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Ann Thorac Surg 2009;88:1185-1190. doi:10.1016/j.athoracsur.2009.04.076
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Thoracoscopic Versus Open Mitral Valve Repair: A Propensity Score Analysis of Early Outcomes

Rakesh M. Suri, MD, DPhila,*, Hartzell V. Schaff, MDa, Steven R. Meyer, MD, PhDb, W. Clark Hargrove, III, MDb

a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
b Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Accepted for publication April 22, 2009.

* Address correspondence to Dr Suri, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Email: suri.rakesh{at}mayo.edu).

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


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: The very low risk of mitral valve repair performed through median sternotomy must be reproducible when using a port-access approach to justify early repair employing minimally invasive platforms. We compared the outcomes of mitral valve repair performed through port access using thoracoscopic assistance (port) versus median sternotomy (open).

Methods: The early results after mitral valve repair performed by two different surgeons at two separate institutions were analyzed. Between January 1999 and December 2006, isolated mitral valve repair was performed with a port approach in 350 patients and an open approach in 365 patients.

Results: The mean age was similar between the two groups; however, port patients were more frequently female (148 [42%] versus 119 [33%], p = 0.007), and had a higher likelihood of having New York Heart Association class III to IV symptoms (100 [29%] versus 48 [13%], p < 0.001), diabetes mellitus (19 [5%] versus 8 [2%], p = 0.023), congestive heart failure (90 [26%] versus 26 [7%], p < 0.001), and a lower ejection fraction (53% versus 64%, p < 0.001) preoperatively. Cross-clamp time (104 versus 24 minutes, p < 0.001) and bypass time (140 versus 33 minutes, p = 0.001) were significantly lower for the open group. On univariate analysis, the duration of postoperative ventilatory support was significantly lower in the port group (5.0 versus 11.0 hours, p < 0.001); however, the length of hospital stay was longer (6.95 versus 6.19 days, p < 0.001). There were 2 early deaths (2 port versus 0 open). A propensity score factor was calculated and utilized to account for differences between groups. After adjusting for propensity score and significant factors identified in multivariate models, port mitral repair independently predicted a diminished duration of postoperative ventilatory support (p = 0.045), but there were no significant differences in other outcomes including postoperative blood transfusion, reoperation for hemorrhage, or length of stay in hospital.

Conclusions: Despite longer cross-clamp and bypass times, early outcomes using a thoracoscopic port-access approach were similar to those for mitral valve repair performed through median sternotomy. Minimally invasive mitral valve repair was associated with a shorter time to extubation, but that did not translate into a diminished duration of postoperative hospitalization.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
The surgical management of mitral valve (MV) regurgitation (MR) caused by leaflet prolapse has evolved significantly over the past 2 decades. During that time, there has been a change in the pathology and, consequently, in the pathophysiology of patients referred for operative treatment. Most patients currently presenting for MV surgery in the Western world have isolated MR due to degenerative valve disease, which is amenable to correction with simplified repair techniques [1]. Additionally, patients are identified earlier in their disease course and followed more regularly in an attempt to prevent the development of deleterious consequences of chronic MR on left ventricular size and function. Finally, the outcome of surgical management has improved, and the long-term durability of primary and reoperative MV repair in the current era has been clearly established [2, 3].

During the same period, medical interventions in general have evolved toward less invasive platforms. The use of high-definition imaging systems and robotic technology now allow complex cardiac surgery to be carried out through small incisions, with the complete avoidance of sternotomy [4, 5]. The putative benefits of such an approach include decreased morbidity, such as a reduced need for blood transfusion, shorter hospital stay, decreased postoperative functional limitation, and quicker return to normal activity. Yet, the incorporation of minimally invasive valve surgery into mainstream cardiac surgical practice has occurred largely in the absence of proven equivalence. We sought to compare the early outcomes of MV repair performed through either standard median sternotomy or by a port-access thoracoscopic approach by two high-volume cardiac surgeons at two separate academic centers.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
This study involved a retrospective review of the medical records of patients undergoing primary MV repair for MR due to leaflet prolapse through median sternotomy (open) at the Mayo Clinic, Rochester, Minnesota (H.V.S.), or thoracoscopically through a port-access approach (port) at the University of Pennsylvania Hospitals, Philadelphia, Pennsylvania (W.C.H.). The study was approved by the Institutional Review Board of both institutions, which waived the need for patient consent for the study. We excluded patients who declined involvement in clinical research, required surgical coronary revascularization, had previous MV surgery, concomitant cardiac procedures, or a primary diagnosis of MR caused by congenital or ischemic heart disease or other forms of cardiomyopathy. Also excluded were patients with endocarditis causing leaflet defects or subvalvar abscess at the time of the primary MV repair. We included patients who underwent concomitant closure of a patent foramen ovale.

