Minimally Invasive Mitral Valve Surgery Provides Excellent Outcomes Without Increased Cost: A Multi-Institutional Analysis

Abstract

Background Minimally invasive mitral valve surgery (mini-MVR) has grown in popularity. Although single centers have reported excellent outcomes, there is limited data on real world outcomes and costs of mini-MVR. Moreover, mini-MVR has been criticized as adding additional cost without clear benefit. We hypothesized that mini-MVR provides superior outcomes with incremental increased costs in a multi-institutional cohort. Methods Records for patients undergoing mitral valve surgery with or without atrial ablation from 2011-2014 were extracted from a multi-institutional, regional Society of Thoracic Surgeons database and stratified according to right chest approach/ minimally invasive or conventional sternotomy. Patients undergoing CABG or other concomitant procedures were excluded. Patients undergoing isolated mitral surgery were propensity matched based on factors including age, comorbidities, and preoperative laboratory values; clinical outcomes and cost differences were assessed by approach. Results A total of 1304 patients underwent mitral surgery, including 425 (32.6%) via minimally invasive approach. In the propensity-matched analysis (n=355 per group), mini-MVR patients had similar rates of mortality, stroke, and other complications compared to conventional MVR. Meanwhile, mini-MVR patients experienced shorter ICU and hospital lengths of stay, as well as fewer transfusions. Importantly, total hospital costs were no different between the two matched groups. Conclusions Compared to conventional sternotomy, mini-MVR in the “real world” demonstrated no differences in major morbidity, but was associated with shorter length of stay and fewer transfusions. Contrary to our hypothesis, mini-MVR can be performed with similar total hospital costs as conventional sternotomy. In summary, minimally invasive mitral surgery in select patients can provide superior outcomes without increased cost.

Predictors of Stroke After Minimally Invasive Mitral Valve Surgery Without the Cross-Clamp

“…16 We have used RAP in the vast majority (97%, n = 1210/1247) of our mini-MVS patients and have reserved antegrade perfusion to patients with either intraoperative transesophageal echocardiographic findings of grade IV or V arch/descending aortic atherosclerotic disease or severe iliofemoral atherosclerotic disease. Our study revealed that RAP was not an independent predictor of stroke/TIA, which is consistent with previously reported experiences by 2 STS database reports 1,4 and other single-center propensity-matched studies. 25,26 Furthermore, whereas other investigators have reported the impact of preoperative 3-dimensional multidetector computed tomography (MDCT) to assess aortoiliac atherosclerosis on the change in surgical approach for MV surgery, there were no reported associations between a reduction in stroke and such CT screening.…”

Early and long-term results of minimally invasive mitral valve surgery through a right mini-thoracotomy approach: a retrospective propensity-score matched analysis

“…However, some newer publications disprove these findings. Several studies showed no significant differences regarding the incidence of stroke in comparison to both surgical approaches ( Atluri et al, 2016 ; Downs et al, 2016 ; Goldstone et al, 2013 ). Modi et al reported a systemic meta-analysis of six studies, that showed similar stroke rates between mini-MVS and the conventional method ( Modi, Hassan & Chitwood, 2008 ).…”

“…Minimally invasive mitral valve procedures were introduced into clinical practice in the 1990s and represent a standard approach at specialized centers for mitral valve surgery (MVS). Various recent studies have demonstrated similar or superior outcomes after minimally invasive MVS compared with MVS through conventional median sternotomy (conv-MVS) ( Atluri et al, 2016 ; Downs et al, 2016 ; Galloway et al, 2009 ; Walther, Falk & Mohr, 2004 ). Despite longer cardiopulmonary bypass (CPB) and cross-clamp times in mini-MVS, this approach led to comparable rates for early mortality, long-term survival and freedom from redo surgery ( Atluri et al, 2016 ; Goldstone et al, 2013 ; Sundermann, Czerny & Falk, 2015 ).…”

The assessment of cost effectiveness and the effectiveness of cost assessment in cardiothoracic surgery

“…The authors 1 determined that minimally invasive MV surgeries performed with peripheral perfusion were cost-neutral to sternotomy, matching observations from other recent institutional and multi-institutional experiences. [2][3][4] Cost, price, and value; how do we reconcile these elements when evaluating the effectiveness of innovation in thoracic surgery? Value is net patient contribution (quality þ outcomes/cost) and cost-effectiveness attempts to balance the multitude of related factors when comparing alternate therapies.…”

“…8 Durable repair rates for degenerative MV disease and low surgical mortality and major morbidity rates must remain stable or improved as we innovate. As Hawkins et al 1 and others [2][3][4] have shown, adoption of minimally invasive approaches to MV repair or MV replacement is an example of innovation that can be performed with equal cost while maintaining and perhaps enhancing patient outcomes.…”