Invasive Mitral Surgery Research Articles

RIGHT AXILLARY MINI–THORACOTOMY FOR MINIMALLY INVASIVE MITRAL SURGERY: A 5–YEAR SINGLE–CENTER EXPERIENCE

Abstract Objectives To report early– and long–term outcomes of patients undergoing minimally invasive mitral surgery (MIMS) through right axillary mini–thoracotomy (RAMT) over a 5–year period. Methods From July 2016 to December 2021, a total of 172 patients underwent MIMS through RAMT at “Vito Fazzi” Hospital. Results Mitral valve diseases were degenerative (62.8%), rheumatic (13.9%), functional (13.4%), Barlow (5.2%), and endocarditis (4.7%) mitral disease. Mitral valve repair was performed in 142 patients (82.5%) and 30 (17.5%) had mitral replacement. Repair techniques included neochordae implantation (53.5%), isolated annuloplasty (28.9%), leaflet resection (11.3%), sliding plasty (4.9%) and Alfieri procedure (0.7%). Furthermore, in 29 patients (16,8%) concomitant procedures were associated. All cardiac procedures were performed under direct vision and without using thoracoscopes. Mean length of skin incision under the armpit (fig 1) was 5.7 ± 1.3 cm. Of note, conversion to median sternotomy occurred only in 2 (1.2%) cases. Stroke incidence was 0.9% and in–hospital mortality 0.5%. Overall survival and freedom from reoperation at 5 years were 91.5% and 99.1%, respectively (fig 2). Conclusions RAMT access for MIMS is a safe and reproducible approach associated with low mortality and morbidity, the possibility to perform complex mitral surgery under direct vision, high rate of mitral valve repair, and excellent late results. Importantly, limited skin incision under the armpit provided excellent aesthetic results.

Impact of Frailty in Patients Undergoing Minimally Invasive Mitral Valve Surgery.

Psoas muscle size is a reliable marker of sarcopenia and frailty that correlates with adverse outcomes after cardiac surgery. However, its use in mitral and minimally invasive cardiac surgery is lacking. We sought to determine whether frailty, as measured by psoas muscle index, increases surgical risk for minimally invasive mitral valve surgery. Patients undergoing isolated minimally invasive mitral surgery via right minithoracotomy were identified. Patients who underwent maze, tricuspid intervention, and those who were emergent were excluded. Total psoas muscle area was calculated using the average cross-sectional area at the L3 vertebra on computed tomography scan and indexed to body surface area. Sarcopenia was defined as <25th gender-specific percentile. Patients were stratified by sarcopenia status and outcomes compared. Of 287 total patients, 192 patients met inclusion criteria. Sarcopenic patients were 6 years older (66 vs 60 years, P = 0.01), had lower preoperative albumin levels (4.0 vs 4.3 g/dL, P < 0.001), and had higher Society of Thoracic Surgeons risk of morbidity/mortality (13.1% vs 9.0%, P = 0.003). Operative major morbidity or mortality was 6.4% versus 5.5% (P = 0.824), while the 1-year mortality rate was 2.1% versus 0% (P = 0.08). After risk adjustment, psoas index did not predict operative morbidity or mortality. However, sarcopenia was associated with higher odds of readmission (odds ratio = 0.74, P = 0.02). Contrary to other cardiac operations, for patients undergoing isolated minimally invasive mitral valve surgery, sarcopenia was not associated with increased perioperative risk except for higher readmission rates. Minimally invasive surgical approaches should be strongly considered as the approach of choice in frail patients.

Fine tuning for totally endoscopic mitral valve surgery: ERAS applications.

