliding valvuloplasty with placement of an annuloplasty ring was used in the majority of patients. Anterior leaflet pathology was implicated in 184 (26%) of the reparative procedures. The most frequently inserted annuloplasty device was the Cosgrove–Edwards ring (Edwards Lifesciences, Irvine, Calif). Twenty-seven patients did not receive an annuloplasty ring because there was no perceived annular dilatation, the annulus was too heavily calcified, severe systolic anterior motion on insertion of the ring prompted its removal, or because of concern about recent acute endocarditis.


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  		Table 3 Surgical repair techniques (n = 707)
 

   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
Operative results are listed in Table 4 . There were 3 operative deaths (<30 days or same hospital admission) in 707 patients (0.4%). Blood transfusions were required during the hospitalization of 220 (31%) patients. New-onset atrial fibrillation occurred in 115 (20%) of the 564 patients admitted in sinus rhythm. Reoperation for bleeding occurred in 14 (2%) patients. Twelve (1.7%) had a cerebral vascular accident documented by computed tomographic scan. A permanent pacemaker for conjunctional rhythm or complete heart block was required in an additional 12 patients. Five (0.7%) patients had a myocardial infarction. Wound complications consisted of 5 (0.7%) deep sternal infections and 2 (0.3%) dehisced parasternal incisions necessitating reoperation from early in the series. There were 10 (2.3%; 5/130 arterial, 5/300 venous) femoral cannulation–related injuries in 8 patients necessitating surgical revision. In addition, 3 (0.4%) patients from our early experience incurred local ascending aortic dissections as a result of cardioplegia needle placement. Surgical repair of the aorta was accomplished in each case through the original incision. Finally, 1 patient's course was complicated by biventricular failure and cardiogenic shock resulting in the implantation of a biventricular assist device and eventual heart transplantation. Median length of hospital stay was 5 days. Only 49 (7%) patients required convalescence at a rehabilitation facility on hospital discharge. All other patients were discharged directly home.


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  		Table 4 Perioperative morbidity and mortality (n = 707)
 
Late Follow-up
Clinical follow-up was achieved in 698 (98.7%) patients with a mean follow-up of 68.2 months (range 0.5–135) (Table 5 ). Nine patients residing in foreign countries were lost to follow-up. There were 49 (7%) late deaths, and the overall survival at 11.2 years was 83% (95% CI, 76.4–88.0) (Figure 1 ). The cause of death could only be determined for 13 (27%) patients, of which 7 were cardiac related. Freedom from reoperation at 11.2 years was 92% (95%CI, 86.2&ndash94.9) (Figure 2 ). Thirty-four (4.8%) patients had a failed MVP requiring a second operation. The cause of failed repair was myxomatous in 24 (24/622, 3.9%) patients, rheumatic in 5 (5/25, 20%), prior endocarditis in 4 (4/22, 18%), and ischemic in 1 (1/4, 25%) patient. Anterior leaflet involvement (12/34, 35%) or an inability to accommodate annuloplasty ring insertion (9/34, 26%) was involved in 65% of the failed repairs (Table 5). In addition to 9 patients having had a repair without an annuloplasty ring, other indications for reoperation included the following: chordal rupture (n = 4), loosening of artificial chordae (n = 2), ring dehiscence (n = 1), leaflet perforation (n = 2), mitral stenosis (n = 2), progressive Libman–Sacks endocarditis (n = 1), progressive ischemic cardiomyopathy (n = 1), scarred fixation of the posterior leaflet (n = 3), and a failed complicated anterior repair that necessitated multiple artificial chordae and two anterior leaflet resections (n = 1). The 8 remaining patients underwent reoperation at other institutions. Rerepair was possible in 7 patients with 27 patients undergoing MVR. Other reoperations included aortic valve replacement (n = 2) and heart transplantation for end-stage dilated cardiomyopathy (n = 1).


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  		Table 5 Late clinical follow-up
 

Figure 1
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  		Figure 1. Actuarial survival estimates.

 

Figure 2
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  		Figure 2. Actuarial event-free survival estimates. MVP, Mitral valve repair.

 
With 6 months used to define minimum long-term follow-up, 656 (92%) of 707 patients were eligible for late follow-up echocardiographic assessment (Table 6 ). Criteria for exclusion were early death, early reoperation, or less than 6 months of follow-up time at the start of the study.


