The Impact of Era and Technical Innovation on Outcome and Operative Times in Minimally Invasive Mitral Surgery

Background: Minimally invasive mitral valve surgery (MIMVS) has evolved over the last two decades. Clinical results have been improved over time due to increased experience and technical developments. Crucial developments include remote access perfusion, optimization of cardioplegia, 3D endoscopy and chordal replacement techniques. The aim of the study was to identify the impact of era and technical improvements on perioperative outcome after MIMVS.

Method: Consecutive patients N = 1,000 (mean age: 60.8 ± 12.7 years, 60.3% male) underwent MIMVS or endoscopic mitral valve surgery between 2001 and 2020 in a single institution. The patients were allocated to four groups according to the case number quartiles. Three technical interventions were introduced during the observed period of 19 years:

(1) Fully endoscopic technique through 3D visualization.

(2) The adoption of pre-measured loops of neochordae for prolapse correction.

(3) The implementation of a preoperative CT scan to exclude unsuitable candidates for MIMVS.

Comparisons were made between the four quartiles and before and after the introduction of technical improvements by chi-square test and one-way ANOVA.

Results: A total of 741 patients underwent isolated first mitral valve procedure, whereas 259 received concomitant procedures. These consisted of tricuspid valve repair (208), LA-ablation (145) and PFO or ASD closure (172). The etiology was degenerative in 738 (73.8%) patients and functional in 101 patients (10.1%). A total of 701 patients received MV repair (95%), whereas 37 patients (5%) underwent MV replacement. Perioperative survival was 99.1%, periprocedural success 93.5% with a periprocedural safety of 96.3%. Significant improvement in periprocedural safety within the different eras mainly attributed to the lower need for ECMO support (p = 0.036) and less reoperations for bleeding (p = 0.007). There was no influence of the era according to the different quartiles (Q1–4) on periprocedural success (p = 0.590). 3D visualization improved periprocedural success but not on safety and X-clamp but not CPB times. The use of loops and preoperative CT scan both had no impact on periprocedural success or safety, but improved CPB and X-clamp times.

Conclusion: Increased surgical experience improves safety in MIMVS. Technical improvements are related to increased operative success and decreased operative times in patients undergoing MIMVS.

Publication History

Article published online:
03 February 2022