Minimally Invasive Mitral Valve Surgery After Coronary Artery Bypass Grafting With Both Internal Mammary Arteries
Maximilian Vondran1, Tamer Ghazy2, Ramy Elzaida2, Martin Moscoso Ludueña2, Eugen Tillmann2, Marc Irqsusi1, Terezia Bogdana Andrási1, Ardawan Julian Rastan1.
1Philipps University Hospital Marburg, Marburg, Germany, 2Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg an der Fulda, Germany.
BACKGROUND Mitral valve surgery in patients who have undergone coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) is of particular risk when performed through redo sternotomy. The outcome of minimally invasive mitral valve surgery (MIMVS) via a right anterolateral minithoracotomy (5-7cm) that can also be performed without aortic clamping, has not yet been evaluated in these patients. METHODS From 534 patients undergoing MIMVS between 01/2012 and 04/2018 at our institution, ten patients (median age 72, 8 male) required MIMVS at 99 month (33-179) postoperatively. Nine of the 10 patients underwent the procedure under hypothermic ventricular fibrillation without aortic clamping. The preoperative, intraoperative and postoperative data were retrospectively collected and analyzed. RESULTS Preoperative LV-EF was 44 (30 - 55) % and EuroScore II was 25.0% (6.7 - 33.0). Mitral valve replacement with biological prosthesis was performed in 8 (80%) and reconstruction in 2 (20%) patients. Four patients (40%) required concomitant tricuspid valve repair. There was no conversion to sternotomy, no intraoperative death, no postoperative neurological deficit, no bypass damage and no myocardial infarction. Reoperation for bleeding was required in 2 patients whereas cardiac resuscitation was required in 1 patient. Reintubation was necessary in 3 (30%) patients and temporary hemodialysis in 4 (40%) patients all suffering from sepsis. Cardiac arrhythmias were documented in 6 patients, from which one required pacemaker implantation. The median ICU stay was 5 days (3-10), whereas hospital stay was 9 days (7-19). Mortality at discharge was 20% and was associated with resuscitation and sepsis. All discharged patients (80%) survived the follow-up period of 21 month (9-29) without complications. CONCLUSIONS MIMVS can be performed safely after BIMA CABG also in elderly patients with reduced LV-EF. The low mortality was not related to the operative characteristics and postoperative cardiac function, but rather to advanced age, postoperative need for mechanical ventilation and dialysis, development of sepsis and multiorgan failure.
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