Joseph Lamelas

Outcomes of Minimally Invasive Valve Surgery Versus Median Sternotomy in Patients Age 75 Years or Greater

BACKGROUND Advanced age is a major predictor of poor outcome in patients undergoing valve surgery. We hypothesized that elderly patients who underwent minimally invasive valve surgery for aortic or mitral valve disease would do better when compared with those undergoing the standard median sternotomy. METHODS We retrospectively reviewed 2,107 consecutive heart operations at our institution and identified 203 patients, age 75 years or greater, who underwent isolated mitral or aortic valve surgery. Outcomes of those who had minimally invasive valve surgery through a right minithoracotomy were compared with those who had a median sternotomy. RESULTS Of the 203 patients, 119 (59%) underwent a minimally invasive approach, while 84 (41%) had a median sternotomy. The median postoperative length of stay was 7 days (interquartile range [IQR] 6 to 10) versus 12 days (IQR 9 to 20), p less than 0.001, and intensive care unit length of stay was 52 hours (IQR 44 to 93) versus 119 hours (IQR 57 to 193), p less than 0.001 for minimally invasive and median sternotomy, respectively. In-hospital mortality was 2 (1.7%) versus 8 (9.5%, p=0.01 and composite postoperative morbidity and mortality occurred in 25 (21%) versus 38 (45.2%), p less than 0.001, in minimally invasive versus median sternotomy, respectively. The difference was driven by the following: a lower incidence of acute renal failure, 1 (0.8%) versus 14 (16.7%), p<0.001; prolonged intubation 23 (19.3%) versus 32 (38.1%), p=0.003; wound infections 1 (0.8%) versus 5 (6%), p=0.034; and death. CONCLUSIONS Minimally invasive surgery for isolated valve lesions in elderly patients yields a lower morbidity and mortality when compared with median sternotomy and should be considered when such individuals require valve surgery.

Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery.

BACKGROUND We hypothesize that composite in-hospital surgical complications are lower in obese patients who undergo minimally invasive valve surgery for aortic and (or) mitral valve disease, when compared with the standard median sternotomy approach. METHODS We retrospectively reviewed 2,288 heart operations done at our institution between January 3, 2005 and January 10, 2010, and identified 160 consecutive obese patients, defined as patients with a body mass index of greater than 30 kg/m(2), who underwent isolated mitral and (or) aortic valve surgery. The outcomes of those who had minimally invasive valve surgery were compared with a matched control group who had valve surgery through a median sternotomy approach. RESULTS Of the 160 patients, 64 underwent the minimally invasive approach and 96 had a median sternotomy. The mean age was 69.4 ± 11 years for the minimally invasive group, and 64.7 ± 11.5 for the median sternotomy group (p = 0.015). Composite postoperative complications occurred in 15 (23.49%) versus 49 (51.0%) patients (p = 0.034) in the minimally invasive group versus median sternotomy, respectively. The difference was driven by a lower incidence of acute renal failure (0 vs 6 patients [6.25%], p = 0.041), prolonged intubation (12 [18.7%] vs 33 [34.3%], p = 0.049), reintubation (3 [4.68%] vs 15 [15.6%], p = 0.032), deep wound infections (0 vs 4 [4.1%], p = 0.098), and death (0 vs 8 [8.3%], p = 0.041), respectively. All patients in the minimally invasive group were alive at 30 days. CONCLUSIONS Minimally invasive surgery for isolated valve lesions in obese patients has a lower morbidity and mortality when compared with the standard median sternotomy approach.

Staged percutaneous coronary intervention and minimally invasive valve surgery: Results of a hybrid approach to concomitant coronary and valvular disease

BACKGROUND We compared a hybrid approach combining staged percutaneous coronary intervention (PCI) and minimally invasive valve surgery with concurrent valve surgery plus bypass via a median sternotomy approach. METHODS We retrospectively evaluated 65 consecutive patients with coronary disease and surgical valvular heart disease who underwent planned PCI followed within 60 days by minimally invasive valve surgery, and we compared them with 52 matched control patients who underwent conventional bypass grafting and valve surgery. RESULTS There were no in-hospital deaths in the hybrid group, compared with 2 (3.8%) observed in the matched group (P = .11). Death, renal failure, or stroke occurred in 1 (1.5%) in the hybrid group versus 15 (28.8%) in the conventional group (P = .001). The median number of days between PCI and surgery was 24 (interquartile range, 2.5-37). At surgery, 23 hybrid patients were receiving both aspirin and clopidogrel;, 18, clopidogrel alone; 4, aspirin alone; and 22 stopped the antiplatelet agents 5 days before the operation. Intensive care unit hours and total hospital length of stay, including PCI stay for the hybrid group, were less in the hybrid group (P = .001 for both comparisons). In the hybrid group, average blood use was 1.6 ± 1.6 U per patient versus 1.9 ± 2.4 U per patient with conventional surgery (P = .35. There were no reoperations for postoperative bleeding in the hybrid group compared with 2 (3.8%) in the conventional group (P = .43). CONCLUSIONS Staged PCI with minimally invasive valve surgery may offer an alternative to coronary bypass grafting with concurrent valve surgery and should be tested prospectively.