One of the philosophies of minimally invasive mitral surgery is to enhance recovery after surgery (ERAS). Beyond surgical applications, ERAS applications provide a complementary approach to optimize postoperative course and discharge. In this report, we aim to present institutional protocol for ERAS and its results in patients who underwent totally endoscopic mitral valve surgery (TEMVS). Between 2021 and 2023, totally 113 patients who underwent TEMVS were included in this study. TEMVS was performed by peripheral cannulation and 3D endoscopic technique. As a dedicated team, institutional ERAS protocols which are used are listed above: (1) Education; operative course, cessation of smoking and alcohol. (2) Anemia; diagnostic evaluation and its treatment by iv iron. (3) Optimization of blood glucose; checking of HbA1c and control of hyperglycemia. (4) Rehabilitation; Physical and pulmonary rehabilitation. (5) Anxiety and Analgesia treatment. (6) Blood Conservation techniques; Antifibrinolytic, acute normovolemic hemodilution, less priming volume, mini-incision, meticulous surgery by 3D endoscope. (7) Postoperative; early extubation, prevention of nausea, aggressive analgesia, early mobilization, early removal of tubes. (8) Restrictive transfusion strategy. (9) Early discharge. The mean age was 54.7 years, and 56% was female. The rate of iv iron therapy for anemia was 26.5%. Mitral repair was performed in 58.4% of the cases. The repair rate of degenerative mitral valve was 96.9%. Of all, 68.1% did not have any red packed cells and 15.9% had only one unit. Ninety-five patients (90.2%) did not have any unit of fresh frozen plasma. The median extubation time was 7 h. On the postoperative first day, 96% of foley catheters, 87% of all central venous catheter and 93% of all drainage tubes are removed. The rates of respiratory, infectious, and renal complications were 9%, 3.5%, 3.4% respectively. The median ICU, and hospital stays were 1 and 5 days respectively. There was only one mortality in the early postoperative period. Totally endoscopic mitral valve surgery provides minimal surgical trauma. By the addition of well-established and nurse-based ERAS protocols, complication and transfusion rates can be decreased, early recovery and discharge can be provided.

Application of Cut-and-Sew Technique in Thoracoscopic Minimally Invasive Mitral Valve Surgery and Concomitant Maze Procedure.

Atrial fibrillation is one of the common complications of mitral valve disease. Currently, in the absence of freezing equipment, it's still impossible to fully conduct a minimally invasive Cox-maze IV procedure to treat atrial fibrillation. We analyzed the clinical data of 28 patients who underwent thoracoscopic minimally invasive mitral valve full maze surgery in our hospital from October 2021 to September 2022; 13 patients were male and 15 were female, three suffered from paroxysmal atrial fibrillation, and 25 suffered from permanent atrial fibrillation; average age was 61.88±8.30 years, and mean preoperative left atrial diameter was 47.12±8.34 mm. Isolation of left atrial posterior wall (box lesion) was completed in all patients by cut-and-sew technique and bipolar clamp ablation. For these subjects, the median cardiopulmonary bypass time was 169 (109.75-202.75) minutes, aortic cross-clamping time was 106 (77.75-125.50) minutes, and ventilator assistance time was 6.5 (0-10) hours. Among them, eight subjects had the endotracheal tubes removed immediately after surgical operation. Three subjects were in the blanking period; two subjects still had atrial fibrillation at three months after operation, one of whom resumed sinus rhythm after electrical cardioversion therapy; and all the remaining 23 subjects had sinus rhythm. The minimally invasive cut-and-sew technique for electrical isolation of left pulmonary veins can improve sinus conversion rate of patients suffering from both mitral valve disease and atrial fibrillation. In selected subjects, it is safe and has good results in the short-term postoperative period.

Propensity Matched Outcomes of Minimally Invasive Mitral Surgery: Does a Heart-Team Approach Eliminate Female Gender as an Independent Risk Factor?

