Comparative study of total thoracoscopic mitral valve surgery and traditional open mitral valve surgery :propensity score matching study
Main Article Content
Abstract
Background: Conventional median open mitral valve replacement surgery usually requires a 20-30cm size incision to ensure adequate visual exposure. So, while we complete the valve replacement, it also brings about a series of problems. The appearance of TV thoracoscope changes the exposure of the surgical field. Because the microscopic field is enlarged, it not only makes the surgical vision clearer, but also greatly shortens the incision, reduces bleeding, and conceals the incision, minimizing the trauma and shortening the postoperative recovery time, which is in line with the concept of modern health.
Aim: All technological innovation is controversial in the early stage, and it is such debate that can promote the progress and development of technology.This study was conducted in the context of this debate to summarize the experience of Total thoracoscopic mitral valve surgery in our center.Total thoracoscopic mitral valve replacement surgery and traditional median incision mitral valve replacement surgery were compared by the propensity score matching method.Evaluate its safety and merits.
Methods: From January 2018 to December 2020, a total of 139 patients in the thoracoscopic group were eligible in the cardiothoracic surgery department of our hospital, and 1066 cases of traditional median sternotomy mitral valve replacement. After propensity score matching, 125 patients were selected in the thoracoscopic group, among 1066 patients with median incision MVR, 1:1 matched to 125, as the control group in the thoracoscopic group.
Results: The results showed that the mean operative time in the thoracoscopic MVR group was significantly longer than that in the control group (185.73 ± 43.04 vs. 164.58 ± 40.28, p=0.0016). Similarly, both the mean CPB time and aortic block time were significantly longer than those in the control group (108.37±30.57min vs. 79.18±17.65min, p <0.0001; 66.59±29.63min vs. 45.09±19.68min, p <0.0001. Moreover, the proportion of patients with CPB greater than 120min and aortic block greater than 90min was significantly higher than the control group (24.1% vs. 3.2%, p <0.0001,14.4% vs. 2.4%, p=0.0237). In addition, there was no significant difference in the mean ICU observation time between the two groups (49.35±34.51h vs. 48.72±25.89h, p=0. 8792). Differently, the mean endotracheal intubation time was significantly lower in the thoracoscopic MVR group compared to the control group (18.52±6.07h vs. 25.45±14.18h, p=0.0032). Similarly, the length of stay in the thoracoscopic group was 9.13 ± 4.58 days, which was significantly lower than 11.12 ± 5.76 days in the control group (p=0.0004).
There was no significant difference in the postoperative hemoglobin concentration or platelet count between the two groups of MVR patients. Mean intraoperative bleeding volume in the thoracoscopic MVR group was significantly less than that in the control group (158.37±100.91ml vs.250.74 ± 81.34, P <0.0001). Similarly, the mean postoperative discharge in the thoracoscopic MVR group was significantly than in the control group (428.39±361.38ml vs. 514.07 ± 347.92ml, p=0.0383). For patients with postoperative blood products, there were 37 (29.6%) in the thoracoscopic group and 33 (26.4%) in the control group. There was no significant difference between the two groups. Similarly, there was no significant difference in the mean total hospital costs between the two groups.
Conclusion: This study shows that it has feasibility and safety for total thoracoscopic mitral valve replacement for mitral valve lesions, which can reduce the time and stay of the hospital compared with conventional direct surgery, and obtain good minimally invasive and cosmetic effect, and lay a theoretical and clinical foundation for the application of thoracoscopic technology in cardiac surgery, which has important scientific significance.
Downloads
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Yu SQ，Wang G，Cai ZJ，Cheng YG,Kang YF,Xu XZ,Shao JF,Wang HS.Video-assisted thoracoscopic management of Ebstein's anomaly[J].J Fourth Mil Med Univ,2002, 23 (1), 86.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, 3rd, Thomas JD. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [J]. J Am Coll Cardiol, 2014,63(22)/57-185.
Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study[J]. Lancet, 2006,368(9540): 1005-1011.
Carabello BA, Nakano K, Corin W, Biederman R, Spann JF, Jr. Left ventricular function in experimental volume overload hypertrophy[J]. Am J Physiol, 1989,256(4 Pt 2): H974-981.
Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V,Scott C, Schaff HV,Tajik AJ. Quantitative determinants of the outcome of asymptomatic mitral regurgitation[J]. N Engl J Med, 2005,352(9): 875-883.
Savage EB, Ferguson TB, Jr., DiSesa VJ. Use of mitral valve repair: analysis of contemporary United States experience reported to the Society of Thoracic Surgeons National Cardiac Database[J]. Ann Thorac Surg, 2003,75(3): 820-825.
