The Advantages Of Minimally-invasive Mitral Valve Surgery Can Be Safely Translated To The Elderly: A Propensity-matched Analysis
Carol W. Chen, Jennifer J. Chung, Ann C. Gaffey, Michael A. Acker, W. Clark Hargrove, Pavan Atluri.
University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVE: Increasingly more patients over age 80 are referred for mitral valve operations. Though techniques associated with improved recovery are desirable in this population, minimally-invasive approaches are technically challenging. We hypothesize that mitral valve surgery with a minimally-invasive thoracotomy has equivalent outcomes compared to the traditional median sternotomy.
METHODS: A retrospective review of patients undergoing mitral valve surgery from 2002 to 2015 was performed at a single institution. Patients were stratified by operative approach via full sternotomy or minimally-invasive port access techniques. Cox proportional hazard modeling was performed to assess predictors of 30-day hazard of death. Clinically-important patient characteristics were adjusted for, including age, sex, body mass index, diabetes, renal failure, hypertension, smoking status, previous myocardial infarction, creatinine, mitral procedure, and cardiopulmonary bypass (CPB) time. Propensity score matching allowed for the comparison of post-operative complications.
RESULTS: Of 6386 patients who underwent mitral valve surgery, 718 (11%) were age 80 or older. Patients who underwent concomitant cardiac surgery or an emergent salvage procedure were excluded. Median sternotomy was performed for 136 patients and mini-thoracotomy for 55 patients. Hazard ratios for 30-day mortality were increased in patients with diabetes (HR=3.7, p=.021) and longer CPB time (HR=1.4, p=.016) but equivalent in patients who received a mini-thoracotomy compared to sternotomy. Propensity score matching identified 50 patients each in the sternotomy and the mini-thoracotomy groups. CPB time was significantly prolonged in the mini-thoracotomy group, 117 (103-148) minutes, compared to the sternotomy group, 83 (69-110) minutes, p<.001. However, the postoperative transfusion rate was higher in the sternotomy group, 2.5 (1-6) units vs. 1.0 (1-2) units, p=.032. Other postoperative characteristics were equivalent between groups.
CONCLUSIONS: Though sternotomy is the gold standard for mitral valve surgery, minimally-invasive thoracotomy can be performed with equivalent short-term outcomes in patients age 80 and older, as seen in this propensity score analysis. In this population, the improvement in pain and sternal stability associated with the minimally-invasive approach may confer the benefit of early mobilization and rapid recovery.
|Bypass Time (Minutes)||83 (69, 110)||117 (103, 148)||<.001|
|Crossclamp Time (Minutes)||63 (50, 76)||83 (67, 110)||<.001|
|Pneumonia||2 (6.5%)||2 (6.3%)||.974|
|Renal Failure||2 (6.5%)||1 (3.1%)||.535|
|Red Blood Cell Transfusion (Units)||2.5 (1-6)||1 (1-2)||.032|
|Total ICU Time (Hours)||50 (27-123)||48 (26-81)||.309|
|Length of Stay after Surgery (Days)||9 (7-11)||8.5 (7-12)||.989|
|30-Day Mortality||4 (8.0%)||2 (4.0%)||.400|
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