Faculty Bibliography

OBJECTIVE: Although minimally invasive aortic valve replacement (MIAVR) has recently become popular, additional outcome evaluation is required. This study analyzed a single institutional experience with MIAVR with respect to hospital morbidity and mortality. METHODS: Between 12/96 and 06/02, 482 consecutive patients at a single institution underwent MIAVR, including concomitant procedures in 123 pts: 55 multiple valves, 18 CABGs, 21 myomectomies, and 29 other procedures. These patients (mean age 65 yrs; range 15-94) had severe stenosis (58.9%), severe insufficiency (33.0%), or mixed disease (8.1%). Thirty-three percent had a previous MI, 13.3% had a previous cardiac operation, and 17.3% were >80 years old. Right anterior minithoracotomy was performed in 87.3%. Ascending aortic cannulation was used in 68% of the patients while direct external cross clamping was used in 97% of cases. RESULTS: Hospital mortality was 6.2% (30/482) overall and 5.3% (19/359) for isolated AVR. Mean aortic crossclamp and cardiopulmonary bypass times were 87 and 122 min, respectively. Postoperative complications included stroke in 2.3% (11/482) and 82.5% of patients were free from any complications. Neither aortic dissection nor mediastinitis was observed. Univariant analysis demonstrated that female gender, renal failure, CHF, and age >80 years were risk factors for mortality. Multivariable analysis revealed that age and CHF were independently associated with increased risk of mortality (p<0.05). CONCLUSIONS: These results demonstrate that MIAVR is a safe procedure, with low morbidity and acceptable perioperative mortality, and may be used routinely in a large series of patients

BACKGROUND: This study analyzes a single institutional experience with minimally invasive mitral valve operations of 6 years, reviewing short-term morbidity and mortality and long-term echocardiographic follow-up data. METHODS: Seven hundred fourteen consecutive patients had minimally invasive mitral valve procedures between November 1995 and November 2001; concomitant procedures included 91 multiple valves and 18 coronary artery bypass grafts. Of these 714 patients, 561 patients had isolated mitral valve operations (375 repairs, 186 replacements). Mean age was 58.3 years (range, 14 to 96 years; 30.1% > 70 years), and 15.4% of patients had previous cardiac operations. Arterial cannulation was femoral in 79.0% and central in 21%, with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%. RESULTS: Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median ventilation time was 11 hours, intensive care unit time was 19 hours, and total hospital stay was 6 days. Complications for all patients included permanent neurologic deficit (2.9%), aortic dissection (0.3%); there was no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair patients had only trace or no residual mitral insufficiency. CONCLUSIONS: This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative morbidity and mortality and with late outcomes that are equivalent to conventional operations

OBJECTIVE: To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. SUMMARY BACKGROUND DATA: MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. METHODS: Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5-20.5). RESULTS: Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy; =.4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows ( >.05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. CONCLUSIONS: These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques