Minimally Invasive Mitral Valve Repair: Indications and Approach

Transcription

1 Minimally Invasive Mitral Valve Repair: Indications and Approach Juan P. Umaña, M.D. Chief Medical Officer Director, Cardiovascular Medicine FCI - Institute of Cardiology Bogota Colombia 1

2 Mitral Valve Repair The Gold Standard STS/EACTS Latin America Cardiovascular Surgery Conference

3 Early Mitral Valve Repair Clear Benefit Survival Benefit Risk of CHF Suri RM et al, Association Between Early Surgical Intervention vs Watchful Waiting and Outcomes for Mitral Regurgitation Due to Flail Mitral Valve Leaflets. JAMA 2013; 310(6):609 3

4 Mitral Valve Procedures Trends Adult Cardiac Surgery Database. Executive Summary 10 years. STS Period ending 3/31/ /30/2017 Executive Summariy contents 4

5 Isolated MV repair (n=28,140) operative mortality was 1.2%. For asymptomatic patients, operative mortality was 0.6%. Gammie JS et al, Ann Thorac Surg 2009;87:1431 5

6 World Trends in MIVS Aortic CAGR: 16%* Mitral CAGR: 17% 6

7 Trends in MIVS Society of Thoracic Surgeons Database Gamie et al, Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database Ann Thorac Surg 2010;90:

8 Minimally Invasive Valve Surgery Benefits to the Patient Less pain Shorter hospital stay Lower blood loss Faster recovery and return to normal activity Greater satisfaction 8

9 Minimally Invasive Valve Surgery Benefits to the Surgeon Excellent visualization of structures Clear sterile field perception More direct access to the mitral valve 9

10 Initial Concerns Less-Invasive Mitral Valve Operations: Trends and Outcomes from the STS Adult Cardiac Surgery Database Equivalent mortality Longer CPB and cross-clamp times Higher repair rates in MIS group Lower blood transfusions Significantly higher stroke rate Gammie, et al, Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database Ann Thorac Surg 2010;90:

11 Minimally Invasive vs. Conventional Mitral Valve Surgery: A Meta-Analysis and Systematic Review Similar mortality between MIVS and conventional MIVS has higher incidence of: Aortic Dissection, CVA & Phrenic paralysis MIVS is superior in: POP AF Mediastinal drainage Patient s satisfaction and pain Cheng DC. Innovations

12 Mitral Valve Surgery Right Lateral Minithoracotomy or Sternotomy? Sünderman et al Neurologic Events 30-day mortality equivalent for MIS and CS Lower blood loss Longer CPB and clamp times No Difference Higher incidence of vascular complications Sunderman SH, Sromicki J, Rodriguez H, Seifert B, Holubec T, Falk V, Jacobs S. Mitral valve surgery:right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg

13 What Is the Role of Minimally Invasive Mitral Valve Surgery in High-Risk Patients? A Meta-Analysis of Observational Studies Comparable early mortality Lower transfusion requirement Less atrial fibrillation Lower stroke rate Moscarelli et al. What Is the Role of Minimally Invasive Mitral Valve Surgery in High-Risk Patients? A Meta-Analysis of Observational Studies. Ann Thorac Surg 2016;101:981 9) 14

14 Right Minithoracotomy vs Full Sternotomy for Mitral Valve Repair: A Propensity Matched Comparison Lange et al. Right Minithoracotomy Versus Full Sternotomy for Mitral Valve Repair: A Propensity Matched Comparison Ann Thorac Surg 2017;103:

15 Minimally Invasive vs Conventional Mitral Valve Repair 2010 Gammie Significantly Higher Stroke Rate 2011 Cheng Ao. Diss and Stroke Risk 2013 Cao No difference 2014 Sünderman No difference in neurologic events More vascular complications 2017 Lange Similar functional outcome and QOL variables 16

16 The Challenge AVOID TRANSFERRING THE LEARNING CURVE TO THE PATIENT Minimize neurologic complications Avoid vascular complications 17

17 Minimally Invasive Mitral Valve Repair Learning Curves Average Surgeon Surgeries to overcome Learning Curve >50 Surgeries/Year to mantain competence Overperforming Surgeon MIVS Team Underperforming Surgeon David M. Holzhey et al. Circulation. 2013;128:

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19 The Question Are these results reproducible in smaller centers? What about LatAm? What are the indications/contraindications How to do it? 20

20 FCI - Institute of Cardiology Patients & Methods Historical cohort of patients undergoing mitral valve repair between January 2004 and June 2017 Prospective harvest from July 2008 Inclusion criteria: First-time isolated mitral valve repair Conventional or minimally invasive Dedicated Team Exclusion criteria History of preoperative arrhythmias Previous surgery 21

21 Sampling Algorithm Mitral Procedures n= 1602 Replacement N=980 Repair N= 622 Dedicated Team N= CONVENTIONAL N= 282 VA MIVR N= 64 Exclusion Criteria Previous surgery and arrhythmias CONVENTIONAL N= 142 VA MIVR N= 58 22

22 Results Preoperative Variables Variables Conventional Minimally invasive n =142 n =58 p value Body mass index Median (IQR) 25.9 (23,6-19.4) 24.5 ( Ejection fraction Median (IQR) 55 (46-60) 60 (55-61) Renal Impairment n (%) 75 (45.3) 435 (60.3) NYHA > II n (%) 104 (78.8) 52 (91.2) Pulmonary hypertension n (%) 60 (42.5) 14 (26.4) Elective; n (%) 86 (60.5) 45 (77.6)

23 Preoperative Euroscore II 3.5 (IQR ) 0.9 (IQR ) 24

24 Variables Affecting Euroscore II Variables Conventional Minimally invasive p value n =142 n =58 Renal Impairment n (%) 75 (45.3) 435 (60.3) NYHA > II n (%) 104 (78.8) 52 (91.2) Pulmonary hypertension n (%) 60 (42.5) 14 (26.4) Elective; n (%) 86 (60.5) 45 (77.6)

25 Mitral Valve Procedures - Trends Replacement Repair %

26 Mitral Valve Repair Trends in Degenerative MR 27

27 Intraoperative Results Minutes Median (IQR) 105 (90-106) 83 (69-100) 132 ( ) 99 (88-117) 28

28 Learning Curve CBP Time VA-MIVR CONVENTIONAL Linear (VA-MIVR) 29

29 Learning Curve Aortic Cross-Clamp Time VA-MIVR CONVENTIONAL Linear (VA-MIVR) 30

30 Primary Outcomes Variables Conventional Minimally invasive p value n =142 n =58 Bleeding requiring reoperation n (%) 9 (6.3) 1 (1.7) Deep wound infection n (%) 3 (2.1) Stroke n (%) 2 (1.4) 2 (3.4) Mortality (%) Postoperative AF n (%) 45 (31.7) 2 (3.4) <

31 Secondary Outcomes VARIABLES CONVENTIONAL VA-MIVR P VALUE Differences between groups ICU stay (hours); Median (IQR) 24 (24-72) 24 (21-24) Transfusion; n (%) 35 (38.5) 1 (1.9) Hospital stay (days); Median (IQR) 6.5 (5-12) 5 (4-8)

32 Freedom from Cardiac Death 33

33 Freedom from Reoperation 35

34 Conclusions MIVS should be performed by surgeons who have already mastered conventional repair techniques Heart Team Approach Flattens Learning Curve Outcomes are progressively improving Already better than conventional surgery? Indications are the same as for conventional MV repair Establish Heart Valve Centers of Excellence to Increase Case Volume 36

35 Thank You 37