Minimally Invasive Versus Sternotomy Approach For Mitral Valve Surgery In Octogenarians A Propensity-matched Analysis
Erik Cura Stura, Davide Ricci, Giovanni Marchetto, Cristina Barbero, Massimo Boffini, Mauro Rinaldi.
Cittą della Salute e della Scienza di Torino - Molinette, Torino, Italy.
Objective: The aging of the population in western countries has determined the increase of fragile complex patients due to multiple comorbidities. Among these, a significant number of octogenarians with mitral disease is not referred to surgical treatment because of the high operative risk.
Methods: We performed a retrospective analysis of our 12-year experience in mitral valve surgery. 1560 patients underwent mitral valve surgery from January 2006 to March 2018. Patients under 80 year old were excluded (1432), resulting in a reference population of 128 octogenarians: 96 patients (75%) were operated with minimally invasive technique (MIMVS) and 32 (25%) with standard technique (Sternotomy). MIMVS pre-operative characteristics compared to Sternotomy are comparable in most variables, they differ only in pulmonary hypertension (47.1±16.7 vs 56.4±15.5, p<0.01 respectively). There were no differences in intra-operative data: comparable cardio-pulmonary by-pass (128.5±39.7 vs 122.4±50.7 min, p>0.05) and aortic cross-clamping time (85.5±28.5 vs 84.6±31.6 min, p>0.05). Mitral repair rate was higher in MIMVS group (36.5% vs 25.0%, p>0.05). The only exception was a more frequent tricuspid associated procedure in sternotomy group (50% vs 3.5%).
Results: MIMVS outcomes compared to sternotomy showed reduction of ventilation time (37.2±104.2 vs 52.8±84.9 hours, p<0.0001), intensive care unit stay (4.0±8.6 vs 4.4±5.4 days, p<0.0279), transfusions (3.6±5.1 vs 4.3±2.8, p<0.0158), thoracentesis (2.1% vs 15.6%, p<0.0107), creatinine values (0.99±0.46 vs 1.23±0.63 mg/dl, p<0.0334), total complications (0.5±0.9 vs 1.3±1.1, p<.0001), and 30-day mortality (3.1% vs 15.6%, p<0.0232). A Propensity Score (AUC=0.82) was used to identify 27 patient pairs. The matched comparison confirmed a trend of advantage for MIMVS: less prolonged ventilation (7.4% vs 15.4%), re-intubation (7.4% vs 11.1%), tracheostomy (3.7% vs 7.4%), ICU stay (2.9±3.4 vs 3.4±5.0 days), patients transfused (40.7% vs 55.6%), re-exploration for bleeding (3.7% vs 11.1%), neurological events (7.4% vs 11.1%), PM implantation (0.0% vs 7.4%) and hospital stay (10.5±4.2 vs 11.6±7.3 days) respectively. Significant advantage for MIMVS remained in ventilation time (22.5±29.5 vs 40.3±77.5 hours, p=0.0105) and total complications (0.6±0.9 vs 1.1±0.9, p=0.01539).
Conclusions: In octogenarians MIMVS is feasible, reduces hospitalization, complications and post-operative morbidity and allows early post-operative mobilization as well as improved quality of life.
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