Minimally Invasive Mitral Valve Surgery Research Articles

Early and mid-term outcomes of minimally invasive mitral valve surgery in high operative risk patients at University Medical Center, Ho Chi Minh City

Introduction: Minimally invasive mitral valve surgery (MIMVS) has seen significant advancement in the past decades, offering numerous benefits to patients. However, there remain cohorts of patients with mitral valve pathologies, deemed at higher surgical risk, who may face rejection for MIMVS due to concerns regarding potential postoperative complications associated with this approach. Objective: To assess early and midterm outcomes of MIMVS in higher-operative-risk patients at the University Medical Center of Ho Chi Minh City. Methods: A retrospective descriptive study of the patients meeting our high operative risk criteria, who underwent mitral valve surgery at the University Medical Center of Ho Chi Minh City from January 2017 to March 2023. Results: A total of 68 eligible cases were included in our study. The male-to-female ratio was 0.6:1. Among these cases, 21 patients underwent valve repair and 47 others underwent mitral valve replacement. 30.9% of cases presented with NYHA class III or above heart failure. The mean cardiopulmonary circulation time and aortic cross-clamp time were 157.4 ± 38.8 minutes and 102.7 ± 26.3 minutes, respectively. Three cases experienced minimally invasive surgery related complications, including one case of limb ischemia requiring fasciotomy, one case of femoral wound seroma, and one case of postoperative wound infection necessitating debridement. No instances of conversion to sternotomy or in-hospital mortality were observed. The mean ICU stay and postoperative length of stay at ward were 4.6 ± 3.5 days and 10.8 ± 5.9 days, respectively. Patients showed rapid recovery during the postoperative period. During ICU care, one patient suffered a non-disabling cerebrovascular accident, one case required continuous renal replacement therapy, three cases necessitated intra-aortic balloon pump placement, and three cases required reoperation due to hemorrhagic pleural effusion. During follow-up period, three patients died within 6 months, and another patient died after their surgery one year. Other patients had favorable outcomes at the time of discharge and at subsequent follow-up. Conclusion: Minimally invasive mitral valve surgeries highlight the feasibility and safety of minimally mitral valve surgery in higher-operative-risk patients.

Concomitant tricuspid valve regurgitation repair in patients with minimally invasive mitral valve surgery: a Single-Center experience in Vietnam

Background: This study aims to present the early and mid-term outcomes of combining Minimally Invasive Mitral Valve Surgery (MIMVS) with Tricuspid Valve Repair (TVR) at our center. Methods: From January 2017 to March 2022, our center treated a total of 67 patients with both MIMVS and TVR. Among these patients, 41 were women (61.2%), and 26 were men (38.8%). The average Euro SCORE II was 2.67±1.54%, and the patients had an average follow-up period of 25.45±16.2 months. Results: Pre-discharge echocardiography revealed no or mild TR in 82.8% of cases. The overall 30-day mortality rate was 4.5%, with 3 deaths. Five-year survival was 94.5%±3.2%. In patients with mild or moderate preoperative Tricuspid Regurgitation (TR), the five-year survival rate was 95.7%±4.3%, while for those with severe TR, it was 93.7%±4.5% (P=0.947). Conclusions: Our five-year experience demonstrates that the combination of MIMVS and TVR can be routinely performed with favorable peri- and post-operative outcomes in patients undergoing non-high-risk surgery. Additionally, there is no significant difference in five-year survival between the severe TR and mild to moderate TR groups preoperatively.

Concomitant Surgical Ablation for Treatment of Atrial Fibrillation in Patients Undergoing Minimally Invasive Mitral Valve Surgery: A Single-Center Experience in Vietnam

Abstract Background This study presents the early and midterm outcomes of combining atrial fibrillation (AF) treatment with minimally invasive mitral valve surgery (MIMVS) at our center. Methods From January 2017 to June 2022, our center treated a total of 86 patients with both MIMVS and surgical AF ablation. The patient cohort included 62 women (72.1%) and 24 men (27.9%). The average EuroScore II was 2.64 ± 1.49%, and the patients were followed up for an average period of 46.31 ± 9.84 months. Results Postoperatively, 95.3% of patients experienced a change in sinus rhythm, and 86.2% were discharged in sinus rhythm. The hospital's mortality rate was 2.3%, with a late mortality rate of 3.5%. Survival analysis revealed an atrial fibrillation–free 5-year follow-up rate of 59.1 ± 9.1%. The 5-year survival rate was 92.7 ± 3.3%. Conclusion Our 5-year experience demonstrates that the combination of MIMVS and surgical AF ablation can be routinely performed with favorable peri- and postoperative outcomes. This reflects our hospital's culture and guidance on patient selection, particularly when adopting minimally invasive approaches for multiple procedures.

