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Ann Thorac Surg 2001;71:807-810
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Impact of minimally invasive valvular heart surgery: a case-control study

^a Division of Cardiothoracic Surgery, Department of Surgery, New York University School of Medicine, New York, New York, USA

Accepted for publication June 9, 2000.

Address reprint requests to Dr Grossi, New York University Medical Center, 530 First Ave, Suite 9V, New York, NY 10016
e-mail: grossi{at}cv.med.nyu.edu

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. The port access (PA) approach for valvular heart surgery is widely used, but few studies evaluating outcomes compared with the sternotomy approach have been performed.

Methods. One hundred nine consecutive patients undergoing PA-isolated valve surgery were compared with 88 matched patients who underwent sternotomy-isolated valve surgery before the institution of the PA program. Case matching was performed by age, surgeon, congestive heart failure, position of operated valve, and history of previous surgery.

Results. Analysis revealed that PA was associated with similar hospital mortality (p = 0.62), longer bypass times (p < 0.001), shorter length of stay (p = 0.02), fewer transfusions (p = 0.02), and fewer septic complications (p = 0.05).

Conclusions. The PA approach for isolated valvular heart surgery provided patients with significantly improved clinical outcomes in their immediate perioperative course. Further studies are required to measure the impact of the PA approach on the patients’ recovery after hospitalization.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Rapid advances in minimally invasive surgical techniques have led to a number of innovative approaches to valvular heart surgery. The advent of intravascular aortic clamping and percutaneous coronary sinus cardioplegia delivery systems [1–3] has permitted performance of valvular heart surgery through small versions of traditional thoracotomy incisions. It was anticipated that among the advantages of this minimally invasive approach would be reduced tissue trauma resulting in less blood loss and enhanced patient recovery. While several laboratory [4] and preliminary clinical reports [5] regarding this technique have been published, few outcome data from comparative studies with standard sternotomy are available [6]. This report presents our initial clinical experience with the port access approach for isolated valvular disease and uses a case-control study methodology for analysis of the clinical outcomes.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
From May 1996 through October 1998, 109 consecutive patients underwent isolated aortic valve replacement or isolated mitral valve replacement or repair using the port access technique at NYU Medical Center. These 109 patients represent 100% of all adult isolated aortic or mitral procedures performed by these surgeons during this time period. Patients who underwent isolated valve surgery via a sternotomy approach by the same group of surgeons in the year before the availability of the port access procedure were analyzed as case-matched controls. These control patients were matched to the minimally invasive patients by age, valve type, surgeon, previous cardiac surgery, and the presence of congestive heart failure. A total of 88 case-matched controls were identified and used in this analysis.

For port access mitral valve surgery, a small interspace incision was created in the inframammary crease on the patient’s right chest. Myocardial protection was obtained by delivery of either antegrade or retrograde cardioplegia. Peripheral cardiopulmonary bypass was employed via exposure of the femoral vessels as previously described [7]. Arrest of the heart was achieved by balloon occlusion of the proximal aorta with an endo-clamp. This specialized catheter allows for endoaortic occlusion, aortic root pressure monitoring, and either aortic root cardioplegia administration or venting. Using the port access approach with peripheral cannulation for cardiopulmonary bypass, the incision to access the heart is kept to a minimum, because the operative field remains unobstructed by cannulas or cross-clamps. No supplementary incisions are required.

A simplified version of this technique was used for aortic valves. Preferentially, a small anterior second right interspace chest incision was made to expose the aortic root. Because the aorta was available, direct aortic cannulation was performed and an external cross-clamp was applied. Retrograde cardioplegia and venous drainage were unaltered.

Intraoperative transesophageal monitoring was used in all patients. The descending aorta and transverse aorta were evaluated initially for the presence of any intraluminal atheromatous disease. Additionally, during the procedure, transesophageal echocardiography was used for positioning and monitoring the placement of the various cannulas and catheters. During the time period of this study, 10 isolated valve patients (9.2%) were not attempted with the minimally invasive approach due to the presence of either severe peripheral vascular disease or central atheromatous disease.