There is increasing evidence that female gender is an independent risk factor for cardiac surgery. Minimally invasive mitral surgery (MIV) has proven to have excellent long-term results, but little is known about gender-dependent outcomes. The aim of our study was to analyze our heart team's decision-based MIV-specialized cohort. In-hospital and follow-up data were retrospectively collected. The cohort was divided into gender groups and propensity-matched groups. Between 22 July 2013 and 31 December 2022, 302 consecutive patients underwent MIV. Before matching, the total cohort showed that women were older, had a higher EuroSCORE II, were more symptomatic, and had more complex valve pathology and tricuspid regurgitation resulting in more valve replacements and tricuspid repairs. Intensive and hospital stays were longer. In-hospital deaths (n = 3, all women) were comparable, with more atrial fibrillation in women. The median follow-up time was 3.44 (0.008-8.9) years. The ejection fraction, NYHA, and recurrent regurgitation were low and comparable and atrial fibrillation more frequent in women. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.9 and p = 0.2). Propensity matching compared 101 well-balanced pairs; women still had fewer resections and more atrial fibrillation. During the follow-up, women had a better ejection fraction. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.3 and p = 0.3). Despite women being older and sicker, with more complex valve pathology and subsequent replacement, early and mid-term mortality and the need for reoperation were low and comparable before and after propensity matching, which might be the result of the MIV setting combined with our patient-tailored decision-making. We believe that a multidisciplinary heart team approach is crucial to optimize patient outcomes in MIV, and it might also reduce the widely reported increased surgical risk in female patients. Further studies are needed to prove our findings.

Risk-related clinical outcomes after minimally invasive mitral valve surgery: insights from the Mini-Mitral International Registry.

With the popularization of catheter-based mitral valve procedures, evaluating risk-specific differentiated clinical outcomes after contemporary mitral valve surgery is crucial. In this study, we assessed the operative results of minimally invasive mitral valve operations across different patient risk profiles and evaluated the value of EuroSCORE (ES) II predicted risk of mortality model for risk prediction, in the large cohort of Mini-Mitral International Registry (MMIR). The MMIR database was used to analyse mini-mitral operations between 2015 and 2021. Patients were categorized as low (<4%), intermediate (4% to <8%), high (8% to <12%) and extreme risk (≥12%) according to ES II. The observed-to-expected mortality ratio was calculated for each risk group. A total of 6541 patients were included in the analysis. Of those, 5546 (84.8%) were classified as low risk, 615 (9.4%) as intermediate risk, 191 (2.9%) as high risk and 189 (2.9%) as extreme risk. Overall operative mortality and stroke rates were 1.7% and 1.4%, respectively, and were significantly associated with patient's risk. The observed mortality was significantly lower than expected-according to the ES II-in all risk categories (observed-to-expected ratio < 1). The present study provides an international contemporary benchmark for operative outcomes after minimally invasive mitral surgery. Operative results were excellent in low-, intermediate- and high-risk patients, but were less satisfactory in extreme risk. The ES II model overestimated the in-hospital mortality. We believe that findings from the MMIR may assist surgeons and cardiologists in clinical decision-making and treatment allocation for patients with mitral valve disease.

A qualitative improvement program for minimally invasive mitral surgery: technical advancements ameliorate outcome and operative times.

Minimally invasive mitral valve surgery (MIMVS) has evolved over the last 2 decades. The aim of the study was to identify the impact of era and technical improvements on perioperative outcome after MIMVS. A tota of 1000 patients (mean age: 60.8 ± 12.7 years, 60.3% male) underwent video-assisted or totally endoscopic MIMVS between 2001 and 2020 in a single institution. Three technical modalities were introduced during the observed period: (i) 3D visualization, (ii) use of premeasured artificial chordae (PTFE loops) and (iii) preoperative CT scans. Comparisons were made before and after the introduction of technical improvements. A total of 741 patients underwent isolated mitral valve (MV) procedure, whereas 259 received concomitant procedures. These consisted of tricuspid valve repair (208), left atrium ablation (145) and persistent foramen ovale or atrial septum defect (ASD) closure (172). The aetiology was degenerative in 738 (73.8%) patients and functional in 101 patients (10.1%). A total of 900 patients received MV repair (90%), and 100 patients (10%) underwent MV replacement. Perioperative survival was 99.1%, and periprocedural success 93.5% with a periprocedural safety of 96.3%. Improvement in periprocedural safety attributed to the lower rates of postoperative low output (P = 0.025) and less reoperations for bleeding (P < 0.001). 3D visualization improved cross-clamp (P = 0.001) but not cardiopulmonary bypass times. The use of loops and preoperative CT scan both had no impact on periprocedural success or safety but improved cardiopulmonary bypass and cross-clamp times (both P < 0.001). Increased surgical experience improves safety in MIMVS. Technical improvements are related to increased operative success and decreased operative times in patients undergoing MIMVS.