Minimally Invasive Mitral Valve Repair: From Total Endoscopic To Closed-Chest Robotic.

Minimally invasive cardiac surgery has evolved over the past few decades, thanks to advancements in technology and surgical techniques. These advancements have allowed surgeons to perform cardiac interventions through small incisions, reducing surgical trauma and improving patient outcomes1. However, despite these advancements, thoracoscopic mitral repair has not been widely adopted by the cardiac surgery community, possibly due to the lack of familiarity with video-assisted procedures1. Over the years, various minimally invasive mitral valve surgery (MIMVS) techniques have been developed to achieve comparable or better results while minimizing surgical trauma. These techniques have evolved from direct-vision procedures performed through a right thoracotomy with a rib retractor to video-directed approaches using long-shafted instruments1. Robotic surgery, introduced in the late 90s, has also played a significant role in mitral valve repair. The da Vinci system, the only robotic platform currently used for cardiac surgery, provides surgeons with enhanced dexterity and high-definition 3D visualization, allowing for precise and accurate procedure2, and is now the preferred approach for mitral repair in many programs3. The first mitral repair using the da Vinci system was performed in Europe by Carpentier and Mohr in 1998, followed by the first mitral replacement by Chitwood in the USA in 20002-4. The advantages of robotic technology allow surgeons to perform complex repair techniques such as papillary muscle repositioning and sliding leaflet plasty4. Studies have shown that robotic mitral surgery results in shorter ICU and hospital stays, better quality of life postoperatively, and improved cosmesis compared to conventional surgery5,6. In our experience, we have also observed significant benefits with robotic surgery, including reduced blood loss and the need for transfusions. This can be attributed to the closed-chest technique, which eliminates the need for a thoracotomy and rib retractor, reducing the risk of bleeding associated with these approaches7. In this article, we will compare the surgical steps of endoscopic and robotic mitral valve repair, providing detailed information on patient selection, operative techniques, and the requirements for building a successful program. By understanding the advantages and challenges of both approaches, surgeons can make informed decisions and provide the best possible care for their patients. Combined ablation and multivalvular procedures are mostly performed in few centers by minimally invasive techniques.

Elderly patients benefit from minimally invasive mitral valve surgery: perioperative risk management matters.

The goal was to assess the single-centre results of minimally invasive mitral valve surgery (MIMVS) in the elderly population. All patients referred for minimally invasive valve surgery underwent a standardized preoperative screening. We performed a retrospective analysis of 131 consecutive elderly patients (≥75 years) who underwent endoscopic MIMVS through a right mini-thoracotomy. Survival and postoperative course were assessed in 2 groups: a repair group and a replacement group. Eighty-five patients underwent mitral valve repair, and 46 had mitral valve replacement. The mean age was 79 ± 2.9 years, and the median follow-up duration was 3.8 years. The cardiopulmonary bypass time (128.7 min vs 155.9 min, P = 0.012) and the cross-clamp time (84.9 min vs 124.1 min, P = 0.005) were significantly longer in the replacement group. Except for more reinterventions for bleeding in the replacement group (10.9% vs 0%, P = 0.005), there were no significant differences in the postoperative course between the 2 groups. Low mortality rates at the midterm follow-up were observed in both groups, and no differences were observed between the 4-and the 12-month follow-up. Survival rates after 1 year and 5 years were 97.6% and 88.6%, respectively, with no significant differences between the 2 groups. MIMVS is an excellent treatment option in vulnerable elderly patients with excellent short- and long-term results. Although other studies suggest that repair could be superior to replacement even in older patients, our experience suggests that replacement is equivalent to repair in terms of mortality and major adverse cardiac and cerebrovascular events. Experience and standardized preoperative screening are mandatory to achieve optimal results.

A propensity matched comparison of robotic vs. traditional minimal access approach for mitral valve repair with concomitant cryoablation.

