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Background: Compared with conventional full sternotomy (FS) approaches, minimally invasive mitral valve surgery (MIMVS) offers improved cosmesis, decreased pain and bleeding, and faster recovery without compromising repair or survival rates. However, little is known about outcomes in patients with pulmonary hypertension (PH), an independent risk factor for morbidity and mortality., Methods: Retrospective review was performed between 2002 and 2019 for all adult patients undergoing isolated mitral valve surgery. Patients with PH (mean pulmonary artery pressure ≥25 mm Hg) were stratified by FS or MIMVS, and nearest-neighbor propensity score matching was performed to adjust for differences in baseline characteristics., Results: Overall, 591 operations (317 MIMVS, 274 FS) met inclusion criteria during the study period. Nearest-neighbor propensity matching generated 112 well-matched pairs. Cardiopulmonary bypass (137 vs 89.5 minutes, P < .001), cross-clamp (102 vs 63 minutes, P < .001), and total operative times (241 vs 178.5 minutes, P < .001) were longer for the MIMVS group. Postoperatively, MIMVS was associated with shorter initial ventilator times (6 vs 9.6 hours, P < .001) and hospital lengths of stay (7 vs 8 days, P = .049), as well as blood product usage rates (26.8% vs 41.1%, P = .03). Survival at 30 days (0.0% vs 2.7%, P = .12) and 10 years (log-rank, P = .661) were similar between groups., Conclusions: MIMVS is safe in patients with PH and provides traditional benefits of minimally invasive surgery, including shorter initial ventilator times and hospital length of stay, without compromising on long-term survival., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.

Objective: Mitral valve surgery is increasingly performed through minimally invasive approaches. There are limited data regarding the cost of minimally invasive mitral valve surgery. Moreover, there are no data on the specific costs associated with mitral valve surgery. We undertook this study to compare the costs (total and subcomponent) of minimally invasive mitral valve surgery relative to traditional sternotomy., Methods: All isolated mitral valve repairs performed in our health system from March 2012 through September 2013 were analyzed. To ensure like sets of patients, only those patients who underwent isolated mitral valve repairs with preoperative Society of Thoracic Surgeons scores of less than 4 were included in this study. A total of 159 patients were identified (sternotomy, 68; mini, 91). Total incurred direct cost was obtained from hospital financial records., Results: Analysis demonstrated no difference in total cost (operative and postoperative) of mitral valve repair between mini and sternotomy ($25,515 ± $7598 vs $26,049 ± $11,737; P = .74). Operative costs were higher for the mini cohort, whereas postoperative costs were significantly lower. Postoperative intensive care unit and total hospital stays were both significantly shorter for the mini cohort. There were no differences in postoperative complications or survival between groups., Conclusions: Minimally invasive mitral valve surgery can be performed with overall equivalent cost and shorter hospital stay relative to traditional sternotomy. There is greater operative cost associated with minimally invasive mitral valve surgery that is offset by shorter intensive care unit and hospital stays., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Minimally invasive, right thoracotomy (port access) approaches to intracardiac operations (mitral valve, tricuspid valve, atrial septal defect, intracardiac tumors) are becoming increasingly accepted by surgeons, cardiologists, and patients alike. Standard techniques for cardioplegic arrest of the heart have included endoaortic balloons and Chitwood clamps. Concerns have been raised regarding the potential increased risk of vascular adverse events (embolization, dissection, stroke, lower extremity ischemia) associated with endoaortic balloon occlusion. We undertook this study to evaluate the vascular risk associated with endoaortic balloon use., Methods: All patients undergoing minimally invasive, port access, right thoracotomy operations from 1998 to 2012 at our institution were retrospectively analyzed. Patients undergoing aortic occlusion with the Chitwood clamp (n=189) were compared with patients undergoing occlusion with the endoaortic balloon (n=875)., Results: There was no statistical difference in the rate of dissection between patients undergoing aortic occlusion with an endoaortic balloon (1.03%) and those receiving a Chitwood clamp (1.06%). Similarly, there was no difference in the rate of type A dissection between aortic occlusion strategies (endoaortic balloon=0.57%, n=5, vs Chitwood clamp=1.06%, n=2, p=0.28). No difference in the incidence of stroke was identified between the endoaortic balloon and the Chitwood clamp (2.2% vs 2.1%, p=1.0)., Conclusions: Minimally invasive cardiac operations using a peripheral cannulation strategy can be safely performed with minimal vascular adverse events incorporating either endoaortic balloon or Chitwood clamp aortic occlusion. As experience with the endoaortic balloon is gained, the incidence of vascular adverse events can be reduced to nearly negligible rates., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Minimally invasive approaches to mitral valve surgery are increasingly used, but the surgical approach must not compromise the clinical outcome for improved cosmesis. We examined the outcomes of mitral repair performed through right minithoracotomy or median sternotomy., Methods: Between January 2002 and October 2011, 1011 isolated mitral valve repairs were performed in the University of Pennsylvania health system (455 sternotomies, 556 right minithoracotomies). To account for key differences in preoperative risk profiles, propensity scores identified 201 well-matched patient pairs with mitral regurgitation of any cause and 153 pairs with myxomatous disease., Results: In-hospital mortality was similar between propensity-matched groups (0% vs 0% for the degenerative cohort; 0% vs 0.5%, P = .5 for the overall cohort; in minimally invasive and sternotomy groups, respectively). Incidence of stroke, infection, myocardial infarction, exploration for postoperative hemorrhage, renal failure, and atrial fibrillation also were comparable. Transfusion was less frequent in the minimally invasive groups (11.8% vs 20.3%, P = .04 for the degenerative cohort; 14.0% vs 22.9%, P = .03 for the overall cohort), but time to extubation and discharge was similar. A 99% repair rate was achieved in patients with myxomatous disease, and a minimally invasive approach did not significantly increase the likelihood of a failed repair resulting in mitral valve replacement. Patients undergoing minimally invasive mitral repair were more likely to have no residual post-repair mitral regurgitation (97.4% vs 92.1%, P = .04 for the degenerative cohort; 95.5% vs 89.6%, P = .02 for the overall cohort). In the overall matched cohort, early readmission rates were higher in patients undergoing sternotomies (12.6% vs 4.4%, P = .01). Over 9 years of follow-up, there was no significant difference in long-term survival between groups (P = .8)., Conclusions: In appropriate patients with isolated mitral valve disease of any cause, a right minithoracotomy approach may be used without compromising clinical outcome., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Clinical results are reviewed in 269 patients who underwent subendocardial resection for recurrent sustained ventricular tachycardia secondary to ischemic heart disease. Operative mortality is 15%. Factors increasing operative mortality rates are ejection fraction less than 20%, emergency operation, and history of previous heart operation. Use of amiodarone preoperatively does not alter operative risk. Clinical control of ventricular tachycardia is achieved in 93% of operative survivors. Two thirds of these patients do not need antiarrhythmic agents. Five-year actuarial survival is approximately 60%. Patient results with the automatic internal cardioverter defibrillator at the Hospital of the University of Pennsylvania and nationwide are also reviewed. As of June 1987, almost 1,500 patients had one or more devices implanted. Most patients had a prior documented cardiac arrest. Coronary artery disease is the cause of heart disease in over 70% of patients. Operative mortality is low (0.8-3.9%). Approximately 50% of patients have had therapeutic discharge of the device; however, asymptomatic discharge occurs in up to 45% of patients. Incidence of sudden death is 1.5% at 1 year and 5% at 5 years. Five-year actuarial survival is approximately 60%. Long-term mortality is primarily from heart failure.