Early Outcome of Minimally Invasive Versus Conventional Mitral Valve Replacement Surgery

Early Outcome of Minimally Invasive Versus Conventional Mitral Valve Replacement Surgery

Robotic and endoscopic mitral valve repair for degenerative disease.

Minimally invasive mitral valve repair has been proven to be a safe alternative to open sternotomy and may be accomplished through classic endoscopic and robotic endoscopic approaches. Outcomes across different minimally invasive techniques have been insufficiently described. We compare early and late clinical outcomes across matched patients undergoing robotic endoscopic and classic endoscopic repair. From 2011 to 2020, 786 patients underwent minimally invasive mitral surgery, from which we were able to generate 124 matched patients (62 patients in each cohort). Clinical results were then compared between the two matched populations. Survival analysis was used to compare freedom from mortality to 10 years among matched classic endoscopic and robotic endoscopic mitral valve repair cohorts and to calculate freedom from moderate or severe mitral insufficiency at latest follow-up. Histograms of cardiopulmonary bypass (CPB) and aortic cross-clamp times were constructed, and mean bypass and cross-clamp times were compared between classic endoscopic and robotic endoscopic cohorts. There was no difference in early or late mortality at 10 years in either cohort. Freedom from moderate or severe mitral regurgitation or mitral valve replacement at last echocardiogram was 86.4% vs. 73.5% at 10 years, P=0.97. Patients undergoing robotic endoscopic mitral repair had a significantly longer CPB run when compared to the classic endoscopic cohort, with 148 min of CPB in the robotic endoscopic cohort compared to 133 min in the classic endoscopic group, P=0.03. Overall post-operative length of stay was not statistically significant between the robotic endoscopic and classic endoscopic groups, 6.3±0.5 and 6.0±0.3 days, respectively. No patients in either cohort developed renal failure or wound infection. The classic endoscopic group had a slightly higher risk of prolonged ventilation when compared to the robotic endoscopic group, with three classic endoscopic patients remaining intubated >8 hours post-operatively, compared to a single patient in the robotic endoscopic group. There were no unplanned reoperations in either group. Rates of postoperative stroke were comparable between groups (three in the classic endoscopic cohort, and two in the robotic endoscopic cohort). Index mitral valve surgery via a classic endoscopic approach yields similar clinical outcomes when compared to robotic endoscopic surgery. We demonstrate that both classic endoscopic and robotic endoscopic approaches allow repair of degenerative mitral valves with excellent short- and medium-term outcomes in a tertiary referral center.

Robotic vs. minimally invasive mitral valve repair: A 5-year comparison of surgical outcomes.