Atrial fibrillation (AF) occurs frequently in patients with mitral valve disease. Results of cryoablation concomitant with either minimally invasive video-assisted [minimally invasive mitral valve surgery (MIMVS)] or with robotic-assisted (RMV) mitral valve surgery have previously been separately reported. However, there are up-to-date no studies comparing the two procedures in terms of safety, efficacy, and mid-term follow-up. Between January 2017 and March 2022, 294 patients underwent MIMVS, and 187 patients underwent RMV at our institution. After 1:1 propensity score matching using 22 preoperative variables, the study included 104 patients. Group 1 (MIMVS) included 52 patients operated on between 2017-2022 using a minimally invasive video-assisted right-sided mini-thoracotomy. Group 2 (RMV) included 52 patients operated on between 2019-2021 using a robotic-assisted approach. Early and mid-term outcomes were assessed, including maintenance of sinus rhythm. Follow-up was 100% complete at a median follow-up of 2 years. For the entire propensity matched cohort, the median EuroSCORE II was 3.14 [interquartile range (IQR), 1.93-4.99], the median age was 68 (IQR, 61-74) years, and two thirds of the patients were male. Most (72.1%) underwent mitral valve surgery, and 26.9% had an additional tricuspid procedure. Only four patients underwent mitral valve replacement (3.8%). The majority (87.5%) received a left-sided atrial Maze and 12.5% a bi-atrial Maze. The left atrial appendage was occluded in 72.1% cases. Overall, there were no significant differences between the two propensity matched groups in baseline demographics or intra-operative characteristics. Similarly, there were no significant differences in the post-operative short and mid-term outcomes between the two groups. There were no in-hospital or 30-day deaths. At the mid-term survival was similar between groups, log-rank test P=0.056. Maintenance of sinus rhythm at follow-up was 76%. Mitral or double valve repair with concomitant cryoablation can be safely performed with either a MIMVS or RMV approach. Both methods demonstrated outstanding early and mid-term outcomes.

Discussion to: Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

Discussion to: Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

Adoption of minimally invasive mitral valve surgery: single-centre implementation experience in Vietnam

The adoption of minimally invasive mitral valve surgery (MIMVS) has become a prominent trend in mitral valve procedures. This article emphasizes that the success of the MIMVS program relies not only on effective teamwork but also on comprehensive hospital support and a clearly defined training strategy. Additionally, targeted marketing initiatives that highlight the value of the heart valve centre are crucial for sustaining the program’s success and attracting a consistent patient flow. The implementation of these strategies requires diligent execution, consistent maintenance, and continuous improvement to ensure the triumph of the MIMVS program. This article aims to share our experience in implementing MIMVS at our centre, providing valuable insights for centres that have yet to adopt this approach or have low adoption rates. While acknowledging that sharing our centre’s experience cannot guarantee success in all centres, customizing the implementation by selecting appropriate features and access points is vital. Each centre may encounter unique challenges, and tailoring the strategy to address specific needs will enhance the effectiveness of the MIMVS program.

Minimally Invasive Procedure Versus Conventional Redo Sternotomy for Mitral Valve Surgery in Patients with Previous Cardiac Surgery: A Systematic Review and Meta-Analysis.

The heightened morbidity and mortality associated with repeat cardiac surgery are well documented. Redo median sternotomy (MS) and minimally invasive valve surgery are options for patients with prior cardiac surgery who require mitral valve surgery (MVS). We conducted a systematic review and meta-analysis comparing the outcomes of redo MS and minimally invasive MVS (MIMVS) in this population. We searched PubMed, EMBASE, and Scopus for studies comparing outcomes of redo MS and MIMVS for MVS. To calculate risk ratios (RRs) for binary outcomes and weighted mean differences (MDs) for continuous data, we employed a random-effects model. We included 12 retrospective observational studies, comprising 4157 participants (675 for MIMVS; 3482 for redo MS). Reductions in mortality (RR, 0.54; 95% confidence interval [CI], 0.37-0.80), length of hospital stay (MD, -4.23; 95% CI, -5.77 to -2.68), length of intensive care unit (ICU) stay (MD, -2.02; 95% CI, -3.17 to -0.88), and new-onset acute kidney injury (AKI) risk (odds ratio, 0.34; 95% CI, 0.19 to 0.61) were statistically significant and favored MIMVS (p<0.05). No significant differences were observed in aortic cross-clamp time, cardiopulmonary bypass time, or risk of perioperative stroke, new-onset atrial fibrillation, surgical site infection, or reoperation for bleeding (p>0.05). The current literature, which primarily consists of retrospective comparisons, underscores certain benefits of MIMVS over redo MS. These include decreased mortality, shorter hospital and ICU stays, and reduced AKI risk. Given the lack of high-quality evidence, prospective randomized control trials with adequate power are necessary to investigate long-term outcomes.

