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Comparison of Minimally Invasive Approach with Conventional Sternotomy in Reoperative Mitral Valve Surgery After Previous Sternotomy
Ho Jin Kim, Joon Bum Kim, Sung-Ho Jung, Suk Jung Choo, Cheol Hyun Chung, Jae Won Lee.
Asan Medical Center, Seoul, Korea, Republic of.

Objectives
Redo cardiac surgery through median sternotomy poses a technical challenge to cardiac surgeons due to risks of damaging critical cardiac structures tightly adhering to the sternum. In performing redo mitral valve (MV) surgery, an approach via minimally invasive right mini-thoracotomy may be beneficial in minimizing such risks with enhanced visualization of MV. This study aims to evaluate the clinical impacts of minimally invasive (MI) approach on the ealry and long-term outcomes.
Methods
We retrieved consecutive 265 patients (aged 51.015.0 years, 165 females) undergoing redo MV surgery in our institution between 2002 and 2015 after excluding those undergoing concomitant aortic valve or coronary surgeries. Of these, sternotomy and MI approach was used in 148 and 117 patients, respectively. Clinical outcomes between the two groups were compared after adjusting with propensity scores.
Results
Early mortality occurred in 16 (10.8%) and 4 (3.4%) patients in the sternotomy and MI approach group, respectively. Concomitant procedures were as follows: tricuspid valve surgery in 116 (43.8%), maze procedure in 47 (17.7%) and atrial septal defect closure in 6 (2.2%) patients. On logistic regression analysis, patients with MI approach showed significantly lower risks of early mortality (P=0.03) and prolonged ventilation (>24 hours) (P=0.03). After adjustment, MI approach still tended to be associated with lowered risks of early mortality and morbidities, compared with those with sternotomy (Table). During a median follow-up of 56.2 months (interquartile range, 24.0-114.6 months), 57 (21.5%) patients died and overall mortality risks were comparable between the both groups (Table).
Conclusions
A minimally invasive approach can become a viable alternative to conventional sternotomy in performing redo MV surgery with comparable early and long-term clinical outcomes.
Table. Comparative outcomes of minimally invasive approach vs conventional sternotomy

OutcomesCrudeIPTW-Adjusted
OR/HR*95% CIP valueOR/HR*95% CIP value
Early Outcomes
Early mortality0.290.08-0.820.030.400.12-1.080.09
LCOS requiring MCS0.460.17-1.100.090.630.24-1.550.33
Early CVA0.410.15-1.040.080.500.18-1.270.16
Bleeding0.940.37-2.310.901.410.57-3.530.45
New-onset dialysis0.300.12-0.680.010.550.24-1.190.14
Pneumonia0.740.30-1.730.491.020.44-2.310.96
Prolonged ventilation (>24h)0.520.28-0.940.030.750.42-1.350.35
Long-term Outcomes
Overall mortality0.600.35-1.060.080.730.42-1.280.27

*Early outcomes are given as odds ratio; long-term outcomes are given as hazard ratio. OR, odds ratio; HR, hazard ratio; CI, confidence interval; IPTW, inverse-probability-of-treatment weighting; LCOS, low cardiac output syndrome; MCS, mechanical circulatory support; CVA, cerebrovascular accident


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