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Ann Thorac Surg 2009;88:1180-1184. doi:10.1016/j.athoracsur.2009.05.023
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

A Decade of Minimally Invasive Mitral Repair: Long-Term Outcomes

Aubrey C. Galloway, MD, Charles F. Schwartz, MD, Greg H. Ribakove, MD, Gregory A. Crooke, MD, George Gogoladze, MD, Patricia Ursomanno, PhD, Margaret Mirabella, MSN, Alfred T. Culliford, MD, Eugene A. Grossi, MD*

Department of Cardiothoracic Surgery, New York University Medical Center, New York, New York

Accepted for publication May 8, 2009.

* Address correspondence to Dr Grossi, New York University Medical Center, 530 First Ave, Skirball Institute Suite 9V, New York, NY 10016 (Email: grossi{at}cv.med.nyu.edu).

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: Short-term results with minimally invasive approaches for mitral valve repair in degenerative disease have been encouraging, with potential for diminishing blood loss and hospital length of stay. Little is known, however, about the long-term efficacy of this approach. This report analyzes a single institution's results over 12 years with minimally invasive mitral repair.

Methods: Since 1986, 3,057 patients have undergone mitral valve repair; 1,601 patients had degenerative disease and are the subject of this report. Minimally invasive mitral repair was done in 1071 patients with a right anterior minithoracotomy and direct vision. Clinical and echocardiographic variables were entered prospectively into a database.

Results: Hospital mortality was 2.2% for all patients (36 of 1601); 1.3% for isolated minimally invasive (9 of 712) and 1.3% (3 of 223) for isolated sternotomy mitral valve repair; and 3.6% (24 of 666) for valve repair plus a concomitant cardiac procedure. For isolated valve repair, 8-year freedom from reoperation was 91% ± 2% for sternotomy and 95% ± 1% for minimally invasive (p = 0.24), and 8-year freedom from reoperation or severe recurrent insufficiency was 90% ± 2% for sternotomy and 93% ± 1% for minimally invasive (p = 0.30). Eight-year freedom from all valve-related complications was 86% ± 3% for sternotomy and 90% ± 2% for minimally invasive (p = 0.14).

Conclusions: These data indicate that long-term outcomes after minimally invasive mitral repair are excellent and equivalent to results achieved with sternotomy. In view of previously published advantages of short-term morbidity, minimally invasive approaches to mitral valve surgery deserve expanded use.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Minimally invasive techniques for the surgical treatment of mitral valve disease have advanced over the last 15 years. Beginning in 1994, experimental work performed both at Stanford University and at New York University [1, 2] led to the introduction of a minimally invasive technique termed "port access." Initial clinical reports were very encouraging [3], and midterm analyses did not demonstrate any compromise in the efficacy of mitral valve repair when compared with the then-standard sternotomy approach [4].

During this period, different minimally invasive surgical approaches to the mitral valve have evolved. At New York University (NYU), the operative incision most often utilized is still the right anterolateral minithoracotomy incision with direct vision (RAMT-DV). While alternative surgical approaches have been suggested by Cosgrove and colleagues [5], Gundry and coworkers [6], and Cohn and others [7, 8], we have consistently been satisfied with the efficacy of the RAMT-DV approach. This report analyzes our results with this technique for minimally invasive mitral repair over a 12 year period.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Patient Selection
Between January 1, 1986, and January 1, 2008, 3,057 patients underwent mitral valve repair, with 1,601 patients having repair plus annuloplasty for degenerative disease. These patients are the subject of this report. Minimally invasive mitral repair was performed in 1,071 patients with right anterior minithoracotomy and direct vision. Perioperative clinical and echocardiographic variables were entered prospectively into our mitral repair database; clinical and echocardiographic follow-up were maintained on an annual basis. On echocardiographic follow-up, severe mitral regurgitation was defined as 3+ or 4+.

Surgical Technique
The surgical incision for minimally invasive mitral valve repair at NYU has remained consistent over the years. The isolated mitral valve operation is typically approached through a third or fourth interspace minithoracotomy incision, and has been described in detail [9, 10]. This approach provides both cosmesis for the patient, particularly in the inframammary crease for women, and a direct view from a lateral perspective into the left atrium and onto the mitral valve. Relative exclusion criteria include prior right chest surgery and pectus excavatum. Whereas the original approach involved retrograde arterial perfusion and balloon endoclamping, the approach has evolved to a technique with ascending aortic cannulation (antegrade perfusion), long femoral venous cannula drainage, and direct external aortic clamping [11]. Although initially the procedure relied upon the anesthesiologist for internal jugular placement of a coronary sinus cardioplegia catheter, it is now placed directly by the surgeon through a pursestring suture in the wall of the right atrium under transesophageal echocardiographic guidance. Mitral valve repair is performed under direct vision using long, low-profile surgical instruments. Posterior and anterior leaflet pathology from degenerative valve disease were repaired using standard techniques. An annuloplasty band or ring was placed in all of these patients to reinforce the repair and remodel the annulus to the correct size and shape.

