Elderly patients benefit from minimally invasive mitral valve surgery: perioperative risk management matters.

OBJECTIVES: The goal was to assess the single-centre results of minimally invasive mitral valve surgery (MIMVS) in the elderly population. METHODS: All patients referred for minimally invasive valve surgery underwent a standardized preoperative screening. We performed a retrospective analysis of 131 consecutive elderly patients (≥75 years) who underwent endoscopic MIMVS through a right mini-thoracotomy. Survival and postoperative course were assessed in 2 groups: a repair group and a replacement group. RESULTS: Eighty-five patients underwent mitral valve repair, and 46 had mitral valve replacement. The mean age was 79 ± 2.9 years, and the median follow-up duration was 3.8 years. The cardiopulmonary bypass time (128.7 min vs 155.9 min, P = 0.012) and the cross-clamp time (84.9 min vs 124.1 min, P = 0.005) were significantly longer in the replacement group. Except for more reinterventions for bleeding in the replacement group (10.9% vs 0%, P = 0.005), there were no significant differences in the postoperative course between the 2 groups. Low mortality rates at the midterm follow-up were observed in both groups, and no differences were observed between the 4-and the 12-month follow-up. Survival rates after 1 year and 5 years were 97.6% and 88.6%, respectively, with no significant differences between the 2 groups. CONCLUSIONS: MIMVS is an excellent treatment option in vulnerable elderly patients with excellent short- and long-term results. Although other studies suggest that repair could be superior to replacement even in older patients, our experience suggests that replacement is equivalent to repair in terms of mortality and major adverse cardiac and cerebrovascular events. Experience and standardized preoperative screening are mandatory to achieve optimal results.

At the Crossroads of Minimally Invasive Mitral Valve Surgery-Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology.

Almost 30 years after the first endoscopic mitral valve repair, Minimally Invasive Mitral Valve Surgery (MIMVS) has become the standard at many institutions due to optimal clinical results and fast recovery. The question that arises is can already good results be further improved by an Institutional Risk Management Performance (IRMP) system in decreasing risks in minimally invasive mitral valve surgery (MIMVS)? As of yet, there are no reports on IRMP and learning systems in the literature. (2) Methods: We described and appraised our five-year single institutional experience with MIMVS in isolated valve surgery included in the Netherlands Heart Registry (NHR) and investigated root causes of high-impact complications. (3) Results: The 120-day and 12-month mortality were 1.1% and 1.9%, respectively, compared to the average of 4.3% and 5.3% reported in the NHR. The regurgitation rate was 1.4% compared to 5.2% nationwide. The few high-impact complications appeared not to be preventable. (4) Discussion: In MIMVS, freedom from major and minor complications is a strong indicator of an effective IRMP but remains concealed from physicians and patients, despite its relevance to shared decision making. Innovation adds to the complexity of MIMVS and challenges surgical competence. An IRMP system may detect and control new risks earlier. (5) Conclusion: An IRMP system contributes to an effective reduction of risks, pain and discomfort; provides relevant input for shared decision making; and warrants the safe introduction of new technology. Crossroads conclusions: investment in machine learning and AI for an effective IRMP system is recommended and the roles for commanding and operating surgeons should be considered.

Prehabilitation to prevent complications after cardiac surgery - A retrospective study with propensity score analysis.

BACKGROUND: The rising prevalence of modifiable lifestyle-related risk factors (e.g. overweight and physical inactivity) suggests the need for effective and safe preoperative interventions to improve outcomes after cardiac surgery. This retrospective study explored potential short-term postoperative benefits and unintended consequences of a multidisciplinary prehabilitation program regarding in-hospital complications. METHODS: Data on patients who underwent elective cardiac surgery between January 2014 and April 2017 were analyzed retrospectively. Pearson's chi-squared tests were used to compare patients who followed prehabilitation (three times per week, at a minimum of three weeks) during the waiting period with patients who received no prehabilitation. Sensitivity analyses were performed using propensity-score matching, in which the propensity score was based on the baseline variables that affected the outcomes. RESULTS: Of 1201 patients referred for elective cardiac surgery, 880 patients met the inclusion criteria, of whom 91 followed prehabilitation (53.8% ≥ 65 years, 78.0% male, median Euroscore II 1.3, IQR, 0.9-2.7) and 789 received no prehabilitation (60.7% ≥ 65 years, 69.6% male, median Euroscore II 1.6, IQR, 1.0-2.8). The incidence of atrial fibrillation (AF) was significantly lower in the prehabilitation group compared to the unmatched and matched standard care group (resp. 14.3% vs. 23.8%, P = 0.040 and 14.3% vs. 25.3%, P = 0.030). For the other complications, no between-group differences were found. CONCLUSIONS: Prehabilitation might be beneficial to prevent postoperative AF. Patients participated safely in prehabilitation and were not at higher risk for postoperative complications. However, well-powered randomized controlled trials are needed to confirm and deepen these results.