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  		Table 6 Late echocardiographic follow-up (n = 544)
 
Late follow-up echocardiographic studies were obtained in 544 (83%) of the 656 eligible patients for a total of 2369 patient-years. In the instance in which a patient underwent a reoperation for a failed repair beyond 6 months and the mitral valve was successfully rerepaired, only the echocardiography report at the time of reoperation was used in the analysis of recurrent MR. Reasons for not attaining late echocardiographic studies in eligible patients were late death (24 patients), foreign residence (9 patients), failure to receive a follow-up echocardiogram at the referring center (56 patients), or loss to follow-up (23 patients). Duration of follow-up ranged from 5.6 to 133.2 months (mean 52.3 ± 34 months). Long-term MR was reduced from a mean preoperative grade of 3.80 (95% CI, 3.76–3.83) to 1.42 (95% CI, 1.34–1.51) (P < .0001). Mean preoperative left ventricular ejection fraction decreased from 60.7% (95% CI, 59.8–61.5) to 56.3% (95% CI, 55.5–57.0) (P < .0001) over the same period. Over half (56%) of all patients had trace or no MR at follow-up and 88% (475/544) had mild MR or less. Ten patients had severe MR, 16 patients had moderately severe MR, and 43 patients had moderate MR.

Of those patients with recurrent MR of high significance (moderately severe to severe MR), only 6 patients (5 patients with moderately severe MR, 1 patient with severe MR) have yet to undergo reoperation. The combined risk of death, reoperation, and recurrence of moderately severe to severe MR was 7.7% (43/555).


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
In this the second of what will likely be several revisits to the outcomes from a large cohort of minimally invasive MVP, the promising results from the initial review have continued to endure with time.1Go Operative mortality is less than 0.5%, major morbidity has remained low, and rates of reoperation have decreased from 5.8% to 4.8%. Moreover, previously known risk factors for MVP failure, those being anterior leaflet pathology6Go and reparative procedures that do not include the insertion of an annuloplasty ring,7,8Go were expectantly reaffirmed. The incidence of reoperation for anterior leaflet pathology continues to be 7% in this cohort. With respect to ring insertion, since the previous review, which documented one fourth of reoperations to occur in patients who did not have a ring annuloplasty insertion, only 7 of 349 patients have undergone minimally invasive MVP without incorporation of an annuloplasty ring. Despite more than a 2-fold reduction in MVP performed without an annuloplasty ring, one fourth of all reoperations were still a result of surgical repairs performed without ring insertion. To date, 33% of repairs without an annuloplasty ring have required reoperation, despite achieving intraoperative competence, re-emphasizing the key importance of these devices for good long-term results.

Beyond revisiting clinical outcomes, efforts were made to acquire echocardiographic data so as to assess in a more objective manner the long-term durability of minimally invasive MVP. MR was shown to have decreased from a qualitative grade of 3.80 to 1.43, both a statistically and clinically significant finding. Outcome studies have demonstrated the benefits of mitral valve surgery for both symptomatic9Go and asymptomatic10Go patients with organic MR. Over 95% of this cohort had organic pathology, and the majority had preserved left ventricular function. To have sustained what is a clear, clinically relevant improvement in MR grade, in the face of low surgical complication rates, over a duration of 2000 patient-years, lends further credence to the importance of referring patients for MVP early in the disease process.

The decrease in left ventricular ejection fraction from 60.7% to 56.3% was also a statistically significant finding and is in keeping with previous reports from conventional MVP.11Go Still, contrary to the statistical findings for MR grade at late follow-up, the statistical significance of the reduction in left ventricular ejection fraction from 61% to 56% does not correlate to an overt clinical significance and can be interpreted to show modest preservation over time.

Recurrent MR was identified to be moderately severe or worse (≥3.5+) in 4.8% of patients. Reports in the literature on the recurrence of significant MR have a broad range, from 4.8% to 29%.12Go Notably, between studies comparisons are problematic. Dissimilarities in disease processes and echocardiographic intraobserver variability render such comparisons fraught with confounding results and therefore misleading.

