Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications.

OBJECTIVE: This study reviews the 223 consecutive mitral valve operations for ischemic mitral insufficiency performed at New York University Medical Center between January 1976 and January 1996. The results for mitral valve reconstruction are compared with those for prosthetic mitral valve replacement. METHODS: From January 1976 to January 1996, 223 patients with ischemic mitral insufficiency underwent mitral valve reconstruction (n = 152) or prosthetic mitral valve replacement (n = 71). Coronary artery bypass grafting was performed in 89% of cases of mitral reconstruction and 80% of cases of prosthetic replacement. In the group undergoing reconstruction, 77% had valvuloplasty with a ring annuloplasty and 23% had valvuloplasty with suture annuloplasty. In the group undergoing prosthetic replacement, 82% of patients received bioprostheses and 18% received mechanical prostheses. RESULTS: Follow-up was 93% complete (median 14.6 mo, range 0-219 mo). Thirty-day mortality was 10% for mitral reconstruction and 20% for prosthetic replacement. The short-term mortality was higher among patients in New York Heart Association functional class IV than among those in classes I to III (odds ratio 5.75, confidence interval 1.25-26.5) and was reduced among patients with angina relative to those without angina (odds ratio 0.26, confidence interval 0.05-1.2). The 30-day death or complication rate was similarly elevated among patients in functional class IV (odds ratio 5.53; confidence interval 1.23-25.04). Patients with mitral valve reconstruction had lower short-term complication or death rates than did patients with prosthetic valve replacement (odds ratio 0.43, confidence interval 0.20-0.90). Eighty-two percent of patients with mitral valve reconstruction had no insufficiency or only trace insufficiency during the long-term follow-up period. Five-year complication-free survivals were 64% (confidence interval 54%-74%) for patients undergoing mitral valve reconstruction and 47% (confidence interval 33%-60%) for patients undergoing prosthetic valve replacement. Results of a series of statistical analyses suggest that outcome was linked primarily to preoperative New York Heart Association functional class. CONCLUSIONS: Initial mortalities were similar among patients undergoing prosthetic replacement and valve reconstruction. Poor outcome was primarily related to preexisting comorbidities. Patients undergoing valve reconstruction had fewer valve-related complications. Valve reconstruction resulted in excellent durability and freedom from complications. These findings suggest that mitral valve reconstruction should be considered for appropriate patients with ischemic mitral insufficiency.

Impact of minimally invasive valvular heart surgery: a case-control study.

BACKGROUND: The port access (PA) approach for valvular heart surgery is widely used, but few studies evaluating outcomes compared with the sternotomy approach have been performed. METHODS: One hundred nine consecutive patients undergoing PA-isolated valve surgery were compared with 88 matched patients who underwent sternotomy-isolated valve surgery before the institution of the PA program. Case matching was performed by age, surgeon, congestive heart failure, position of operated valve, and history of previous surgery. RESULTS: Analysis revealed that PA was associated with similar hospital mortality (p = 0.62), longer bypass times (p < 0.001), shorter length of stay (p = 0.02), fewer transfusions (p = 0.02), and fewer septic complications (p = 0.05). CONCLUSIONS: The PA approach for isolated valvular heart surgery provided patients with significantly improved clinical outcomes in their immediate perioperative course. Further studies are required to measure the impact of the PA approach on the patients' recovery after hospitalization.

Late results of mitral valve reconstruction in the elderly.