An International Survey-Based Assessment of Minimally Invasive Mitral Valve Surgery.

Minimally invasive mitral valve surgery (MIMVS) has been shown to be safe and feasible however its adoption has lagged globally. The international consortium is lacking a set of guidelines that are specific to MIMVS. The aim of this study was to capture the practices of MIMVS in different centres. A survey was constructed containing 52 multiple-choice and open-ended questions about various aspects of MIMVS. The survey was sent to centers that routinely and frequently perform MIMVS. All surgeons provided informed consent for participating in the survey and publication of data. The survey was sent to 75 known surgeons from whom 32 (42%) completed the survey. All survey responders performed more than 25 MIMVS cases annually. Twenty (68%) of the surgeons thought that simulation training, MIMVS fellowship, and proctorship are all essential prior to commencing a MIMVS program. Eleven (34%) of the surgeons stated that 50-100 MIMVS cases are required to overcome the learning curve, followed by 6 (18%) who said 21-30 cases should suffice. Eighteen (62%) of the surgeons had adopted a fully endoscopic approach for their MIMVS, followed by 15 (51%) surgeons who had performed cases via endoscopic-assisted strategies, 5 (17%) surgeons had conducted the operation under direct visualization, and 6 (20%) surgeons had used a robot for their MIMVS. The study highlights a marked variability on training and approach to MIMVS. Consensus guidelines should be established to allow standardisation of MIMVS.

Tricuspid intervention for less-than-severe regurgitation at time of minimally invasive mitral valve surgery in patients with AF.

While to address moderate tricuspid regurgitation (TR) at time of left-side heart surgery is recommended by the guidelines, the procedure is still seldom performed and especially in the minimally invasive setting. Atrial fibrillation (AF) is known marker of both mortality and TR progression after mitral valve surgery. The current study aimed to address the safety of adding a tricuspid intervention to minimally invasive mitral valve surgery (MIMVS) in patients with preoperative AF. We retrospectively analyzed data from Polish National Registry of Cardiac Surgery Procedures between 2006 and 2021. We included all patients who underwent MIMVS (mini-thoracotomy-, totally thoracoscopic- or robotic surgery) and presented with moderate tricuspid regurgitation and AF preoperatively. The primary endpoint was death from any cause at 30 days and at longest available follow between MIMVS with tricuspid intervention vs MIMVS alone. We used propensity score matching to account for baseline differences between groups. We identified 1,545 patients with AF undergoing MIMVS, 54.7% were men aged 66.7±9.2years. Of those, 733 (47.4%) underwent concomitant tricuspid valve intervention. At 13 years, addition of tricuspid intervention was associated with 33% higher mortality as compared to MIMVS alone. HR 1.33; 95 CIs (1.05-1.69); P=0.02. PS matching resulted in 565 well-balanced pairs. Concomitant tricuspid intervention did not influence long-term follow-up: HR, 1.01; 95 CIs (0.74-1.38); P=0.94. After adjusting for baseline cofounders the addition of tricuspid intervention for moderate tricuspid regurgitation to MIMVS did not increase perioperative mortality nor influence long-term survival.

Combined Minimally Invasive Mitral Valve Surgery and Percutaneous Coronary Intervention: A Hybrid Concept for Patients with Mitral Valve and Coronary Pathologies.

We evaluated the feasibility of hybrid percutaneous coronary intervention (PCI) and minimally invasive mitral valve surgery (MIMVS) in patients with concomitant coronary and mitral disease. Of 534 patients who underwent MIMVS at our institution between 2012 and 2018, those with combined mitral and single vessel coronary pathologies who underwent MIMVS and PCI were included. Patients were excluded if they had endocarditis or required emergency procedures. Preprocedural, procedural, and postprocedural data were retrospectively analyzed. In total, 10 patients (median age, 75 years; 7 males) with a median ejection fraction (EF) of 60% were included. Nine patients underwent PCI before and one after MIMVS. The success rate was 100% in both procedures. There were no postoperative myocardial infarctions or strokes. Two patients developed delirium and one required re-thoracotomy for bleeding. The median stay in intensive care and the hospital was 3 and 8 days, respectively. The 30-day survival rate was 100%. A hybrid PCI and MIMVS approach is feasible in patients with mitral valve and single vessel coronary disease. In combined pathologies, the revascularization strategy should be evaluated independent from the mitral valve pathology in the presence of MIMVS expertise. Extension of this recommendation to multivessel disease should be evaluated in future studies.