Outcomes of Right Minithoracotomy Mitral Valve Surgery in Patients With Previous Sternotomy

BACKGROUND We evaluated the outcomes of patients with a history of previous sternotomy who underwent minimally invasive mitral valve surgery through a right minithoracotomy approach. METHODS We reviewed all the isolated mitral valve operations performed at our institution between January 1, 2005, and October 8, 2010, and selected for analysis only patients who had had a prior sternotomy. The outcome of patients who underwent a minimally invasive approach was compared with that of patients whose mitral surgery was performed through a standard median sternotomy. RESULTS There were 88 patients with prior sternotomy, with 59 having minimally invasive surgery and 29 undergoing a repeat median sternotomy. Significant baseline differences (minimally invasive versus sternotomy, respectively) included the number of male patients (76% versus 45%, p=0.003), prior coronary artery bypass graft surgery (71% versus 45%, p=0.02), prior valve surgery (47% versus 72%, p=0.03), congestive heart failure (46% versus 76%, p=0.008), and diabetes mellitus (34% versus 10%, p=0.02). The in-hospital mortality and composite postoperative complications were 3% versus 14% (p=0.07) and 29% versus 66% (p=0.001) for the minimally invasive versus the median sternotomy group, respectively. The intensive care unit stay and hospital length of stay were 48 hours (interquartile range [IQR], 41 to 90) versus 118 hours (IQR, 67 to 167; p<0.001), and 8 days (IQR, 6 to 12) versus 13 days (IQR, 9 to 18; p=0.001), for the minimally invasive and median sternotomy groups, respectively. CONCLUSIONS Minimally invasive mitral valve surgery in patients who have had a prior sternotomy is associated with improved postoperative outcomes and reduced resource utilization, when compared with a median sternotomy approach.

Minimally Invasive Valve Surgery: When Less Is More

Sternotomy has been the gold standard in cardiac surgery and generally provides and unobstructed view of the heart. However, expertise in this traditional method may no longer suffice for the professional survival of cardiac surgeons, We must consider minimally invasive approaches to treating diseases of the heart. As such, the focus of this article will be on the past, present, and future of mini-valve surgery.

Outcomes of minimally invasive valve surgery in patients with chronic obstructive pulmonary disease

OBJECTIVES We hypothesize that minimally invasive valve surgery in patients with chronic obstructive pulmonary disease (COPD) is superior to the conventional median sternotomy approach. METHODS We retrospectively reviewed 2846 consecutive surgery performed at our institution between January 2005 and September 2010, and identified 165 patients with COPD who underwent isolated valve surgery. In-hospital mortality, composite complication rates, intensive care unit and total hospital length of stay of those who had undergone a minimally invasive approach were compared with a cohort that underwent a standard median sternotomy approach. RESULTS Of the 165 patients, 100 underwent a minimally invasive approach and 65 had a median sternotomy. Baseline characteristics did not differ between the two groups. The mean age was 71 ± 11 years for the minimally invasive group and 68 ± 12 years for the median sternotomy group, (P = 0.31). In-hospital mortality was 1 (1%) in the minimally invasive group and 3 (5%) in the median sternotomy group, P = 0.14. Composite postoperative complications were significantly reduced in the minimally invasive group (30 versus 54%, P = 0.002). The median intensive care unit length of stay was 47 h (IQR 40-70) versus 73 h (IQR 51-112), P < 0.001, and the median postoperative length of stay was 6 days (IQR 5-9) versus 9 days (IQR 7-13), P < 0.001, for the minimally invasive and the median sternotomy groups, respectively. CONCLUSIONS Minimally invasive valve surgery in patients with COPD is associated with excellent short-term results, and thus should be considered an option in these patients.

