Mitral Valve Operations through Standard and Smaller Incisions
Objective: Evaluate the operative results of mitral valve repair (MVV) and mitral valve replacement (MVR) performed through standard and smaller incisions.
Methods: From January 1997 through December 2002, 821 consecutive patients underwent mitral valve operation. Of these procedures, 475 were MVV and 346 were MVR. A logistic regression model was developed to identify the risk factors for early mortality and to evaluate the effect of replacement versus repair and standard versus small incision.
Results: Replacement patients were older, more likely New York Heart Association (NYHA) class III or IV, more likely female, and had more frequent previous median sternotomy and stroke (all P < .05). The mitral diagnoses in the 2 groups were markedly different. Prolapse and ischemia dominated the repairs, whereas calcific and rheumatic diagnoses required replacement. There were 667 concomitant procedures performed on these patients, most commonly coronary artery bypass graft (229), aortic valve replacement (170), maze (79), and tricuspid valve (TV) repair/replacement (73). Thirty-three patients (4.0%) died in the postoperative period, 2.3% after repair and 6.4% after replacement (P < .01). Endocarditis (4/17), calcific disease (7/73), and ischemic disease (9/121) accounted for 26% of patients and 60% of deaths. Multivariate regression analysis identified NYHA class, emergent status, concomitant TV operation, and history of renal failure, but not repair versus replacement, as independent risk factors predicting mortality. We estimated that 356 of the 821 patients (43%) were candidates for small-incision operations, the others were excluded by the need for concomitant procedure or other cause. A total of 205/356 (57%) actually underwent small-incision operations, all with central cannulation and standard techniques. From 1997-1999, 32% of eligible patients were so treated, but from 2000-2002, with increasing surgeon experience, this percentage rose significantly to 71% (P < .01). Eligible patients who underwent small-incision operation were younger and had lower NYHA classifications, lower preoperative creatinine, and shorter length of stay (all P < .01) than those who had standard incisions. Cross-clamp time, perfusion time, and mortality rate were not significantly different.
Conclusions: The mortality rate for MV operations is concentrated among a few diagnoses. In some patients surgery may be approached safely through smaller incisions without introducing new elements of operative risk.
Bolling SF, Deeb GM, Brunsting LA, Buch DS. 1995. Reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg 109:676-83.nCarpentier A, Chauvaud S, Fabiani JN, et al. 1980. Reconstructive surgery of mitral valve incompetence: a ten-year appraisal. J Thorac Cardiovasc Surg 79:338-48.nCarpentier A. 1983. Cardiac valve surgery--"the French correction." J Thorac Cardiovasc Surg 86:323-37.nChitwood WR, Nifong LW. 2000. Minimally invasive videoscopic mitral valve surgery: the current role of surgical robotics. J Card Surg 15:61-75.nCohn LH, Peigh PS, Sell J, DiSesa VJ. 1989. Right thoracotomy, femoral-femoral bypass, and deep hypothermia for re-replacement of the mitral valve. Ann Thorac Surg 48:69-71.nColvin SB, Galloway AC, Ribacove G, et al. 1998. Port access mitral valve surgery: summary of results. J Card Surg 13:286-89.nCosgrove DM, Sabik JF, Navia JL. 1998. Minimally invasive valve operations. Ann Thorac Surg 65:1535-39.nDavid TE. 1994. Papillary muscle-annular continuity: is it important? J Card Surg 9(Suppl):252-4.nGalloway AC, Colvin SB, Baumann FG, et al. 1989. A comparison of mitral valve reconstruction with mitral valve replacement: intermediateterm results. Ann Thorac Surg 47:55-62.nGillinov AM, Wierup PN, Blackstone EH, et al. 2001. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 122:1125-41.nGillinov AM, Faber C, Houghtaling PL, et al. 2003. Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. J Thorac Cardiovasc Surg 125:1197-9.nGlower DD, Landolfo KP, Clements F, et al. 1998. Mitral valve operation via port-access versus median sternotomy. Eur J Cardiothoracic Surg 14(Suppl 1):143-7.nGrossi EA, Galloway AC, LaPietra A, et al. 2002. Minimally invasive mitral valve surgery: a 6-year experience with 714 patients. Ann Thorac Surg 74(3):660-4.nGrunkemeier GL, Jin R. 2001. Receiver operating characteristic curve analysis of clinical risk models. Ann Thorac Surg 72:323-6.nLemeshow S, Hosmer DW. 1982. A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 115:92-106.nGundry SR, Shattuck OH, Razzouk AJ, et al. 1998. Facile minimally invasive cardiac surgery via mini-sternotomy. Ann Thorac Surg 65:1100-4.nMohty D, Orszulak TA, Schaff HV, et al. 2001. Very long-term survival and durability of mitral valve repair for mitral valve prolapse. Circulation 104(12 Suppl 1):I1-I7.nReichensprunger H, Welz A, Gulielmos V, Boehm D, Riechart B. 1998. Port-access cardiac surgery using endovascular cardiopulmonary bypass: theory, practice, and results. J Card Surg 13:275-80.nSarris GE, Fann JI, Niczyporuk MA, et al. 1989. Global and regional left ventricular systolic performance in the in-situ ejecting canine heart: importance of mitral valve apparatus. Circulation 80(Suppl 1):24-42.nSavage EB, Ferguson TB, DiSesa VJ. 2003. Use of mitral valve repair: analysis of contemporary United States experience reported to the Society of Thoracic Surgeons national cardiac database. Ann Thorac Surg 75:820-25.nTribble CG, Killinger WA, Harman PK, et al. 1987. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve. Ann Thorac Surg 43:380-2.nn
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