Minimally Invasive Mitral Repair For Degenerative Mitral Regurgitation: Does Disease Complexity Affect Short And Long-term Outcomes?
Fadi Hage, Ali Hage, Usha Manian, Nikolaos Tzemos, Bob Kiaii, Michael W.A. Chu
Western University, London, ON, Canada
BACKGROUND: Critics of endoscopic mitral repair suggest that only simple mitral lesions can be treated with this approach. We set out to compare in a prospective cohort study, the long-term clinical and echocardiographic outcomes of mini-mitral repair (MMR) for simple (posterior prolapse) versus complex regurgitation (anterior/bileaflet prolapse).
METHODS: Two hundred and forty-five consecutive patients underwent MMR for severe degenerative mitral regurgitation (MR) through a right, endoscopic approach (n=145 simple vs. n=100 complex). The most common repair technique was annuloplasty + artificial chordae (84%, n=121 for simple vs. 88%, n=88 for complex, p=0.3). Patients were prospectively followed for a maximal duration of 9 years. Patients’ characteristics were well balanced between groups (age: 63±12 years simple, 60±15 years complex, p=0.06; male: 71%, n=103 vs. 68%, n=68, p=0.6; LVEF: 62 ± 7% simple vs. 62 ± 7% complex, p=0.9; NYHA≥3: 31%, n=45 vs. 34%, n=34, p=0.6; MR grade 3-4+: 100%, n=145 vs. 100%, n=100, p=1).
RESULTS: The 30-day/in-hospital mortality was similar (0%, n=0 simple vs.1%, n=1 complex, p=0.2). Both groups had similar rates of early post-operative complications: myocardial infarction (1.4%, n=2 vs. 0%, n=0, p=0.2); neurological complications (1.4%, n=2 vs. 0%, n=0, p=0.2); re-operation for bleeding (0.7%, n=1 vs. 3%, n=3, p=0.2); intensive care unit length of stay (median, [IQR]) (1 [1,1] days vs. 1 [1,1] days, p=0.7). Early in-hospital residual mitral regurgitation was similar between groups (MR grade ≤1: 100%, total n=245, for both groups, p=1.0). Late survival (83% for simple vs 92% for complex, p=0.3) and actuarial freedom from re-operation or any valve-related complications (100% vs. 88%, p=0.07) at 9 years were similar between both repair groups. Actuarial freedom from NYHA>2 (90% for simple vs. 100% for complex, p=0.12) or MR>2 (97% for simple vs. 98% for complex, p=0.8) at 9 years was similar for all patients.
CONCLUSIONS: Repair of degenerative MR through a right mini-thoracotomy yields to excellent long-term clinical and echocardiographic outcomes regardless of the complexity of the disease. Patients presenting at experienced cardiac centres with complex mitral regurgitation should not be excluded from minimally invasive approaches on the basis of the complexity of the disease. 
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