Right Minithoracotomy Versus Full Sternotomy for Mitral Valve Repair: A?Propensity Matched Comparison

摘要

Background Mitral valve (MV) repair through a right minithoracotomy (RT) is technically more demanding than through a median sternotomy (MS) and has been cited for a higher rate of reoperation, increased postoperative bleeding, thromboembolic events, poor visualization, and longer operative times. Randomized studies are not available, however, and specific characteristics of patients who undergo operation with either technique are usually highly different. Therefore, a propensity matching study was performed to reduce selection bias.;Methods A retrospective analysis was made of 745 patients, 501 in group RT (67%) and 244 in group MS (33%), who underwent isolated MV repair between 2000 and 2010. Propensity matching identified 97 matched patient pairs for comparison of functional outcome, survival, incidence of reoperation, and quality of life after MV repair.;Results Propensity matched patients in group RT had longer cardiopulmonary bypass time (120 ± 28 versus 99 ± 30 minutes, p < 0.001) and cross-clamp time (86 ± 23.5 versus 74 ± 25 minutes, p < 0.001). Thirty-day mortality was similar for both groups (RT, 0%; MS, 1%; p?= 0.13). There were no significant differences in other outcomes such as amount of red blood cell transfusion, ventilation time, and hospital stay. Five-year survival in group RT (93.5% ± 3.7%) versus group MS (87.4% ± 3.6%, p?= 0.556) and freedom from MV reoperation (93.3% ± 2.9% versus 97.9% ± 1.5%, respectively; p?= 0.157) were not different. Functional outcome and quality of life variables were similar.;Conclusions Mitral valve surgery through a right minithoracotomy is a safe procedure associated with a very low operative mortality comparable to the standard sternotomy approach. In addition to improved cosmetics, minimally invasive MV surgery provides equally durable results as the standard sternotomy approach.;;Drs Lange and Voss disclose a financial relationship with Medtronic Inc.;The Research Ethics Committee of the Technical University, Munich School of Medicine, approved the study protocol (number 2624/09). Between January 2000 and October 2010, 1,490 patients with isolated MV regurgitation underwent MV repair at our institution. In all, 745 consecutive patients (68.5% men; average age at operation 58 ± 13 years; range, 17 to 86.5; median 64.6) who underwent isolated MV repair entered the study. Patients with concomitant coronary artery bypass graft surgery, aortic or tricuspid valve procedures, and surgical ablation of atrial fibrillation were excluded from the study. All operations were performed by four senior surgeons experienced in MV repair and minimally invasive surgery. The severity of mitral regurgitation was classified as none/trivial (0), mild (1), moderate (2), and severe (3). Patient characteristics are summarized in Table?1Table?1.Table?1Characteristics of Unmatched and Propensity Matched PatientsCharacteristicsUnmatched Patients (n?= 745)Matched Patients (n?= 194)Group RT(n?= 501)Group MS(n?= 244)p ValueGroup RT(n?= 97)Group MS(n?= 97)p ValueAge, years55 ± 1264 ± 15<0.00163 ± 1263 ± 100.892Male361 (72)149 (61)0.00257 (59)61 (63)0.556No sinus rhythm71 (14)70 (29)<0.00129 (30)23 (24)0.331LVEF, %64 ± 1060 ± 12<0.00163 ± 1162 ± 110.812Previous MI4 (0.8)7 (2.9)0.0271 (1.0)1 (1.0)0.984Previous cardiac operation2 (0.4)16 (6.6)<0.0010 (0)0 (0)Urgent/emergent operation14 (2.8)27 (11)<0.0013 (3.1)4 (4.1)0.791Postoperative IABP1 (0.2)4 (1.6)0.0110 (0)2 (2.1)0.123 View Table in HTML Values are mean ± SD or n (%).IABP?= intraaortic balloon pump; LVEF?= left ventricular ejection fraction; MI?= myocardial infarction; MS?= median sternotomy; RT?= right minithoracotomy.;Statistical analysis was performed with the IBM SPSS Statistics, version 22 (IBM Corporation, Armonk, NY). Continuous variables are reported as mean ± SD, and categoric variables are reported as actual and relative frequencies. The χ2 test (for categoric variables) and the Mann-Whitney U te