Between January 1999 and December 2006, 365 patients meeting the study criteria who were undergoing isolated (with or without patent foramen ovale closure) open MV repair and 350 patients having repair through a port-access approach were identified, and their records were analyzed. The techniques and outcomes of MV repair utilizing both approaches have been published previously elsewhere [1, 3, 6–9]. Briefly, port-access surgery has become the preferred approach for mitral valve surgery at Penn Presbyterian Hospital and therefore was indicated for all patients requiring MV surgery. Contraindications included need for AVR or coronary artery bypass graft surgery and lack of adequate peripheral access.

Port-access surgery was performed using standardized procedures similar to those described by Casselman and colleagues [8, 9]. The patient is intubated with a double-lumen endotracheal tube, and bilateral radial arterial lines are placed. The right internal jugular vein is cannulated with a 16F femoral cannula before draping. A small (4 cm) skin incision is made inferior to the right breast, and the chest is entered through the fourth intercostal space. A soft-tissue retractor is placed through the opening. Femoral venous cannulation is performed with a 25F venous cannula and femoral artery cannulation with a 21F cannula with side port for endoaortic balloon and cardioplegia. The pericardium is entered, and the free edges suspended. Cardiopulmonary bypass is initiated with active venous drainage and vacuum assist. The majority of cases are performed with endoaortic balloon clamping and antegrade cardioplegia. Positioning of the endoaortic balloon is confirmed using transesophageal echocardiography and symmetry of upper extremity arterial lines. Alternatively, a cross clamp is applied directly to the aorta, and cardioplegia administered through a separate cannula in the aortic root. After the heart is arrested, the left atrium is opened along the interatrial groove, and mitral valve repair/replacement is performed using standard procedures. A vent is placed across the valve before closing the atrium. A bipolar pacemaker wire is placed on the base of the right ventricle or left ventricle through a separate incision. Once the heart is beating, the vent is removed. After weaning from cardiopulmonary bypass, control transesophageal echocardiography is performed. All patients were dismissed from hospital with mild or less residual mitral regurgitation.

Statistical Analysis
Group statistics were expressed as the mean ± 1 SD. Categorical variables were compared between groups using the {chi}2 test for independence. A two-sample t test was used to compare continuous factors between groups. All p values of less than 0.05 were considered significant. Propensity scores were calculated through logistic regression comparing patient characteristics stratified by procedure type (open versus port). The propensity score included the following variables: age, body surface area, preoperative ejection fraction (EF), sex, congestive heart failure, New York Heart Association (NYHA) functional class (I, II versus III, IV), diabetes mellitus, hypertension, number of noncritically stenosed coronary arteries, MR, and coexistent mitral stenosis.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Baseline preoperative characteristics were compared between the two groups (Table 1). Port patients were more frequently female (148 [42%] versus 119 [33%], p = 0.007), and had a higher likelihood of having NYHA class III or IV symptoms (100 [29%] versus 48 [13%], p < 0.001), diabetes mellitus (19 [5%] versus 8 [2%], p = 0.023), congestive heart failure (90 [26%] versus 26 [7%], p < 0.001), and a lower EF (53% versus 64%, p < 0.001). Among port patients, 68% had posterior leaflet prolapse; 12% had anterior and 20% had bileaflet disease. In the open group, 59% had posterior leaflet prolapse; 9% had anterior and 32% had bileaflet disease.


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  		Table 1 Baseline Characteristics a
 
Several differences in operative and postoperative variables were identified on univariate analysis (Table 2). Port patients had significantly longer cross-clamp time (104 versus 24 minutes, p < 0.001) and bypass time (140 versus 33 minutes, p = 0.001). There were 2 early deaths (2 port versus 0 open). The duration of postoperative ventilatory support was less in the port group (5.0 versus 11.0 hours, p < 0.001); however, the incidence of postoperative blood transfusion was higher (102 [29%] versus 80 [22%], p = 0.023) and the duration of postoperative hospital stay was slightly longer (6.95 versus 6.19 days, p < 0.001). There was also a trend toward an increased risk of reoperation for postoperative hemorrhage among port patients (6% versus 3%, p = 0.076).


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  		Table 2 Perioperative Data a
 
Multiple variable models were constructed to determine independent factors influencing the following outcomes: postoperative blood transfusion, reoperation for early postoperative hemorrhage, length of postoperative ventilatory support, and length of hospital stay after surgery. There were too few events to create models for the stroke and early mortality endpoints. A propensity score factor accounting for differences in selection to open versus port groups was also incorporated into the models (Table 3). After adjusting for propensity score and significant factors identified in multivariate models, port-access mitral repair independently predicted a diminished duration of postoperative ventilatory support (–7.4 hours, p = 0.045). There were no significant differences in the propensity-adjusted likelihood of postoperative transfusion, reexploration for bleeding, or length of hospital stay.


