The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 4 , Pages 926-932.e2, April 2010

Minimally invasive versus conventional mitral valve surgery: A propensity-matched comparison

  • Lars G. Svensson, MD, PhD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • Corresponding Author InformationAddress for reprints: Lars G. Svensson, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave/Mail Stop J4-1, Cleveland, OH 44195.
    • ,
  • Fernando A. Atik, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • Delos M. Cosgrove, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • Eugene H. Blackstone, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
    • ,
  • Jeevanantham Rajeswaran, MSc

      Affiliations

    • Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
    • ,
  • Gita Krishnaswamy, MS

      Affiliations

    • Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
    • ,
  • Ung Jin, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • A. Marc Gillinov, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • Brian Griffin, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • José L. Navia, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • Tomislav Mihaljevic, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
    • ,
  • Bruce W. Lytle, MD

      Affiliations

    • Center for Aortic Surgery and Marfan and Connective Tissue Disorder Clinic, the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio

Received 3 December 2008; received in revised form 15 July 2009; accepted 17 September 2009. published online 30 November 2009.

Objective

Less invasive approaches to mitral valve surgery are increasingly used for improved cosmesis; however, few studies have investigated their effect on outcome. We sought to compare these minimally invasive approaches fairly with conventional full sternotomy by using propensity-matching methods.

Methods

From January 1995 to January 2004, 2124 patients underwent isolated mitral valve surgery through a minimally invasive approach, and 1047 underwent isolated mitral valve surgery through a conventional sternotomy. Because there were important differences in patient characteristics, a propensity score based on 42 factors was used to obtain 590 well-matched patient pairs (56% of cases).

Results

In-hospital mortality was similar for propensity-matched patients: 0.17% (1/590) for those undergoing minimally invasive surgery and 0.85% (5/590) for those undergoing conventional surgery (P = .2). Occurrences of stroke (P = .8), renal failure (P > .9), myocardial infarction (P = .7), and infection (P = .8) were also similar. However, 24-hour mediastinal drainage was less after minimally invasive surgery (median, 250 vs 350 mL; P < .0001), and fewer patients received transfusions (30% vs 37%, P = .01). More patients undergoing minimally invasive surgery were extubated in the operating room (18% vs 5.7%, P < .0001), and postoperative forced expiratory volume in 1 second was higher. Early after operation, pain scores were lower (P < .0001) after minimally invasive surgery.

Conclusion

Within that portion of the spectrum of mitral valve surgery in which propensity matching was possible, minimally invasive mitral valve surgery had cosmetic, blood product use, respiratory, and pain advantages over conventional surgery, and no apparent detriments. Mortality and morbidity for robotic and percutaneous procedures should be compared with these minimally invasive outcomes.

Abbreviations and Acronyms: CL, asymmetric 68% confidence limits, FEV1, forced expiratory volume in 1 second, MR, mitral regurgitation

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 Supported in part by the Kenneth Gee and Paula Shaw, PhD, Chair in Heart Research (held by Dr Blackstone); the Judith Dion Pyle Chair in Heart Valve Research (held by Dr Gillinov); and the John and Rosemary Brown Endowed Chair in Cardiovascular Medicine (held by Dr Griffin).

 Disclosures: Dr Gillinov is a consultant to Edwards Lifesciences and receives honoraria for speaking from St Jude Medical, Inc. He has an equity interest in Viacor, Inc.

PII: S0022-5223(09)01265-3

doi:10.1016/j.jtcvs.2009.09.038

The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 4 , Pages 926-932.e2, April 2010

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