Enriquez-Sarano M, Sundt TM, 3rd. Early surgery is recommended for mitral regurgitation[J]. Circulation, 2010,121(6): 804-811; discussion 812.
Lillehei CW, Gott VL, Dewall RA, Varco RL. The surgical treatment of stenotic or regurgitant lesions of the mitral and aortic valves by direct vision utilizing a pump- oxygenator[J]. J Thorac Surg, 1958,35(2): 154-191.
Effler DB, Groves LK, Martinez WV, Kolff WJ.Open-heart surgery for mitral insufficiency [J]. J Thorac Surg, 1958,36(5): 665-676.
Xia Q,Li W,Dai GM,Zeng CH,Tang XF,Lai QL.Anesthesia experience of thoracoscopic extracorporeal circulation cardiac surgery[J].J CLIN ANESTH.2004, 20 (12), 722.
Falk V, Walher T, Autschbach R, et al. Robot-assisted minimally invasive solo mitral valve operation. J Thorac Cardiovasc Surg, 1998, 115(2)： 470-471.
Stevens JH, Burdon TA, Peters WS, et al 1. Port-asses coronary artery bypass grafting： aproposed surgical method[J]. J Thorac Cardiovasc Surg, 1996, 111： 567 -573.
Felger JE, Nifong LW, Chitwood WR, Jr. The evolution of and early experience with robot-assisted mitral valve surgery [J]. Surg Laparosc Endosc Percutan lech, 2002,12(1): 58-63.
Gilliov AM, Banbury MK, Cosgrove DM. Hemistemotomy approach for aortic and mitral valve surgery. Journal of Cardiac Surgery. 2000; 15(1):15-20.
Modi P, Hassan A, Chitwood WR., Jr. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. European Journal of Cardio-Thoracic Surgery, 2008; 34(5):943-952.
Seeburger J, Borger MA, Falk V, Kuntze T, Czesla M, Walther T, Doll N, Mohr FW. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. European Journal of Cardio-Thoracic Surgery, 2008; 34(4):760-765.
Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. Journal of the American College of Cardiology. 2010; 56(6): 455-462.
Felger JE, Chitwood WR, Jr., Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach. Annals of Thoracic Surgery. 2001; 72(4): 1203-1209.
Casselman FP, Van Slycke S, Wellens F, De Geest R, Degrieck I, Van Praet F, Venneulen Y, Vanennen H.Mitral valve surgery can now routinely be performed endoscopically.Circulation. 2003 Sep 9; 108 Suppl 1:1148-54.
Schroeyers P, Wellens F, De Geest R, Degrieck I, Van Praet F, Vermeulen Y, Vanermen H. Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience. Ann Thorac Surg. 2001 Sep; 72(3):S 1050-4.
Mohr FW, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, Jacobs S, Autschbach R.Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg, 2001 May; 121(5): 842-53.
Vanermen H, Farhat F, Wellens F, De Geest R, Degrieck I, Van Praet F, Venneulen Y. Minimally invasive video-assisted mitral valve surgery:from Port-Access towards a totally endoscopic procedure. J Card Surg. 2000 Jan-Feb;15(1):51-60.
Tsai FC, Lin PJ, Chang CH, Liu HP, Tan PP, Lin FC, Chiang CW.Video-assisted cardiac surgery. Preliminary experience in reoperative mitral valve su rgery. Chest. 1996 Dec; 110(6):1603-7.
Casselman FP, Van Slycke S, Wellens F, De Geest R, Degrieck I, Vermeulen Y, Van Praet F, Vanennen H.From classical sternotomy to truly endoscopic mitral valve surgery:a step by step procedure. Heart Lung Circ. 2003 12(3):172-7.
Murphy DA, Miller JS, Langford DA, Endoscopic robotic mitral valve surgery. Innovations (Phila). 2007 Mar; 2⑵:56-61.
Murphy D, Smith JM, Siwek L, Langford DA, Robinson JR, Reynolds B, Seshadri-Kreaden U, Engel AM. Multicenter mitral valve study:a lateral approach using the da vinci surgical system. Innovations (Phila). 2007 Mar; 2(2):56-61.
Modi P, Rodriguez E, Hargrove WC 3rd, Hassan A, Szeto WY, Chitwood WR Jr. Minimally invasive video-assisted mitral valve surgery:a 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg. 2009 Jun; 137(6):1481-7.
Carpentier A, Loulmet D, Aupdcle B, Kieffer JP, Toumay D, Guibourt P, Fiemeyer A, Meleard D, Richomme P, Cardon C.Computer assisted open heart surgery. First case operated on with success. C R Acad Sci III, 1998 May; 321(5):437-42.
Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF.Minimally invasive cardiac valve surgery improves patient satisfaction while redu cing costs of cardiac valvereplacement and repair.Ann Surg. 1997 Oct; 226(4):421-6; discussion 427-8.