Minimally invasive mitral valve repair (MVr) is commonly performed. Data on the outcomes of robotic MVr versus nonrobotic minimally invasive MVr are lacking. We sought to compare the short-term and mid-term outcomes of robotic and nonrobotic MVr. We reviewed all patients who underwent robotic MVr (n = 424) or nonrobotic MVr via right mini-thoracotomy (n = 86) at Mayo Clinic, Rochester, MN, from January 2015 to February 2020. Data on baseline and operative characteristics, operative and long-term outcomes were analyzed. Patients were matched 1:1 using propensity scores. Sixty-nine matched pairs were included in the study. The median age was 59 years (interquartile range[IQR]: 54-69) and 75% (n = 103) were male. Baseline characteristics were similar after matching. Robotic and nonrobotic MVr had similar operative characteristics, except that robotic had longer cross-clamp times (57 [48-67] vs. 47 [37-58] min, p < .001) and more P2 resections (83% vs. 68%, p = .05) compared to nonrobotic MVr. There was no difference in operative outcomes between groups. Hospital stay was shorter after robotic MVr (4 [3-4] vs. 4 [4-6] days, p = .003). After a median follow-up of 3.3 years (IQR, 2.1-4.5), there was no mortality in either group, and there was no difference in freedom from mitral valve reoperations between robotic and nonrobotic MVr (5 years: 97.1% vs. 95.7%, p = .63). Follow-up echocardiogram analysis predicted excellent freedom from recurrent moderate-or-severe mitral regurgitation at 3 years after robotic and nonrobotic MVr (90% vs. 92%, p = .18, respectively). Both short-term and mid-term outcomes of robotic and nonrobotic minimally invasive mitral repair surgery are comparable.

Clinical Evaluation of on-Table Extubation in Patients Aged Over 60 Years Undergoing Minimally Invasive Mitral or Aortic Valve Replacement Surgery.

AimsTo evaluate the clinical efficiency of on-table extubation (OTE) versus delayed extubation in patients aged over 60 years that underwent minimally invasive mitral or aortic valve replacement surgery and evaluate the factors associated with successful OTE implementation.MaterialsPatients over 60 years with mitral or aortic valve disease who received minimally invasive mitral or aortic valve replacement surgery from October 2020 to October 2021 were selected retrospectively. We divided patients into the on-table extubated (OTE) group (n = 71) and the delayed extubation (DE) group (n = 22). Preoperative, intraoperative, and postoperative clinical variables were compared between the two groups.ResultsPatients in the DE group underwent longer surgery time, longer aortic occlusion clamping time and longer cardiopulmonary bypass time than those in the OTE group(217.48 ± 27.83 vs 275.91 ± 77.22, p = 0.002; 76.49 ± 16.00 vs 126.55 ± 54.85, p = 0.001; 112.87 ± 18.91 vs 160.77 ± 52.17, p = 0.001). Patients in the OTE group had shorter postoperative mechanical ventilation time (min), shorter ICU time, shorter postoperative hospital length of stay and lower total cost and medication cost (p < 0.05). The AUC for aortic occlusion clamping time was 0.81 (p < 0.01), making it the most significant predictor of on-table extubation success.ConclusionsOn-table extubation following mitral or aortic valve cardiac surgery was associated with a superior clinical outcome and high cost-effectiveness.

Necessity Is the Mother of Invention: How Making Mitral Exposure Easier During Minimally Invasive Surgery Can Improve Adoption Rates

Minimally invasive mitral valve surgery comes in many different forms. Although the adoption rate for minimally invasive mitral surgery in the United States had increased to 30% by 2018, it is still very low compared with other European countries.1 Dissecting the reasons for a low adoption rate compared with other specialties’ minimally invasive techniques, such as robotic prostatectomy, reveals it is not just about the instruments or the optics equipment used. The learning curve for minimally invasive mitral surgery can be steep, and 1 major reason for this is inadequate exposure or “setup.” In surgery, technique is “king” but exposure is “queen,” and the anterior annular–to–posterior leaflet stitch for traction technique described by Peña and colleagues in this issue of The Annals of Thoracic Surgery2 is a tool every minimally invasive mitral surgeon should master.