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  		Table 3 Multivariate Analysis
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The early safety and long-term durability of MV repair for mitral leaflet prolapse performed through median sternotomy have both been clearly established in the literature [2, 3, 10–12]. It is well understood that the referral of asymptomatic patients for early MV repair minimizes postoperative symptoms, while improving life expectancy and long-term recovery of EF. Minimally invasive approaches to MV repair have recently evolved and have rapidly proliferated largely in the absence of objective data establishing equivalence. The current study demonstrates that despite significantly longer cross-clamp and bypass times, the early outcomes of thoracoscopic port-access MV repair are similar to those of an open approach through median sternotomy, aside from a slight decrease in duration of postoperative ventilatory support. Using propensity adjustment, we were unable to demonstrate an advantage of a port-access approach in diminishing postoperative blood transfusion, reoperation for hemorrhage, or postoperative length of stay.

Two recent reviews have summarized important outcomes after "minimally invasive" mitral surgery [4, 13]. The authors defined minimally invasive mitral surgery broadly as any incision less invasive than a complete median sternotomy, and thus were not immediately comparable to our current report. A meta-analysis by Modi and coworkers [4] reviewed 43 publications consisting of 2 randomized control trials, 17 case-control studies, and 24 cohort analyses. They identified 10 studies published between 1998 and 2005 that were suitable for inclusion in the review, incorporating a total of 1,358 patients in the minimally invasive category and 1,469 in the conventional sternotomy group. They found, as we did, that despite longer cross-clamp and bypass times during minimally invasive surgery, early mortality was equivalent; but in contrast to our current report, there was also reduced risk of reoperation for bleeding and a trend toward a decreased length of postoperative stay. They also discerned that case-control publications tended to demonstrate a benefit in terms of postoperative pain and quicker return to normal activities after minimally invasive surgery.

A subsequent analysis comparing MV repair through sternotomy versus a minimally invasive approach was recently published by Richardson and colleagues [13] and revealed similar results. The authors identified 778 publications and further selected 13 "best evidence" reports for inclusion in the review. The minimally invasive MV repair group again encompassed a heterogeneous array of platforms ranging from ministernotomy and thoracotomy to port-access thoracoscopic and robotic approaches. The authors reported that cardiopulmonary bypass time was, on average, 30 minutes longer in the minimally invasive group but that these patients had significantly reduced postoperative bleeding, a shorter time to extubation, less pain, and a quicker return to normal activity. There was also a trend toward shorter total hospital stay, ranging from 6 to 13 days for the minimally invasive group compared with 6 to 15 days for sternotomy patients; however, that did not reach statistical significance.

Four studies detailing the results of a thoracoscopic port-access approach to MV repair have been published in the literature to date [6, 14–16]. A recent impressive series from Leipzig detailed the outcomes of 1,339 patients who underwent minimal invasive MV surgery for MR using a 5-cm to 6-cm right lateral minithoracotomy and femoral cannulation [16]. The authors reported a mean bypass time of 121 minutes and mean cross-clamp time of 70 minutes, which was slightly shorter than our current report. Five-year survival was 83%, and freedom from MV reoperation was 97%. The report by Casselman and coworkers [6] is a retrospective review of a relatively homogeneous population of patients undergoing video-assisted MV repair at their institution and utilizing a technique closest to our own. The study included 187 patients who underwent surgery from February 1997 to October 2001 with complete follow-up obtained at a mean of 19 months postoperatively. One patient died in hospital from a "nontechnology" related cause. Freedom from MV reoperation was 93% at 4 years. According to the authors, 93% of patients were highly satisfied with either no or mild postoperative pain and 98% felt that they had an "aesthetically pleasing scar". No comparison sternotomy group was included in either of these studies, which differs from our current report.

To determine whether a minimally invasive approach to the mitral valve influences myocardial, cerebral, or pulmonary function, Dogan and coworkers [14] compared 40 patients randomly assigned to port-access MV surgery versus conventional median sternotomy. The port-access group underwent a small right anterior thoracotomy, with femorofemoral cardiopulmonary bypass and endoclamp cardioplegia. Mitral valve repair was performed in only 28 patients (70%) from each group. There were no significant differences in serologic evidence of myocardial or cerebral damage, and similar pulmonary and neuropsychological outcomes were observed. Of interest, the mean aortic cross-clamp times were statistically indistinguishable between the two groups (85 minutes port versus 88 minutes open, p = 0.71), which differs from our current findings.

