Editorial (PRO) Re Minimally Invasive Port-Access Mitral Valve Surgery

Abstract

T fundamental issues are raised by publication of the article titled “Minimally Invasive PortAccess Mitral Valve Surgery,” by Professor Mohr and associates from the University of Leipzig (see page 567). First, should The Journal of Thoracic and Cardiovascular Surgery and other surgical journals publish “learning curve/feasibility” results after the introduction of a new surgical technology? Second, how should medicine, or cardiothoracic surgery in particular, safely introduce new technology into the competitive marketplace at a time when evidence based, outcome measured results are increasingly demanded by insurers, government agencies, and patients? In regard to the first question, I believe the Journal has a responsibility to publish not only scientifically valid basic science research and prospective randomized clinical trials, but also articles that might affect safety and efficacy issues, even if not optimally designed. If one looks at articles published in the cardiothoracic literature historically and more recently, the majority of articles remain retrospective reviews, personal series, case reports, or megaanalyses. Technology evolves so rapidly that by the time a prospective randomized trial might be designed and carried out, the variables have changed and the results are no longer applicable. The presentation of Professor Mohr’s experience with Port-Access mitral valve surgery at the 1997 meeting of The American Association for Thoracic Surgery, along with the publication of the abstract, may have already contributed to the dramatic improvements in results. Abstracts submitted for recent cardiothoracic surgery and cardiology meetings have documented dramatically better results with the Port-Access technology and have identified a number of critical issues: (1) There is a learning curve, so training is essential; (2) femoral artery and groin wound complications do occur, and local vascular reconstruction after cannula removal must be meticulous; (3) the descending aorta presents potentially lethal complications if not investigated before the operation (by transesophageal echocardiography or computed tomographic scanning) and respected during the operation; (4) neuropsychologic complications are not decreased with endovascular aortic occlusion and probably occur at a higher incidence because of inadequate deairing, endovascular manipulation, retrograde aortic perfusion, and balloon manipulation in close proximity to the aortic arch; (5) endoaortic balloon migration is common, may be difficult to deal with during the operation, and is potentially dangerous; (6) mitral valve disease must be carefully assessed to avoid a high reoperative rate (6/51 patients in the present study); (7) respiratory management must be conducted aggressively in the postoperative period to avoid prolonged ventilatory management; (8) at present, this particular operative method should not be chosen on the basis of presumed reduction in cost. Surgeons considering using the Port-Access system, or any unfamiliar surgical technique, for that matter, must be aware of all potential complications and have strategies developed in advance to avoid complications or to deal with them if they arise. A report such as Professor Mohr’s assists surgeons in developing these strategies and therefore is a valuable part of the medical literature. With regard to the second question, as a specialty we must think through the issues that apply to advances in surgical techniques. If we look at our specialty in historic terms, modern cardiac surgery is about fifty years old and thus is still in its infancy. Major changes have come rapidly with the introduction of cardiopulmonary bypass, myocardial revascularization, valve replacement and repair techniques, and more recently minimally invasive surgical approaches, transmyocardial laser revascuFrom the Division of Cardiothoracic Surgery, University of Washington, Seattle, Wash. Requested for publication Sept. 23, 1997; received Dec. 2, 1997; accepted for publication Dec. 5, 1997. Address for reprints: Edward D. Verrier, MD, Division of Cardiothoracic Surgery, University of Washington, Box 356310, 1959 NE Pacific St., Seattle, WA 98195. J Thorac Cardiovasc Surg 1998;115:565-6 Copyright © 1998 by Mosby, Inc. 0022-5223/98 $5.00 1 0 12/6/88010