Endoaortic balloon occlusion versus transthoracic cross-clamp for totally endoscopic robotic mitral valve surgery: a retrospective cohort study.

Endoaortic balloon occlusion (EABO) and transthoracic cross-clamping have been shown to have comparable safety profiles for aortic occlusion in minimally invasive mitral valve surgery (MIMVS). However, few studies have focused exclusively on the totally endoscopic robotic approach. We sought to compare outcomes for patients undergoing totally endoscopic robotic mitral valve surgery with aortic occlusion via EABO and transthoracic clamping after a period where EABO was unavailable required us to use the transthoracic clamp. Retrospective review identified 113 patients who underwent robotic mitral valve surgery at our facility between 2019 and 2021 with EABO (n = 71) or transthoracic clamping (n = 42). Relevant data were extracted and compared. Preoperative characteristics were similar other than a higher rate of coronary artery disease [EABO: 69.0% (49/71) vs clamp: 45.2% (19/42), p = .02] and chronic lung disease [EABO: 38.0% (27/71) vs clamp: 9.5% (4/42), p < .01] in the EABO group. Median percutaneous cardiopulmonary bypass time, operative time, and cross-clamp time were comparable. Similar rates of postoperative bleeding complications were observed, and no aortic complications were observed. One patient in each group underwent conversion to an open approach. 30-day mortality and readmission rates were comparable. EABO and transthoracic clamp were associated with similar bleeding and aortic outcomes, and mortality and readmission rates were comparable at thirty days postoperatively. Our findings support the comparable safety of the two techniques, which is well documented in studies encompassing all MIMVS techniques, within the specific context of the totally endoscopic robotic approach.

A review and meta-analysis of conventional sternotomy versus minimally invasive mitral valve surgery for degenerative mitral valve disease focused on the last decade of evidence.

Early meta-analyses comparing minimally invasive mitral valve surgery (MIMVS) with conventional sternotomy (CS) have determined the safety of MIMVS. We performed this review and meta-analysis based on studies from 2014 onwards to examine the differences in outcomes between MIMVS and CS. Specifically, some outcomes of interest included renal failure, new onset atrial fibrillation, mortality, stroke, reoperation for bleeding, blood transfusion and pulmonary infection. A systematic search was performed in six databases for studies comparing MIMVS with CS. Although the initial search identified 821 papers in total, nine studies were suitable for the final analysis. All studies included compared CS with MIMVS. The Mantel - Haenszel statistical method was chosen due the use of inverse variance and random effects. A meta-analysis was performed on the data. MIMVS had significantly lower odds of renal failure (OR: 0.52; 95% CI 0.37 to 0.73, p < 0.001), new onset atrial fibrillation (OR: 0.78; 95% CI 0.67 to 0.90, p < 0.001), reduced prolonged intubation (OR: 0.50; 95% CI 0.29 to 0.87, p = 0.01) and reduced mortality (OR: 0.58; 95% CI 0.38 to 0.87, p < 0.01). MIMVS had shorter ICU stay (WMD: -0.42; 95% CI -0.59 to -0.24, p < 0.001) and shorter time to discharge (WMD: -2.79; 95% CI -3.86 to -1.71, p < 0.001). In the modern era, MIMVS for degenerative disease is associated with improved short-term outcomes when compared to the CS.