The data were collected prospectively using the New York State CSRS Adult Data Collection Instrument [8]. Data analysis was performed with the statistical software SPSS (SPSS Inc, Chicago, IL). ² analysis was used to compare categorical variables and nonpaired Student’s t test was used for continuous variables. Nonparametric testing was performed using the Mann-Whitney test. General linear modeling was used to test for multiple variable analysis. Statistical significance for all tests was noted for p less than 0.05.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Hospital mortality was 3.7% (4 of 109) for the port access group and 3.4% (3 of 88) for the sternotomy group (p = 0.62). Overall mortality for the two groups combined was 5.3% for aortic valve procedures and 2.5% for mitral valve procedures. Table 1 lists pertinent patient demographic data. The port access technique required significantly longer bypass times (139 vs 110 minutes; p < 0.001), but was associated with a shorter length of stay (median 7 vs 9 days; p = 0.001) (Table 2). A decrease in the number of postoperative septic complications was associated with the port access technique (0.9% for port access vs. 5.7% for sternotomy; p = 0.05). One deep sternal infection occurred in the sternotomy group; no deep chest infections occurred in the port access patients (Table 3). There were no aortic dissections in either group of patients, no conversions to sternotomy, and no peripheral vascular complications in either group.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This study documents the impact of the port access minimally invasive surgical approach for isolated valve disease by comparing case-matched controls operated upon using standard techniques during the previous year. One of the largest studies on the outcome of minimally invasive coronary surgery was recently published from the Port Access International Registry data [9]. While demonstrating favorable results, this series was a noncontrolled, nonconsecutive series, which severely obscures its interpretation. In another study, decreased resource utilization has been reported when comparing minimally invasive direct coronary artery bypass (single-vessel direct coronary artery bypass grafting; anterior thoracotomy internal mammary artery to left anterior descending coronary artery) with standard multi-vessel CABG [10]. Several noncontrolled series of minimally invasive valves [11–14] have been published with various results. The present study clearly documents, by the use of case-matched controls from an immediately previous period, that the benefits of the port access minimally invasive surgical approach for patients requiring valvular heart surgery include shorter hospitalization, less exposure to blood, and fewer wound complications.

A variety of surgical approaches are collected under the umbrella term of "minimally invasive." Several "less invasive" techniques for valvular heart surgery have been described. In particular, for mitral valves, both a "parasternal" and "mini-thoracotomy" approach have been illustrated. The parasternal approach consists of resection of either the second and third or third and fourth cartilages from the chest wall and dissection of the pectoralis major muscle from its sternal attachment [6]. This large exposure allows for direct cannulation of the aorta. We do not use this approach because of concerns over destabilizing the chest wall. This type of exposure is not necessary with the endovascular approach using the port access equipment. Chitwood has described a series of mitral valve operations performed with a "micro mitral" technique [15]. This technique includes a mini-thoracotomy and rib resection; a separate chest incision is required for cross-clamp placement. Mohr and colleagues published a disappointing initial experience with the port access approach for mitral valve surgery [11]; subsequently, they have presented improved results. Their initial experience was complicated with significant morbidity, including two (of 51) acute retrograde aortic dissections. No aortic dissections were seen in the present patient series. We can only speculate that longstanding experience with intraoperative transesophageal echocardiography and great familiarity with the port access system (from our laboratory development) greatly assisted our skills in our operative series. We believe that with the proper clinical training, monitoring, and preoperative assessment of the patient, the port access mitral valve procedure is safe and reproducible, as evidenced by our experience.

The primary limitation of this study is that while a case-matched technique was employed, sufficiently large numbers of cases were not available in either group to permit performance of a multivariate analysis of the effects of other variables on other outcome indicators. Larger studies in the future will allow us to analyze the effects of these different techniques on other patient outcomes. Additionally, this study did not attempt to quantify differences in posthospitalization outcomes; patient wellness, home recovery, and return to work were not evaluated, due to lack of collected data in the control sternotomy group. Previously, however, we have documented the beneficial effects of the minimally invasive port access approach upon functional recovery and return to work in a prospective study of our coronary artery bypass graft patients [16]. To complete our understanding of the cost shifts and benefits of these new approaches, it will be necessary to quantify these benefits to patients and society as well as the costs of the advanced technology incurred during hospitalization. Another limitation of this study was that this port access experience was our initial experience, and therefore to some degree includes an early learning phase. Thus, it can be reasonably anticipated that future results will demonstrate even greater improvements in the results of port access surgery.

In conclusion, a single institution’s case-matched analysis approach revealed that the port access technique for isolated valvular heart surgery compared with the sternotomy approach resulted in significantly shorter length of stay and significantly less risk of transfusion. Also, there were fewer episodes of septic complications associated with the port access approach. Based on this experience, this minimally invasive approach has become our procedure of choice for isolated valvular heart surgery.

	Acknowledgments

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This work was supported in part by The Foundation for Research in Cardiac Surgery and Cardiovascular Biology.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The authors acknowledge financial support for their research laboratory from Heartport, Inc, Redwood City, CA.

	References

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eugene A. Grossi Aubrey C. Galloway Peter K. Zakow Stephen B. Colvin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grossi, E. A. Articles by Colvin, S. B. Search for Related Content PubMed PubMed Citation Articles by Grossi, E. A. Articles by Colvin, S. B. Related Collections Mechanical Circulatory Assistance Related Article