BACKGROUND: This study attempts to confirm favorable results with mitral valve reconstruction (MVP) in patients greater than or equal to 70 years of age and to examine complication rates by actual analysis. METHODS: Between June of 1980 and December of 1997, 278 patients 70 years of age or older (mean, 75.2 years; range, 70 to 87 years) underwent MVP for mitral regurgitation. Most involved insertion of an annuloplasty ring. Concomitant procedures were performed in 72.3%, and 55.0% required coronary revascularization. RESULTS: For isolated MVP, the in-hospital mortality rate was 6.5% and 17.0% when combined with coronary revascularization. The mortality rate when combined with another valve procedure was 13.2%. The 5-year freedom from late cardiac death was 100% in the isolated MVP group and 79.7% for MVP with a concomitant procedure (p = 0.006). Complications were analyzed using actual (cumulative incidence) analysis to eliminate the competing risk of noncardiac death. Mean NYHA class improved from 3.32 to 1.71 postoperatively. Repair failure was rare, with a 5-year freedom from reoperation of 91.2%. CONCLUSIONS: These findings confirm the favorable outcome of MVP in elderly patients. Late repair failures are rare; comorbid disease is an important predictor of outcome.

Comparison of post-operative pain, stress response, and quality of life in port access vs. standard sternotomy coronary bypass patients.

OBJECTIVE: Although it has been postulated that minimally invasive cardiac surgery using the port access method would reduce operative stress and postoperative pain and accelerate postoperative recovery to a good quality of life, few data are currently available to document this intuitively appealing claim. Therefore, this study was designed to examine differences in stress response, postoperative pain, rapidity of recovery, and quality of life after port access (PA) isolated coronary artery bypass surgery compared with standard sternotomy (STD) isolated coronary bypass surgery. METHODS: Fourteen PA and 15 STD coronary bypass patients were studied postoperatively for pain score, FEV, catecholamine and cortisol levels, resumption of activity, and Duke Activity Scale ratings. The surgical approach was based on the surgeon's preference. Although the PA patients were younger, there were no other differences between the groups in gender or preoperative risk factors. RESULTS: There were no operative deaths and no differences between the groups in perioperative complications. Repeated measures analysis of variance showed lower pain scale ratings over the first 4 postoperative weeks in the PA group (P < 0.001). The PA patients also had less muscle soreness, shortness of breath, fatigue, and poor appetite at 1, 2, 4, and 8 weeks (P < 0.05), better FEV at 1 day (1.59 vs. 0.97 l/s; P < 0.02) and 3 days (2.20 vs. 1.49 l/s; P < 0.03), and lower norepinephrine levels at days 1, 2, and 3 (P = 0.005). The Duke Activity Scale questionnaire results demonstrated that more PA patients were able to walk 1-2 blocks at 1 week, climb stairs at 1 and 2 weeks, perform light or moderate housework at 1 and 2 weeks, and engage in moderate recreational activities and perform heavy housework at 4 and 8 weeks (P < 0.05). CONCLUSIONS: These results show that compared with STD coronary bypass patients PA patients enjoyed significant postoperative physiologic and quality of life advantages with less pain, less early stress response, better pulmonary function, and superior Duke Activity scores during the first 2 postoperative months.

Choice of mitral prosthesis in the elderly. An analysis of actual outcome.

BACKGROUND: In younger patients requiring mitral valve replacement (MVR), mechanical prostheses (MPs) have been reported to give better freedom from all valve-related complications (VRCs) because of the high incidence of late valve degeneration (VD) associated with bioprostheses (BPs). In older patients, however, the risk of VD may be reduced because of the large competing risk of noncardiac death (NCD). Previous studies on VD in the elderly have used actuarial analysis, which overestimates the risk of VD in this population because it assumes that dead patients are still at risk. In contrast, cumulative incidence (actual) analysis acknowledges that patients who die have no risk of VD. This study compares the results of both "actual" and "actuarial" analyses of the freedom from VD in elderly patients undergoing MVR. METHODS AND RESULTS: From June 1976 through January 1996, 504 patients > or = 70 years of age underwent MVR at our institution. Isolated mitral operations were performed in 159 patients, and 169 had concomitant CABG. Hospital mortality was 59 of 374 (15.9%) for tissue prosthesis versus 24 of 130 (18.5%) for mechanical prosthesis (P = NS). For tissue versus mechanical prosthesis, 10-year freedom from noncardiac death was 75.0% versus 67.6% (P = NS); 10-year actuarial freedom from valve degeneration was 79.8% versus 93.4% (P = NS); 10-year actual freedom from valve degeneration was 92.6% versus 95.4% (P = NS); and 10-year actual freedom from all VRCs was 84.4% versus 92.3% (P = NS). CONCLUSIONS: In elderly patients undergoing MVR, actuarial analysis overestimates the 10-year risk of VD compared with actual analysis (20.2% versus 7.4% for BP, 6.6% versus 4.6% for MP). In these patients, the actual freedoms from VD and all VRCs do not differ significantly between BP and MP. Thus, in this age group, the necessity for anticoagulation or its avoidance may be the predominant factor in choosing a replacement mitral valve.