Greelish JP, Cohn LH, Leacche M, Mitchell M, Karavas A, Fox J, Byme JG, Aranki SF, Couper GS.Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease. J Thorac Cardiovasc Surg. 2003 Aug; 126(2):365-71; discussion 371-3.
Wang D, Wang Q, Yang X, Wu Q, Li Q. Mitral valve replacement through a minimal right vertical infra-axillary thoracotomy versus standard median sternotomy. Annals of Thoracic Surgery.2009; 87(3):704-708.
Iribame A, Karpenko A, Russo MJ, Cheema FH, Umann T, Oz MC, Smith CR, Argenziano M. Eight-year experience with minimally invasive cardiothoracic surgery. World J Surg. 2010 Apr; 34(4):611-5.
Ma ZS, Yin QY, Dong MF, Feng ZY, Wang LX. Quality of life in patients undergoing totally thoracoscopic closure for atrial septal defect. Aim Thorac Surg. 2011;92:2230-4.
Ma ZS, Dong MF, Yin QY, Feng ZY, Wang LX.Totally thoracoscopic repair of atrial septal defect without robotic assistance: a single-center experience. J Thorac Cardiovasc Surg. 2011;141:1380-1383.
Ma ZS, Dong MF, Yin QY, Feng ZY, Wang LX. Totally thoracoscopic closure for atrial septal defect on perfused beating hearts. Eur J Cardiothorac Surg. 2012; 41:1316-1319.
Ma ZS, Dong MF, Yin QY, Feng ZY, Wang LX. Totally thoracoscopic repair of ventricular septal defect: a short-term clinical observation on safety and feasibility. J Thorac Cardiovasc Surg. 2011; 142:850-854.
Ma ZS, Wang JT, Dong MF, Chai SD, Wang LX. Thoracoscopic closure of ventricular septal defect in young children: technical challenges and solutions. Eur J Cardiothorac Surg. 2012; 42:976-979.
Mohr FW ,Falk V ,Diegeler A, Walther T, van Son JA, Autschbach R.Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg, 1998.115(3): 567-74; discussion 574-6.
Suri RM, Schaff HY Meyer SR, Hargrove WC. Thoracoscopic versus open mitral valve repair: a propensity score analysis of early outcomes. Ann Thorac Surg. 2009. 88(4): 1185-90.
Grossi EA, LaPietra A, Ribakove GH, et al. Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results. J Thorac Cardiovasc Surg. 2001.121(4): 708-13.
Svensson LG, Atik FA, Cosgrove DM, et al. Minimally invasive versus conventional mitral valve surgery: a propensity-matched comparison- J Thorac Cardiovasc Surg.2010.139(4): 926-32.e1-2.
Sündermann SH, Sromicki J, Rodriguez CBH, et al. Mitral valve surgery: right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2014.148(5): 1989-1995.e4.
Mihayevic T, Cohn LH, Unic D, Aranki SF, Coiner GS, Byrne JG. One thousand minimally invasive valve operations: early and late results[J]. Ann Surg, 2004,240(3): 529-534; discussion 534.
Sharony R ,Grossi EA, Saunders PC,Schwartz CF, Ribakove GH, Baumann FG, Galloway AC, Colvin SB. Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement[J]. J Heart Valve Dis, 2004,13(6): 887-893.
Kukull WA, Koepsell TD, Conrad DA, Immanuel V, Prodzinski J, Franz C. Rapid estimation of hospitalization charges from a brief medical record review. Evaluation of a multivariate prediction model[J]. Med Care, 1986,24(10): 961-966.
Ling LH, Enriquez-Sarano M, Seward JB, et al. Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. Circulation. 1997. 96(6): 1819-25.
Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW .Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation, 2013. 128(5): 483-91.
Dogon S, Dzemali O, Wimmer-Greinecker G, Derra P, Doss M, Khan MF,Aybek T, Kleine P, Moritz A. Minimally invasive versus conventional aortic valve replacement: a prospective randomized trial[J]. J Heart Valve Dis, 2003,12(1): 76-80.
Tutschka MP, Bainbridge D, Chu MW, Kiaii B, Jones PM. Unilateral postoperative pulmonary edema after minimally invasive cardiac surgical procedures: a case-control study[J]. Ann Thorac Surg, 2015,99(1): 115-122.
Keyl C, Staier K, Pingpoh C, Pache G, Thoma M, Gunkel L, Henschke S, Beyersdorf F. Unilateral pulmonary oedema after minimally invasive cardiac surgery via right anterolateral minithoracotomy[J]. Eur J Cardiothorac Surg, 2015,47(6): 1097-1102.