Clinical trends in surgical, minimally invasive and transcatheter aortic valve replacement†

OBJECTIVES Transcatheter aortic valve replacement (TAVR) and minimally invasive aortic valve replacement (MIAVR) have emerged as alternatives to surgical aortic valve replacement (SAVR) via traditional sternotomy. However, their effect on clinical practice remains unclear. The studys objective is to describe clinical trends between TAVR, MIAVR and SAVR in patients with severe aortic stenosis (AS). METHODS This retrospective observational study analyzed trends in isolated severe aortic valve replacement (AVR) among three high volume TAVR, MIAVR and SAVR centres in the United States. The cohort included 2571 patients from 2011 through 2014 undergoing SAVR ( n  = 842), MIAVR ( n  = 699) and TAVR ( n  = 1030) further stratified into transapical (TA-TAVR) and trans-femoral (TF-TAVR). RESULTS Total AVR volume increased +107% with increases in TF-TAVR (+595%) and MIAVR (+57%). However, SAVR (-15%) and TA-TAVR (-49%) decreased from 2013 to 2014. In the final year, risk stratification by age ≥ 80, redo AVR, patients receiving dialysis and STS score >8% revealed increases in TF-TAVR and MIAVR, while SAVR decreased for all groups. CONCLUSIONS TF-TAVR and MIAVR increased while SAVR and TA-TAVR trended down in the latter periods, which underscore a paradigm shift in the treatment of severe AS and the importance of surgeon adoption of TF-TAVR and MIAVR techniques. As the demand for minimally invasive modalities increases, further studies comparing MIAVR versus TF-TAVR in low and intermediate risk patients are warranted.

Minimally invasive aortic valve replacement: the "Miami Method"

For patients undergoing aortic valve replacement (AVR), a minimally invasive approach performed via a right anterior thoracotomy is the preferred method at our institution. This method has evolved over a 10-year span, being applied to over 1,500 patients with the commitment of one surgeon seeking to offer a simplistic and reproducible minimally invasive alternative. We believe that this is truly the least invasive approach to the aortic valve since it avoids sternal invasion. By virtue of being less traumatic, the morbidity is diminished and therefore the recovery is enhanced. We believe that this approach is most beneficial in the high risk patient such as the elderly, the obese, those with chronic obstructive pulmonary, chronic kidney disease and those requiring re-operative surgery. This method has proven to be safe and effective in all patients requiring isolated AVR surgery. The only relative exclusion criteria would be a porcelain aorta with the inability to cannulate the patient.

Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery

OBJECTIVES Minimally invasive valve surgery has been associated with increased cerebrovascular complications. Our objective was to evaluate the incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery. METHODS We retrospectively reviewed all the minimally invasive valve surgery performed at our institution from January 2009 to June 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed. RESULTS A total of 1501 consecutive patients were identified. The mean age was 73 ± 13 years, and 808 patients (54%) were male. Of the 1501 patients, 206 (13.7%) had a history of a cerebrovascular accident, and 225 (15%) had undergone previous heart surgery. The procedures performed were 617 isolated aortic valve replacements (41.1%), 658 isolated mitral valve operations (43.8%), 6 tricuspid valve repairs (0.4%), 216 double valve surgery (14.4%), and 4 triple valve surgery (0.3%). Femoral cannulation was used in 1359 patients (90.5%) and central cannulation in 142 (9.5%). In 1392 patients (92.7%), the aorta was clamped, and in 109 (7.3%), the surgery was performed with the heart fibrillating. The median aortic crossclamp and cardiopulmonary bypass times were 86 minutes (interquartile range [IQR], 70-107) minutes and 116 minutes (IQR, 96-143), respectively. The median intensive care unit length of stay was 47 hours (IQR, 29-74), and the median postoperative hospital length of stay was 7 days (IQR, 5-10). A total of 23 cerebrovascular accidents (1.53%) and 38 deaths (2.53%) had occurred at 30 days postoperatively. CONCLUSIONS Minimally invasive valve surgery was associated with an acceptable stroke rate, regardless of the cannulation technique.

Outcomes of transaortic edge-to-edge repair of the mitral valve in patients undergoing minimally invasive aortic valve replacement

Gender Male 16 (67%) Female 8 (33%) Age (y, mean SD) 77.8 9.2 Aortic valve lesion Aortic stenosis 20 (83%) Aortic insufficiency 2 (8.5%) Clinically significant mitral regurgitation (MR) is often found in conjunction with severe aortic valve stenosis. Adding mitral valve surgery to aortic valve replacement (AVR) increases the operative risk. This risk may be reduced by performing a transaortic edge-to-edge repair of the mitral valve during the AVR. We describe how to perform this procedure and report our results of using this approach during minimally invasive valve surgery. Prosthetic valve insufficiency 2 (8.5%) Mitral valve lesion Functional 11 (46%) Degenerative calcification 10 (42%) Rheumatic 3 (12%) Reoperation 8 (33%) Prior CABG surgery 6 (25%) Prior AVR 1 (4%) Prior CABG surgery and AVR 1 (4%) Preoperative MR (grade, median, IQR) 3 (3-4)