A matched pairs analysis of non-rib-spreading, fully endoscopic, mini-incision technique versus conventional mini-thoracotomy for mitral valve repair

OBJECTIVES: Advances in video-assistance lead to an increase in minimal access mitral valve surgery (MAMVS) with decreased incision size yet maintaining the same quality of surgery. Further reduction in surgical trauma and at the same time improved visual guidance can be achieved by a non-rib-spreading fully 3D endoscopic technique (NRS-3D). We compared patients who underwent MAMVS either through an NRS fully 3D endoscopic or rib-spreading (RS) access in a retrospective matched-pair analysis.

METHODS: A matched pairs analysis was undertaken of retrospectively collected data of 284 consecutive patients having received an MAMVS between January 2011 and May 2015. Fifty patients with an RS procedure were compared with 50 patients with an NRS fully 3D endoscopic operation. For all patients, access was made through a 3-4 cm incision in the inframammary fold through the fourth intercostal space. In the NRS-3D group, only a soft-tissue protector, and no additional rib-spreader, was used. Operative visualization was provided by 3D endoscopy in the NRS-3D group.

RESULTS: The NRS as well as the RS procedure was successful in all patients without technical repair limitations. Mortality was 0% in both groups. Significant differences were seen for operation times (39.0 min mean shorter operation time in the NRS-3D group; P < 0.001), and length of stay on intensive care unit (1.0 day mean shorter stay in the NRS-3D group; P = 0.002) and in the hospital (1.4 days mean shorter stay in the NRS-3D group; P = 0.003). Postoperative analgesics doses were significantly lower in the NRS-3D group [P = 0.007 (paracetamol); P = 0.123 (metamizole); P = 0.013 (piritramide)]. Postoperative pain rated on a pain-scale from 0 to 10 was significantly lower in the NRS-3D group (mean difference of 1.8; P = 0.006). Patient satisfaction regarding cosmetic results was comparable in both the groups. Repair results, ejection fraction, perioperative morbidity and MACCE during follow-up showed no significant differences between both groups. Early postoperative and follow-up echocardiography showed sufficient repair in all patients of both groups with no case of >mild recurrent mitral regurgitation.

CONCLUSIONS: An endoscopic procedure supported by 3D-visualization enables superior depth perception, facilitating an excellent quality of repair results. 3D-visualization is a helpful tool especially for complex reconstruction cases and exact placement of artificial neochordae. With this, an experienced mitral valve surgeon takes shorter operation times. Patients benefit from shorter hospitalization with reduced postoperative pain and early mobilization.