Research Methods
This study was conducted with the approval of the NYU School of Medicine Institutional Review Board, with specific waiver of the need for individual patient consent. Patient data were collected prospectively using the definitions for preoperative risk factors and perioperative complications chosen by the New York State Cardiac Surgery Reporting System (NYS CSRS). Hospital mortality was defined as death at any time before discharge from the hospital. Standard follow-up included annual clinical contact and echocardiographic surveillance. Statistical analysis was performed using the statistical software SPSS (SPSS, Chicago, IL). Categorical variables were analyzed by the {chi}2 test and continuous variables with the nonpaired t test. A probability value of less than 0.05 was considered to be significant. Life table analysis was used to calculate late survival curves; the Wilcoxon statistic was used to test for the significance of survival differences.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
The operative mortality was 2.2% for all patients (36 of 1601). For patients undergoing isolated mitral valve repair, operative mortality was 1.3% (9 of 712) for the minimally invasive approach and 1.3% (3 of 223) for the standard sternotomy approach. Valve repair plus a concomitant cardiac procedure had a mortality of 3.6% (24 of 666). Basic patient characteristics (Table 1) demonstrate that the preponderance of mitral valve repairs that required concomitant procedures was performed with the sternotomy approach. There was no difference in the perioperative incidence of stroke or endocarditis between surgical approaches. However, there was significantly less surgical site sepsis with the right thoracotomy approach (Table 1). Early in our minimally invasive series, the endoclamp technique was used extensively before our progression to direct aortic clamping. The endoclamp was used in 401 of the first 536 patients (74.8%) but in only 1 patient of the last 536 (0.2%; p < 0.001). Figure 1 demonstrates the incidence of surgical technique by operative year.


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  		Table 1 Basic Patient Characteristics and Perioperative Outcomes
 

Figure 1
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  		Fig 1. Distribution of surgical approach—sternotomy (black bars) or right thoracotomy (gray bars)—for degenerative mitral valve repair by year of operation.

 
Table 2 lists the various reparative procedures performed in our experience. Anterior leaflet procedures were performed more commonly in the minimally invasive patients compared with standard sternotomy patients (33.0% versus 26.4%, p = 0.01). For isolated mitral valve repair, 8-year freedom from reoperation was 91% ± 2% for the sternotomy approach and 95% ± 1% for the minimally invasive technique (p = 0.24; Fig 2), and the 8-year freedom from reoperation or severe recurrent insufficiency was 90% ± 2% for sternotomy and 93% ± 1% for minimally invasive (p = 0.30; Fig 3). Eight-year freedom from all valve-related complications was 86% ± 3% for the sternotomy patients and 90% ± 2% for minimally invasive patients (p = 0.14; Fig 4).


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  		Table 2 Repair Procedures Performed
 

Figure 2
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  		Fig 2. Comparison of standard sternotomy (solid circles) and minimally invasive approach (open circles) for freedom from reoperation in isolated mitral valve repairs. (NS = not significant.)

 

Figure 3
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  		Fig 3. Comparison of standard sternotomy (solid circles) and minimally invasive approach (open circles) for freedom from reoperation or severe mitral insufficiency in isolated mitral valve repairs. (NS = not significant.)

 

Figure 4
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  		Fig 4. Comparison of standard sternotomy (solid circle) and minimally invasive approach (open circles) for freedom from any valve-related complication or reoperation in isolated mitral valve repairs. (NS = not significant.)