P46 TRANSAXILLARY MITRAL VALVE SURGERY IS ASSOCIATED WITH EARLY RECOVERY AND SHORTER ICU AND HOSPITAL STAY

Abstract Background and Aim Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure in minimally invasive mitral valve surgery (MIMVS). Aim of this study is to compare the early outcomes of patients operated through a right trans–axillary (TAxA) approach with those achieved in conventional full sternotomy (FS) operations. Methods Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at two academic centres were reviewed. Among them, 454 patients underwent MIMVS through TAxA access and 667 patients through FS (associated aortic and CABG procedures, infective endocarditis and urgent operations were excluded). A propensity match analysis was performed using seventeen preoperative and intraoperative variables. Results There was no difference in preoperative characteristics in matched populations. The rate of mitral valve repair was similar in both groups. Patients in TAxA group had a higher rate of repair using artificial chordae. Operative times were shorter in FS group but in patients operated in minimally invasive approach there was a trend towards decreasing CPB and cross–clamp time over the study period. Hospital mortality in TAxA group was 0.25%, postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (p&amp;lt;0.001) and ICU stay (p&amp;lt;0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home vs. 5% in the FS group (p&amp;lt;0.001). Conclusions TAxA approach is safe and effective. Compared to FS, it allows shorter mechanical ventilation, ICU and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.

Early outcomes of minimally invasive mitral and tricuspid valve surgery in obese patients

Background: Minimal invasive valve surgery is the new trend in cardiac surgery. Many obstacles are present to increase the number of cases operated on with minimally invasive surgery. Minimal invasive surgery is technically demanding in obese patients with uncertain outcomes. In this study, we compared minimal invasive mitral and tricuspid valve surgery (MIVS) in obese patients with high BMI (body mass index) to normal BMI.&#x0D; Method: We included 240 cases who underwent MIVS. These cases were divided into two groups. Group I (n=120) included patients with BMI &gt;30 Kg/m2, and Group II (n=120) had BMI ≤30 Kg/m2.&#x0D; Result: There was no in-hospital mortality in both group. Postoperative wound infection was nonsignificantly higher in Group I (9 (7.5%) vs. 2 (1.67%); P= 0.059). Drainage (450± 112 vs. 240± 230 ml; P&lt;0.001), mechanical ventilation time (13.4± 1.3 vs. 6.4± 6.8 h; P&lt;0.001), and ICU stay (2± 0.4 vs. 3.5± 1.3 days, P&lt;0.001) were significantly higher in Group I. New onset atrial fibrillation was significantly higher in obese patients (P= 0.029). There were no differences between both groups in other outcomes.&#x0D; Conclusion: Minimally invasive surgery in obese patients had satisfactory outcomes compared to those with normal BMI. Obesity should not be considered a contraindication for minimally invasive surgery.

Evaluating Short-Term Postoperative Outcomes in Minimally Invasive Mitral Valve Surgery for Patients with Rheumatic Disease

Minimally invasive mitral valve surgery (MIMVS) is widespread and has become a standard procedure in cardiac surgery [Chitwood 1997; Carpentier 1996]. Therefore, MIMVS is a common procedure for patients with degenerative disease [Raanani 2010; Iribarne 2010] as well. However, the safety of MIMVS in patients with rheumatic heart disease (RHD) has not thoroughly been investigated, due to the low prevalence of RHD in developed countries, where MIMVS is standardized [Miceli 2015]. Here, we investigated the safety of MIMVS for patients with RHD at Lampang Hospital in Thailand.

A Retrospective Evaluation of Endo-Aortic Balloon Occlusion Compared to External Clamping in Minimally Invasive Mitral Valve Surgery

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N=60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P=0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.

Efficacy of erector spinae plane block for minimally invasive mitral valve surgery: Results of a double-blind, prospective randomized placebo-controlled trial

Study objectiveTo investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing minimally invasive mitral valve surgery (MIMVS). DesignA single-center, double-blind, prospective, randomized, placebo-controlled trial. SettingPostoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital. PatientsSeventy-two patients undergoing video-assisted thoracoscopic MIMVS via right-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program. InterventionsAt the end of surgery, all patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading of dose 30 ml and three additional doses of 20 ml with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal postoperative analgesia including dexamethasone, acetaminophen and patient-controlled intravenous analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial. MeasurementsPrimary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events. Main resultsMedian (IQR) 24-h morphine consumption was not different between the intervention- and control-group, 41 mg (30–55) versus 37 mg (29–50) (p = 0.70), respectively. Likewise, no differences were detected for secondary and safety endpoints. ConclusionsFollowing MIMVS, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.

Early Outcome of Mitral Valve Surgery comparing Minimally Invasive Versus Standard Median Sternotomy Approach

Minimal invasive mitral valve surgery (MIMVS) aims to avoid complications of SMS like, bleeding, postoperative pain, and sternal wound infection. It provides better cosmesis and early recovery. The aim of this study is to evaluate early clinical outcome of MIMVS.