3d Total Endoscopic Vs. Direct Vision Approach In Minimally Invasive Mitral Valve Surgery: A Propensity Score Matched Comparison
Alexander Meyer, Karel Van Praet, Matteo Montagner, Stephan Jacobs, Simon Sündermann, Volkmar Falk, Jörg Kempfert.
German Heart Center Berlin, Berlin, Germany.
Objectives: Minimal invasive mitral valve surgery (MIS) has become the standard-of-care in many centers with various technical variations described previously. In our center all procedures are performed via a right lateral minithoracotomy. We sought to compare two different approaches of MIS mitral procedures: the 'classical' 2D video assisted approach (Chitwood clamp) and the 3D total endoscopic approach (endo-aortic clamping, no rib-spreading). Methods: From 2014 to 2017, a total of 477 patients underwent MIS mitral valve surgery. The "classic" 2D video-assisted approach (mostly direct vision, Chitwood clamp; referred as "2D" group) was performed in 330 patients. The 3D total endoscopic setup (no rib-spreading, endoaortic balloon-clamping [Figure A], periareolar incision in male patients [Figure B]; referred as "3D" group) was used in 147 patients. Multiple imputation and propensity score matching was used to minimize confounding and selection bias. Results: The 3D total endoscopic procedure was feasible in all cases. The use of the endoaortic balloon was not associated with any specific complications. Matching resulted in 120 matched pairs. Carpentier classification (I: 13% vs. 13%, II: 63% vs. 67%, III: 8% vs. 8% in 3D vs. 2D), concomitant procedures (cryoablation: 44% vs. 42%, tricuspid repair: 8% vs. 9% in 3D vs. 2D) and STS-scores (3D: 1.3%, 2D: 1.3%) were almost perfectly balanced. Procedure times (OR-Time: 3D 179 [159-219] vs. 2D 139 minutes [112-176], p<0.001; CPB-Time: 3D 119 [103-143] vs. 2D 90 minutes [75-121], p<0.001; XClamp-Time: 3D 72 [59-88] vs. 2D 60 minutes [50-80], p=0.002) were significantly shorter with the 2D approach. ICU stay (p=0.17) as well as valve repair rate (3D 100% vs. 2D 98%, p=0.5) were similar in both groups. One-year survival (logRank p=0.655, Figure C) and 30day-mortality were similar (p=1.0). Clinical outcome was comparable (Stroke: 3D 2% vs. 2D 0%, p=0.5; postoperative delirium: 3D 2% vs. 2D 3%, p=1.0; Myocardial infarction: 3D 0% vs. 2D 2%, p=0.5; Low cardiac output syndrome: 3D 1% vs. 2D 0%, p=1.0). Conclusion: The 3D-total endoscopic approach utilizing endo-aortic clamping provided excellent valve visualization and enabled a no rib-spreading access in all cases. The micro invasive setup was slightly more time consuming without jeopardizing procedure safety or valve repair rates. Both setups facilitate for MIS valve repair with low rates of severe complications.
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