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
Initial short-term results with minimally invasive approaches for mitral valve repair in degenerative disease have been encouraging, with data from our institution suggesting decreased perioperative morbidity with the minimally invasive approach [12]. The main advantages were related to reduced blood loss, fewer infectious complications, and shorter hospital stay. With respect to functional and echocardiographic outcomes, short-term results after minimally invasive valve repair were found to be equivalent to those achieved with traditional sternotomy [4, 13]. Until now, however, limited data have been available regarding the long-term efficacy of valve repair performed with minimally invasive techniques. This lack of long-term data was discussed in a recent systematic review and meta-analysis performed by Modi and coworkers [14]. A report by Mihaljevic and associates [15] of more than 1,000 minimally invasive valve operations showed excellent all-cause survival, but no information was available on late echocardiographic follow-up and need for late reoperation. Before the current study, the longest functional and echocardiographic follow-up study after minimally invasive mitral repair was by Aybek and colleagues [16] from the JW Goethe University, where in a cohort of 199 mitral repair patients 6-year freedom from reoperation was 96% and freedom from nontrivial recurrent mitral regurgitation was 92%.

The current report of more than 1,000 minimally invasive mitral valve repairs performed through a right minithoracotomy validates the long-term efficacy of the minimally invasive approach for mitral valve repair surgery. Importantly, the excellent late results in terms of freedom from reoperation or recurrent significant mitral insufficiency are almost identical to the results achieved with the standard sternotomy approach. Furthermore, these excellent late results support offering minimally invasive valve repair to patients with degenerative disease and severe mitral insufficiency early, before the development of symptoms or left ventricular dysfunction [17].

Finally, the patients undergoing valve repair in this series had a relatively high incidence of complex anterior leaflet or bileaflet pathology. In fact, the minimally invasive cohort had a 33% incidence of anterior leaflet repair, compared with a 26% incidence of anterior leaflet repair in the standard sternotomy cohort. This difference primarily reflects our greater familiarity with anterior leaflet repair in our chronologically later experience, since more minimally invasive operations were performed later in time. Nonetheless, this experience and the excellent late outcomes reported also support the applicability of the minimally invasive approach for repair of more complex anterior leaflet pathology.

In conclusion, these data indicate that long-term outcomes after minimally invasive mitral repair for degenerative disease are excellent and equivalent to results achieved with the standard sternotomy approach. In view of the previously published advantages of minimally invasive surgery regarding short-term morbidity, we believe this approach for mitral valve repair deserves expanded use.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR TOMISLAV MIHALJEVIC (Cleveland, OH): Aubrey, I really enjoyed your presentation and I congratulate you on excellent results using this approach. I have two questions. The first one is: how has your minimally invasive technique evolved over time? Would you be able to identify one or two things that you have changed over that period that you think have made it easier for you? And secondly, could you summarize what would be currently the contraindication, in your view, for the minimally invasive approach for myxomatous mitral valve disease in your institution?

DR GALLOWAY: Certainly the technique has evolved a lot over the last 12 years as I addressed this at the Tech-Con session on Sunday. We started out with a femoral perfusion and the port-access approach. From 1996 until 2002, that approach was used for the vast majority of patients, but that technology was fairly complicated and difficult for others to adopt. Although we felt comfortable with it, it required the anesthesiologist to place the coronary sinus catheter and had potential issues related to balloon placement and balloon migration. While we did not have a significant incidence of retrograde dissection in our series, there was some concern in the general cardiac surgical community about a routine retrograde perfusion approach.

Therefore, around 2001 or 2002 we decided to try to simplify the minimally invasive operation. We changed the approach from a routine fourth intercostal space, retrograde perfusion, port-access approach to a preferred third intercostal space, direct aortic cannulation approach where the cardioplegic catheters were also placed by the surgeon directly through the wound. Since then we have only used retrograde perfusion for younger female patients, approximately less than 65 years of age, where we want a cosmetic inframammary fouth intercostal interspace incision. The vast majority of patients are not approached with direct aortic cannulation and crossclamping with a flexible cross-clamp, through the third intercostals space. We abandoned balloon endoclamps altogether.

So that was the primary change in our technique. I think the direct cannulation approach simplifies the operation and shortens startup and overall operative time. There is less reliance on nonsurgeons within the operating rooms, and it is less expensive, and in our experience this has been very successful.

We feel very comfortable doing anterior leaflet repair, bileaflet repair, or posterior leaflet repair with the less invasive approach, and long-term outcomes have been excellent. Certainly the vast majority of first-time mitral valve operations are now done less invasively at our institution. The more difficult patient would be the one with a severe pectus excavatum and some extremely overweight patients, so if you had a complex repair in one of these patients, we might decide to do a sternotomy approach, but pretty much everybody else we would do less invasive.

DR MIHALJEVIC: So what do you think is the next step? What is the next step in the evolution of minimally invasive approaches?

DR GALLOWAY: There are really two schools of thought about this. One school of thought is that as a specialty we need to have minimally invasive surgery simplified to the point that we can get more widespread adoption of this technique throughout the cardiac surgical community. We believe this to be true, and therefore our primary focus has been to take a relatively complex minimally invasive technique and try to simplify it so that it will be more widely applicable by the vast majority of cardiac surgeons. A second line of reasoning, however, and this has been advanced by Drs Chitwood, Van Ermen, your group, and others, is to see if we can move toward a totally endoscopic approaches for these patients. I think that that will require specialized centers for the next several years, but I certainly applaud those efforts and I think it might have great value in the future.

DR VINOD H. THOURANI (Atlanta, GA): On a similar track, what are your thoughts about hybrid coronary revascularization in combination with mitral valve repair? Is that something that also is potentially in the future for us?

DR GALLOWAY: I think it is certainly going to be a feasible option. It is going to be something that I think people will demand as they have less invasive techniques available. Our current approach, because we don't have a functional hybrid operating room for stenting right now, would be if they have left anterior descending artery disease to always do it open and do mammary bypass, but if they have non–left anterior descending artery disease without ischemia, then we would do a minimally invasive operation and come back and do the stent. I think that latter group of patients will eventually be taken care of in a hybrid operating room with a hybrid procedure.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Pompili MF, Stevens JH, Burdon TA, et al. Port-access mitral valve replacement in dogs J Thorac Cardiovasc Surg 1996;112:1268-1274.[Abstract/Free Full Text]
  2. Schwartz DS, Ribakove GH, Grossi EA, et al. Minimally invasive mitral valve replacement: port-access technique, feasibility, and myocardial functional preservation J Thorac Cardiovasc Surg 1997;113:1022-1030.[Abstract/Free Full Text]
  3. Colvin SB, Galloway AC, Ribakove G, et al. Port-access mitral valve surgery: summary of results J Cardiac Surg 1998;13:286-289.[Medline]
  4. Grossi EA, LaPietra A, Ribakove GH, et al. Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results J Thorac Cardiovasc Surg 2001;121:708-713.[Abstract/Free Full Text]
  5. Cosgrove DM, Sabik JF, Navia JL. Minimally invasive valve operations Ann Thorac Surg 1998;65:1535-1538.[Abstract/Free Full Text]
  6. Gundry SR, Shattuck OH, Razzouk AJ, et al. Facile minimally invasive cardiac surgery via ministernotomy Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
  7. Byrne JG, Hsin MK, Adams DH, et al. Minimally invasive direct access heart valve surgery J Cardiac Surg 2000;15:21-34.[Medline]
  8. Gillinov AM, Banbury MK, Cosgrove DM. Hemisternotomy approach for aortic and mitral valve surgery J Cardiac Surg 2000;15:15-20.[Medline]
  9. Grossi EA, Ribakove GH, Schwartz DS, Galloway AC, Colvin SB. Port-access approach for minimally invasive mitral valve surgery Operative Techniques in Cardiac and Thoracic Surgery 1998;3:32-46.
  10. Grossi EA, Galloway AC, LaPietra A, et al. Minimally invasive mitral valve surgery: a 6-year experience with 714 patients Ann Thorac Surg 2002;74:660-664.[Abstract/Free Full Text]
  11. Sharony R, Grossi EA, Ribakove GH, et al. Minimally invasive valve surgery: evolution of technique and clinical results Adv Cardiol 2002;39:164-172.[Medline]
  12. Grossi EA, Galloway AC, Ribakove GH, et al. Impact of minimally invasive valvular heart surgery: a case-control study Ann Thorac Surg 2001;71:807-810.[Abstract/Free Full Text]
  13. Galloway AC, Grossi EA, Bizekis CS, et al. Evolving techniques for mitral valve reconstruction Ann Surg 2002;236:288-293.[Medline]
  14. Modi P, Hassan A, Chitwood WR. Minimally invasive mitral valve surgery: a systematic review and meta-analysis Eur J Cardiothorac Surg 2008;34:943-952.[Abstract/Free Full Text]
  15. Mihaljevic T, Cohn LH, Unic D, et al. One thousand minimally invasive valve operations: early and late results Ann Surg 2004;240:529-534.[Medline]
  16. Aybek T, Dogan S, Risteski PS, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy Ann Thorac Surg 2006;81:1618-1624.[Abstract/Free Full Text]
  17. Bonow RO, Carabello BA, Kanu C, 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 (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease) Circulation 2006;114:e84-e231.[Free Full Text]



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Eugene A. Grossi
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