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Early and Late Outcomes in Minimally Invasive Mitral Valve Repair: An Eleven Year Experience in 707 Patients
R. S. McClure, L. H. Cohn*, G. S. Couper, S. F. Aranki, R. M. Bolman, F. Y. Chen, M. J. Davidson. Brigham and Women's Hospital, Boston, MA,
Background: The purpose of this study was to analyze a single institutions experience with minimally invasive mitral valve repair (MVP) and to validate the quality of long-term surgical outcomes, assessing morbidity, mortality and reoperation rates, in addition to long-term echocardiographic follow-up.
Methods: Between August 1996 and October 2007, minimally invasive mitral valve repair was performed in 713 patients (68.2 months mean follow-up). Excluding 6 robotically assisted repairs, an ambidirectional analysis of the remaining 707 patients was carried forth. Mean age was 57±13 years (range 17 to 89). Mean preoperative ejection fraction was 58% ± 11. Surgical access through a lower ministernotomy was used in 524 patients (74%), right parasternal in 168 patients (23.8%), right thoracotomy in 10 patients (1.4%) and upper ministernotomy in 5 patients (0.7%). Mitral valve exposure was left atrial in 58% of cases and transeptal in 42%. Arterial cannulation was accomplished by direct aortic or femoral access in 82% and 18% of the cases respectively. A ring annuloplasty was incorporated into 633 (90%) of the reparative procedures. Concomitant use of various other reparative techniques in combination, largely posterior leaflet resection with leaflet advancement (550 patients; 78%), commisuroplasty (123 patients; 17%) and edge-to-edge Alfieri stitch (70 patients; 10%) were employed. Survival estimates and time-related MVP failure analyses were performed using Kaplan-Meier methods.
Results: There were 3 operative deaths (0.4%). Perioperative morbidity included new onset atrial fibrillation (20%), reoperation for bleeding (2%), stroke (1.9%), permanent pacemaker implantation (1.7%), deep sternal wound infection (1%) and aortic dissection (0.4%). Median length of hospital stay was 5 days. Only 31% of patients required homologous blood transfusion. There were 47 late deaths (6.6%) with a probability of survival at 11.21 years of 84.1% (95%CI; 77.5%,88.9%). There were 30 failed repairs requiring reoperation (4.2%); freedom from reoperation at 11.21 years was 94.1% (95%CI; 91.4%,96.0%). Lost to follow-up was 1.3%. Thus far, mean long-term echocardiographic follow up is 48.3 months (range 5.6 to 129.53) with results on 336 patients. Mean grade of mitral regurgitation is 1.5 ± 1.0 in this subset.
Conclusion: In addition to reaffirming that minimally invasive MVP can be performed safely with low perioperative morbidity, this study demonstrates that long-term outcomes of mortality and reoperation rates for minimally invasive MVP are similar or better than that of conventional operations.  
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