The adoption of minimally invasive techniques at our institution has resulted in long-term outcomes that appear comparable with conventional sternotomy procedures. These outcomes should be given clear recognition as we move forward with percutaneous valve technology.13Go Although advancements in percutaneous valve therapy are to be encouraged in an effort to improve patient care, percutaneous procedures must be held accountable and to the same standards regarding patient outcomes if they are ever to be seriously considered beyond the most select of patient populations. In addition to these long-term results, although it was an unadjusted analysis, we4Go have previously demonstrated reductions in cardiopulmonary bypass time, aortic crossclamp time, and median length of hospital stay for minimally invasive MVP in comparison with conventional MVP. Still, 606 (85%) of 713 minimally invasive MVPs were performed by a single surgeon (L.H.C.), and this accounts for 65% (606/930) of all isolated MVPs performed by this surgeon for the time period of interest. With outcomes that continue to show promise, it is expected that minimally invasive techniques for MVP will disseminate further and adoption at the Brigham will increase. Other centers have also shown promising results with minimally invasive approaches to MVP. Casselman and associates14Go have gained considerable expertise in endoscopic cardiac surgery, publishing results on 226 patients in whom these techniques were used for MVP. In a series in which 15% of patients had anterior leaflet pathology and 7% had endocarditis, they reported 1 (0.4%) early death and 3 conversions to sternotomy; freedom from reoperation at 4 years was 93.3% ± 2.6%. Reviewing their complete endoscopic valve series of 306 patients consisting of both aortic and mitral valve repair and replacement procedures, 94.2% of patients stated no procedural or minimal procedural pain and 99.3% were extremely pleased with the cosmetic results. Chitwood and Rodriguez15Go have become synonymous with robotic cardiac surgery and have performed more than 200 robotic minimally invasive MVPs to date. Early death is 2% in this cohort with no or trace MR via postoperative echocardiography in 96.5% of patients. Independently, the surgical teams of Umakanthan,16Go Loulmet,17Go and their associates have recently reported on their early experience with minimally invasive valve surgery through a right anterolateral minithoracotomy in conjunction with hypothermic or induced fibrillatory arrest to avoid aortic crossclamping and cardioplegic ischemia. Both groups have had success with this approach, maintaining low perioperative morbidity and mortality in the short term.

This review has certain limitations. The review is largely retrospective and lacks a control group for appropriate comparisons. The inability to determine late cause of death in the majority of patients and the inability to attain 100% late echocardiographic assessment are additional weaknesses. Despite these limitations, the strengths of this review are quite conclusive. With near complete clinical follow-up in more than 707 patients and late echocardiographic follow-up in more than 540 patients, the results of this review are robust. This study reaffirms the notion that minimally invasive surgery is an excellent intervention for mitral valve disease.

In conclusion, minimally invasive MVP is safe, with low perioperative morbidity, low rates of recurrent MR, and low rates of reoperation and death at late follow-up.


   Footnotes
 
We have no conflicts of interest to disclose.

Read at the Thirty-fourth Annual Meeting of The Western Thoracic Surgical Association, Kona, Hawaii, June 25–28, 2008.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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  5. Larbalestier RI, Chard RB, Cohn LH. Optimal approach to the mitral valve: dissection of the interatrial groove. Ann Thorac Surg 1992;54:1186-1188.[Abstract/Free Full Text]
  6. David TE, Ivanov J, Armstrong S, Christie D, Rakowski H. A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse. J Thorac Cardiovasc Surg 2005;130:1242-1249.[Abstract/Free Full Text]
  7. Maisano F, Caldarola A, Blasio A, De Bonis M, La Canna G, Alfieri O. Midterm results of edge-to-edge mitral valve repair without annuloplasty. J Thorac Cardiovasc Surg 2003;126:1987-1997.[Abstract/Free Full Text]
  8. Cohn LH, Couper GS, Aranki SF, Rizzo RJ, Kinchla NM, Collins Jr. JJ. Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve. J Thorac Cardiovasc Surg 1994;107:143-151.[Abstract/Free Full Text]
  9. Bonow R, Carabello B, Kanu C, de Leon Jr. AC, Faxon DP, Freed, MD, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2006;114e84-231.
  10. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352:875-883.[Medline]
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  14. Casselman FP, Slycke SV, Wellens F, Geest RD, Degrieck I, Praet FV, et al. Mitral valve surgery can now routinely be performed endoscopically. Circulation 2003;108(Suppl II):II48-II54.[Medline]
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