Ryan and colleagues [15] examined the early outcomes of their first 117 Heartport patients (92 repair, 25 replacement) in comparison with a retrospectively matched sternotomy cohort. The authors confirmed prior reports of a significant increase in cross-clamp and perfusion times in the port group. Three port patients required repair of a coronary sinus perforation, and another underwent open repair of an aortic dissection. No other important differences in 30-day outcome were found. The authors concluded that despite longer cross-clamp times, port surgery could be performed with no increased risk over that of conventional sternotomy. The spectrum of mitral valve disease encountered was likely quite different in this study compared with that in our current report as evidenced by the significant subset undergoing mitral replacement. The remaining published series reporting outcomes after minimally invasive mitral surgery are difficult to compare to our own owing to heterogeneity in several important factors: mitral pathology, incisions (ministernotomy, parasternal, and so forth), and the technological platform utilized (large thoracotomy, robotic, and so forth).

Our study is unique in that it compares the results of a pure population of patients with degenerative MR undergoing isolated MV repair, and not mitral replacement, by two experienced, high-volume surgeons. Furthermore, the incorporation of propensity adjustment into the multivariate analysis allowed us to attempt to account for differences in nonquantifiable selection bias between groups. Port patients had a lower EF before surgery, which, in the absence of confounding variables such as ischemic disease or cardiomyopathy, suggests that they were referred for surgery later in their disease course. This finding is also consistent with more advanced preoperative symptoms (NYHA III or IV 28.6% versus 13.2%, p < 0.0001) and congestive heart failure (25.7% versus 7.1%, p < 0.0001) documented in our port group, which is a trend that differs from prior reports [4, 17]. As has been detailed previously in almost every comparison between minimally invasive and open MV surgery to date [4, 13], aortic cross-clamp and total bypass times were also significantly longer in our port group.

Despite these differences, in both the current series and others [15, 17–25], early mortality was not increased in the port group. Moreover, the rates of aortic dissection, atrial fibrillation, stroke, and deep wound infection were all similarly low. In contrast to a previously published meta-analysis [4], we observed a slightly decreased incidence of blood transfusion and a somewhat shorter hospital length of stay in the open group, whereas the duration of postoperative ventilatory support was slightly longer on univariate analysis (Table 2). These discrepant results may be attributable to several factors unique to our study. First, the patient populations analyzed were different in terms of preoperative risk. That is likely due to variations in institutional policy for referral of patients with significant MR for early MV repair [26]. Second, the two surgeons and their respective perioperative care environments were different, and therefore were likely influenced by a host of nonquantifiable variations. In an attempt to control for these features, a propensity factor was calculated. After accounting for nonrandom variables, the only endpoint with which port access was independently associated was a slightly decreased length of postoperative ventilatory support (–7.4 hours, p = 0.045). The series by Grossi and coworkers [27] detailed a median ventilation time of 11 hours after minimally invasive mitral surgery, which was nearly double that in our port group (5 hours). In contrast to our own results, a study by Gulielmos and colleagues [28] found a comparable duration of postoperative ventilation in open and port-access groups. In summary, as opposed to focusing on small reported variations in postoperative length of ventilation, duration of hospitalization, and so forth, we favor the hypothesis that differing postoperative management strategies between health care teams may explain the observed differences between series.

Limitations
This study is based on a retrospective review of medical records and is subject to typical biases. The fact that these two types of mitral repair surgery were performed at two different institutions is a strength in that the results likely reflect the outcomes of repair across a complete range of degenerative MV pathology. Comparing data from two centers is also a limitation in that certain institutional factors, such as indications for operation, repair techniques, and postoperative management strategies, are likely divergent. Nonetheless, the ability to compare two large and diverse MV repair experiences from two large high-volume academic centers is a useful method of gaining insight into important differences between open and port-access MV surgery in general in current clinical practice.

In conclusion, the proven safety and durability of MV repair in the current era have prompted the recent reevaluation of guidelines to recommend early surgery for asymptomatic patients with severe MR and a normal EF when the chance of repair is high [29, 30]. The ability to justify the referral of otherwise healthy patients for MV repair through either an open or minimally invasive port-access approach demands that certain criteria be met, including a robust safety profile with a low risk of requiring subsequent MV reoperation. Perhaps the greatest potential incremental benefit of minimally invasive MV surgery is in motivating asymptomatic patients with severe MR to pursue early valve repair to benefit from the long-term survival advantage and recovery of normal left ventricular function associated with this procedure, with the seductive potential of minimizing the physiologic impact of surgery. This series demonstrates that the early risk associated with a port-access minimally invasive MV repair is similar to that of standard median sternotomy despite longer cross-clamp and bypass times. Studies designed to quantify the extent to which port-access surgery influences the return to normal activities are necessary and are currently under way.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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