Endoscopic Mitral Surgery In Elderly Patients
Hind Elhassan, Grzegorz Laskawski, Joseph Zacharias.
Blackpool Teaching Hospital, Blackpool, United Kingdom.
BACKGROUND: This study assessed the outcome of endoscopic mitral valve surgery compared to conventional sternotomy approach in elderly patients.
METHODS: retrospective study using prospectively collected data from January 2007 to November 2021, 647 patients underwent isolated mitral valve surgery at our institution (sternotomy, n = 440; minimally invasive, n = 207). Propensity score match analysis to create comparable risk group in the sternotomy and endoscopic mitral was performed. Patients were matched regarding their age, gender, severity of their symptoms (angina and dyspnoea), logistic EuroScore, diabetes, left ventricular ejection fraction, history of stroke, extra cardiac arteriopathy and preoperative atrial fibrillation. The caliper was tightened till the matching set did not display any significant imbalance. Matching was performed using the nearest neighbour algorithm with a caliper distance of 0.1. Clinical outcomes included bypass and cross clamp time, length of hospitalization, morbidity, mortality and discharge location were analysed in the matched data set. RESULTS: Although there was no significant different in bypass time between the two groups, cross clamp was significantly lower in endoscopic mitral patients (P <0.001), and this attributed to the present of patients group who were operated on beating heart. Endoscopic mitral surgery was associated with shorter ventilation time (P<0.001) shorter hospitalisation (P<0.001), and post operative arrhythmia (P<0.001). There were no significant differences in rate of other major postoperative complications or mortality rate (P =0.65). CONCLUSIONS:Endoscopic approach in mitral valve surgery in elderly patients group associated with less post operative arrhythmia, shorter ventilation time, shorter hospitalization, and less post operative arrhythmia with no increased risk in other major post operative morbidity and mortality. Table (1): Patients’ characteristics
| Variables | Unmatched | matched | |||||
| Sternotomy(n=440) | Minimal invasive (n=207) | P value | sternotomy (n=105) | Minimal invasive (n=105) | P value | ||
| Age | 76.3 +/- 4.5 | 76.5 +/- 4.6 | P=0.3 | 75.9 +/-4.4 | 76.1+/- 4.6 | P=0.37 | |
| Gender (Female) | 254 (57.7%) | 103(49.8%) | P=0.047 | 56 (53.3%) | 48 (45.7%) | P=0.27 | |
| BMI | 26.6+/- 7.7 | 25.8+/-4.9 | P=0.05 | 25.3 +/- 4.1 | 25.6 +/- 4 | P=0.29 | |
| CCS grade III/IV | 29 (6.6%) | 0 (0%) | P<0.001 | 0 (0%) | 0 (0%) | P=1 | |
| NYHA grad III/IV | 272 (61.8%) | 0 (0%) | P<0.001 | 6 (5.7%) | 0(0%) | P=0.014 | |
| HTN | 283 (64.3%) | 133 (64.3%) | P=0.98 | 68 (64.8%) | 68 (64.8%) | P=1 | |
| CVA | 22 (5%) | 11 (5.3%) | P=0.39 | 4 (3.8%) | 5 (4.8%) | P=0.69 | |
| COPD | 53 (12%) | 26 (12.6%) | P=0.85 | 11 (10.5%) | 14 (13.3%) | P=0.52 | |
| Hx of MI | 36 (8.2%) | 26 (12.6%) | P=0.078 | 7 (6.7%) | 14 (13.3%) | P=0.1 | |
| Prior cardiac surgery | 46 (10.5%) | 36 (17.4%) | P=0.013 | 11 (10.5%) | 20 (19%) | P=0.08 | |
| Renal function/dialysis | 13 (3%) | 4 (1.9%) | P=0.44 | 1 (1%) | 2 (1.9%) | P=0.56 | |
| Extracardiac arteriopathy | 27 (6.1%) | 12 (5.8%) | P=0.86 | 8 (7.6%) | 6 (5.7%) | P=0.58 | |
| Pre op AF | 239 (69.5%) | 105 (50.7%) | P=0.39 | 54 (51.4%) | 49 (46.7%) | P=0.52 | |
| Urgent surgery | 65 (14.8%) | 13 (6.3%) | P=0.002 | 9 (8.6%) | 7 (6.7%) | P=0.6 | |
| Diabetes | 56 (12.37%) | 19 (9.2%) | P=0.18 | 12 (11.5%) | 11 (10.5%) | P=0.825 | |
| Poor LVEF (EF<30%r) | 22 (5%) | 0 (0%) | P=0.003 | 0 (0%) | 0 (0%) | P=1 | |
| Logistic EuroScore | 13.4 +/- 12.6 | 10.5+/-10. | P<0.001 | 10.47 +/-9.6 | 11.9 +/- 10.2 | P=0.14 | |
Table (2): Operative and post-operative characteristics
| Variables | Sternotomy(n=105) | Minimal invasive (n=105) | P value |
| CPB time | 160.37 +/-58.9 | 162.7 +/- 39.6 | P=0.36 |
| Cross clamp time | 114.5 +/- 42.9 | 86.23 +/- 49 | P<0.001 |
| Mitral valve repair | 67 (63.8%) | 75 (71.4%) | P=0.23 |
| AF ablation | 25 (23.8%) | 25 (23.8%) | P=1 |
| Intubation >12 hours | 52 (49.5%) | 15 (14.3%) | P<0.001 |
| ICU LoS | 2.65 +/- 9.3 | 1.45 +/- 2.8 | P=0.1 |
| LoS post op | 15.3 +/- 16.3 | 8.7 +/- 8.3 | P<0.001 |
| GI complications | 5 (4.8%) | 1 (1%) | P=0.09 |
| Respiratory complications | 14 (13.3%) | 10 (9.5%) | P=0.38 |
| Neurological complications | 6 (5.7%) | 4 (3.8%) | P=0.51 |
| MI | 0 (0%) | 0 (0%) | P=1 |
| Arrhythmias | 37 (35.3%) | 14 (13.3%) | P<0.001 |
| Renal failure (new dialysis) | 3 (2.9%) | 1 (1%) | P=0.31 |
| Return to theatre | 9 (8.6%) | 3 (2.9%) | P=0.12 |
| mortality | 3 (2.9%) | 2 (1.9%) | P=0.65 |
| Discharge distention (convalescence/ other acute care) | 10 (9.5%) | 4 (3.8%) | P=0.09 |
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