Original article
Adult cardiac
Less Invasive Mitral Surgery Versus Conventional Sternotomy Stratified by Mitral Pathology

Presented at the Fifty-sixth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 25-28, 2020.
https://doi.org/10.1016/j.athoracsur.2020.05.145Get rights and content

Background

Our objective was to compare national mitral repair rates and outcomes after less invasive mitral surgery (LIMS) vs conventional sternotomy across the spectrum of mitral pathologies and repair techniques.

Methods

Patients undergoing isolated primary mitral valve surgery in The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2014 to December 2018 were evaluated. Propensity score models were constructed nonparsimoniously, and prediction models used to compute adjusted effects of surgical approach. Hypothesis tests were adjusted for propensity score with inverse-probability weighting.

Results

A total of 41,082 patients met inclusion criteria; comprising 10,238 (24.9%) LIMS and 30,844 (75.1%) conventional sternotomy, with increased LIMS adoption annually. Surgeons reporting LIMS cases had higher annual median mitral case volumes than those who did not (23 vs 8, P < .001). Groups were well-balanced after propensity adjustment including mitral pathology. Propensity score-adjusted outcomes showed increased procedural volume (odds ratio 1.030 [95% confidence interval: 1.028-1.031]) and LIMS (odds ratio 2.139 [95% confidence interval 2.032-2.251]) were independently associated with higher mitral repair rates. Propensity-adjusted outcomes included reduced stroke (P < .001), atrial fibrillation (P < .001), pacemaker (P < .001), renal failure (P < .001), and length of stay (P < .001) for LIMS vs sternotomy, without differences in mortality. Operative volume influenced outcomes in both groups.

Conclusions

LIMS was associated with higher mitral repair rates, and lower morbidity. Further studies regarding the impact of surgeon volume on choice of operative approach are necessary.

Section snippets

Patient Population

Using the STS ACSD, we examined patients undergoing isolated primary mitral valve surgery via either limited (mini) thoracotomy, thoracoscopic- or port-assisted, or robotic-assisted approaches compared with those undergoing conventional sternotomy from 1 July 2014 to 31 December 2018. Partial sternotomy (eg, upper or lower hemisternotomy) was excluded from this analysis, as it is performed infrequently compared with other less invasive approaches for mitral surgery.14 Isolated mitral operations

Patient Population

From July 2014 to December 2018, 97,025 patients underwent mitral surgery. Of these, 55,943 were excluded based on criteria outlined above, yielding 41,082 patients undergoing primary isolated mitral valve surgery via either LIMS or sternotomy, included for propensity score-adjusted analysis (Figure 1). Annual total isolated primary mitral case volumes were relatively constant: 2014 (4331 [6 months]), 2015 (9343), 2016 (9234), 2017 (9768), and 2018 (8406). Patients were treated at 1054

Comment

Approximately 1 in 3 isolated mitral operations in North America is currently performed via a less invasive, sternal-sparing approach, generally in higher-volume settings, suggesting some degree of centralization at centers of excellence, as mitral valve operative volume has previously been correlated with improved outcomes.17,18

After propensity score adjustment, patients were well-balanced in terms of preoperative risk and mitral pathology. Overall, and specifically within both degenerative

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