Port-Access coronary artery bypass grafting: technical considerations and results.

BACKGROUND: This study reviews the results of an initial experience with minimally invasive coronary bypass surgery using the Port-Access approach in terms of early outcome and safety. METHODS: Between October 1996 and July 1997 49 Port-Access minimally invasive coronary artery bypass grafting procedures were performed at our institution. The patients' mean age was 59.8 years (range 34 to 82 years). Sixteen patients received single vessel and 37 patients received multivessel bypass grafts. RESULTS: There were no operative deaths and no perioperative myocardial infarctions, neurological deficits, or conversions to sternotomy. Early complications included reoperation due to bleeding in 4 patients, reoperation for a pulmonary embolus in 1 patient, and angioplasty for occlusion of a right coronary artery graft in 2 patients. Postoperative angiograms were obtained in 86% (42/49) of the patients and showed 100% patency for left internal mammary artery to left anterior descending artery grafts and 96% patency for all grafts. CONCLUSIONS: These results demonstrate that Port-Access coronary artery bypass grafting using endovascular techniques for cardiopulmonary bypass and cardioplegic arrest can be performed safely with minimal morbidity and mortality. This technique allows multivessel revascularization on a protected, arrested heart with excellent anastomotic precision and reproducible early graft patency. Expanded use of Port-Access techniques is indicated in patients with multivessel coronary artery disease and the technique should be considered for patients with left anterior descending artery restenosis and patients with complex left anterior descending artery lesions where angioplasty results are suboptimal.

Port-Access mitral valve surgery: summary of results.

BACKGROUND: The purpose of this study was to review the short-term results of an initial experience with minimally invasive cardiac valve surgery using the Port-Access approach in terms of feasibility, safety, and reproducibility. METHODS: Between October 1995 and October 1997, 151 minimally invasive cardiac valve procedures were performed at our institution using the Port-Access approach. The patients' mean age was 58.1 years (range 21 to 91 years) and 50% were male. Aortic valve replacement was performed in 35 (23.2%) patients, mitral valve repair in 56 (37.1%) patients, mitral valve replacement in 36 (23.8%) patients, and complex valve procedures in 24 (15.9%) patients. RESULTS: The operative mortality rate for isolated mitral valve surgery was 1.1% (1/92) and for all mitral valve surgery 3.5% (4/113). The operative mortality rate for isolated aortic valve patients was 5.7% (2/35). For the total group the operating mortality was 4% (6/151). Early complications for mitral valve patients included reoperation for bleeding or tamponade in 5 (4.4%) patients, myocardial infarction in 2 (1.2%) patients, and transient ischemic attack and wound infection in 1 (0.1%) patient each. One patient required reoperation for mitral valve failure that resulted in aortic dissection unrelated to the Endoaortic Clamp catheter and ultimately led to death. Two (5.6%) aortic valve patients required reoperation for bleeding and two (5.6%) required reoperation for tamponade. CONCLUSIONS: Minimally invasive Port-Access techniques can be applied to most patients with valvular heart disease with minimal morbidity and mortality and good postoperative valve function and may be the preferred approach for isolated mitral and aortic valve surgery.