Minimally Invasive Mitral Valve Repair In A Low Volume Center; Earlier Flattening Of The Learning Curve Through Team Work
Manuel Giraldo-Grueso, Nestor Sandoval, Jaime Camacho, Ivonne Pineda, Juan P. Umaña.
Fundación Cardioinfantil-Instituto de Cardiología, Bogota, Colombia.
Background: Low-volume centers might be reluctant to perform minimally invasive mitral valve repair (Mini-MVr) due to the initial learning curve involved, rates of repair, and outcomes. The objective of this study was to assess the learning process and outcomes of Mini-MVr in a low-volume center and compare the results with the conventional technique. Methods: A Mini-MVr team lead by a MV surgeon was created. Its main emphases were better patient selection, standardization of processes and procedures, education of referring physicians, earlier patient referral, and better postoperative care and follow-up. Between 2004 and 2017, 200 patients underwent a mitral valve repair (MVr) for degenerative mitral valve disease at our institution. Fifty-eight (29%) underwent a Mini-MVr and 142 (71%) a conventional MVr. Mini-MVr was performed by right lateral minithoracotomy or periareolar approach while conventional repair was performed through median sternotomy. Variables were described according to the Society of Thoracic Surgeons database guidelines. Results: Follow-up was 94% complete (mean time 2.3 years). There was no 30-day mortality. Patients from the Mini-MVr group were younger (p=< 0,001) and healthier. Median left ventricular ejection fraction for the Mini-MVr group was 55% (46-60%) and 60% (55-61%) for conventional group (p=0,013). Nine (6,3%) patients from the conventional group and one (1,7%) from the MI-MVr required reoperation due to bleeding (p=0,287). Two patients from each group suffered a stroke (p= 0,581). At last follow-up, 168 patients (89%) showed no or grade I mitral regurgitation. No difference was found between groups in terms of recurrent mitral regurgitation and functional class. We compared cardiopulmonary bypass (CPB) and cross-clamp times of Mini-MVr with standard times of conventional MVr at our institution. Results showed that in the first cases Mini-MVr times were higher than the conventional approach. Nevertheless, after the fiftieth case, they became shorter than conventional times. (Figure) Conclusion: Mini-MVr techniques are safe, effective, and provides excellent short and long-term outcomes. Low-volume centers can accomplish excellent Mini-MVr results and flatten the learning curve with the creation of a Mini-MVr team.
Legend: Figure 1. Image 1 represents the decreasing times of CPB. Image 2 shows the decreasing times of cross-clamp.
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