Characteristics of postoperative pain after mini invasive and conventional mitral surgery in Hanoi Heart Hospital

Introduction: Mini invasive mitral valve surgery had some advantages over conventional surgery in recovery and cosmestic results. Postoperative pain was an interested factor for comparing these two methods, with reported results remained unclear. We realized this study for evaluate the characteristics of postoperative pain between mini invasive and conventional mitral surgery in Hanoi Heart Hospital.&#x0D; Methods: A cross sectional study on patient underwent mitral valve replacement with mini invasive and conventional sternotomy approach.&#x0D; Results: There were 66 patients in the study, divided into 2 group: 43 patient underwent conventional surgery and 23 patient underwent mini invasive surgery. Mean age was 50,7 ± 9,3, female was 78,8% and mean BMI was 20,9 ± 2,7. Erector spinae plane (ESP) block was performed on 16 patients (24,2%) of conventional surgery group. The VAS score at 3 days, 7 days , and 1 month after surgery was 7,7 ± 1,2; 5,2 ± 1,5; 0,9 ± 1,1 in sternotomy group and 6,6 ± 1,6; 3,8 ± 1,5; 1,7 ± 0,9 in mini invasive group, respectively. In patients with ESP block, mean dose of morphine administered in first two days was 0 and 2,3 ± 5,0 mg/kg comparing to the dose of 19,7 ± 5,5 và 17,7 ± 7,1 in sternotomy patients without ESP block.&#x0D; Conclusions: Postoperative pain reduction may not be an advantage of mini invasive mitral surrgery comparing to conventional surrgery, but the time for pain suffering in this group was shorter. ESP was an efficient method for early pain reduction after conventional surgery.

Endoscopic Mitral Valve Repair in a Patient With Persistent Left Superior Vena Cava Draining Into the Coronary Sinus – Cannulation Technique and Surgical Management

Persistence of the left superior vena cava is often an incidental finding during cardiac surgical procedures. In minimally invasive valvular surgery, it may jeopardise venous drainage and myocardial protection. This How-To-Do-It paper describes the cannulation strategy in a case of minimally invasive mitral surgery in a patient with persistence of the left superior vena cava and absence of the anonymous vein detected with preoperative multimodality imaging.

Predictors of safety and success in minimally invasive surgery for degenerative mitral disease.

The aim of this study was to identify predictors of periprocedural success and safety in minimally invasive mitral valve surgery and to determine the impact of pathology localization and repair technique on reoperation-free survival. We isolated 686 patients (mean age 60.5, standard deviation 12.3 years, 69.4% male) who underwent surgery for mitral valve prolapse between 2002 and 2020 in a single institution. Patients with concomitant disease, redo or mitral pathology other than degenerative mitral disease were excluded from the analysis. Periprocedural safety was defined as: freedom from perioperative death, myocardial infarction, stroke, use of extracorporeal membrane oxygenation or reoperation for bleeding. Operative success was defined as: successful primary mitral repair without conversion to replacement or to larger thoracic incisions, without residual mitral regurgitation > mild at discharge or reoperation within 30 days. Predictors for perioperative success and safety were identified using univariable and multivariable analyses. The impact of prolapse localization and repair technique on reoperation-free survival was assessed by Cox regression. The mitral repair rate and the need for concomitant tricuspid repair were 94.6% and 16.5%, respectively. Perioperative mortality occurred in 5 patients (0.7%). The criteria for perioperative safety and success were met in 646/686 (94.2%) and 648/686 (94.5%) patients, respectively. The absence of tricuspid disease requiring repair was the only independent predictor of safety in this cohort [hazard ratio (HR) 0.460 (0.225-0.941), P = 0.033]. The only independent predictor of operative success was the use of chordal replacement [0.27 (0.09-0.83), P = 0.022]. Reoperation-free survival was 98.5%, 94.5% and 86.9% at 1, 5 and 10 years, respectively. Posterior leaflet pathology demonstrated a higher reoperation-free survival as compared to other localizations (log-rank P = 0.002). The localization of leaflet pathology but not the repair method was an independent predictor for reoperation-free survival (HR 1.455, 95% confidence interval 1.098-1.930; P = 0.009). In minimally invasive mitral surgery for degenerative disease, chordal replacement yields higher rates of periprocedural success than leaflet resection. Posterior leaflet pathology is an independent predictor of reoperation-free survival.

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.

Minimally Invasive Mitral Surgery: Patient Selection and Technique.

In most patients, minimally invasive approaches to mitral valve surgery are technically possible. However, in practice, patient selection is critical to mitigate safety concerns when performing the procedure. In this article, we describe our approach to preoperative assessment for minimally invasive mitral valve surgery candidacy, as well as discussing the technical aspects of procedure execution.

Association between pre-operative right ventricular impairment on transthoracic echocardiography and outcomes after conventional and minimally invasive mitral valve surgery

Background Right ventricular (RV) impairment may have prognostic value in patients undergoing mitral valve surgery. It is unclear whether RV dysfunction predicts long-term mortality, especially in the era of minimally invasive mitral surgery. Methods We performed a retrospective analysis of consecutive patients referred for conventional (via sternotomy) and minimally invasive mitral valve surgery (MIMVS) between 01 January 2013 and 29 August 2018 in a tertiary cardiac centre. We truncated follow-up times at 25 March 2020. RV impairment was defined by reduced RV longitudinal function (TAPSE <17 mm) and/or dilated basal RV diameter (RVD1 > 42 mm). Primary outcome was all-cause mortality. Results The study cohort included 359 patients followed up for a median period of 4.2 (1.8) years. MIMVS approach was performed in 127 (35.4%) and conventional approach in 232 (64.6%) patients of whom 36 (28%) and 45 (19%), respectively, had RV impairment. EuroSCORE II was significantly higher in patients with RV impairment compared with patients with preserved RV function, irrespective of the surgical approach. Consequently, in both groups, patients with RV impairment had significantly higher mortality compared to patients with preserved RV function. RV impairment adjusted for EuroSCORE II predicted mortality in the whole cohort (HR 2.139, 95% CI 1.249–3.663) and in conventional approach (HR 2.361, 95% CI 1.249–4.465) in contrast to MIMVS (HR 1.570, 95% CI 0.493–4.997). Conclusion In this real world cohort, patients with RV impairment and/or dilation had reduced long-term survival following both conventional surgery and MIMVS. Patients should be referred to surgery prior to worsening of RV function.

Less Invasive Mitral Surgery Versus Conventional Sternotomy Stratified by Mitral Pathology

Our objective was to compare national mitral repair rates and outcomes after less invasive mitral surgery (LIMS) vs conventional sternotomy across the spectrum of mitral pathologies and repair techniques. Patients undergoing isolated primary mitral valve surgery in The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2014 to December 2018 were evaluated. Propensity score models were constructed nonparsimoniously, and prediction models used to compute adjusted effects of surgical approach. Hypothesis tests were adjusted for propensity score with inverse-probability weighting. A total of 41,082 patients met inclusion criteria; comprising 10,238 (24.9%) LIMS and 30,844 (75.1%) conventional sternotomy, with increased LIMS adoption annually. Surgeons reporting LIMS cases had higher annual median mitral case volumes than those who did not (23 vs 8, P < .001). Groups were well-balanced after propensity adjustment including mitral pathology. Propensity score-adjusted outcomes showed increased procedural volume (odds ratio 1.030 [95% confidence interval: 1.028-1.031]) and LIMS (odds ratio2.139 [95% confidence interval 2.032-2.251]) were independentlyassociated with higher mitral repair rates.Propensity-adjusted outcomes included reduced stroke (P < .001), atrial fibrillation (P < .001), pacemaker (P< .001), renal failure (P < .001), and length of stay (P<.001) for LIMS vs sternotomy, without differences in mortality. Operative volume influenced outcomes in both groups. LIMS was associated with higher mitral repair rates, and lower morbidity. Further studies regarding the impact of surgeon volume on choice of operative approach are necessary.