11. Byrne JG, Aranki SF, Adams DH, Rizzo RJ, Couper GS, Cohn LH. Mitral valve surgery after previous CABG with functioning IMA grafts. Ann Thorac Surg 1999;68:2243–7. 12. Svensson LG, Gillinov AM, Blackstone EH, et al. Does right thoracotomy increase the risk of mitral valve reoperation? J Thorac Cardiovasc Surg 2007;134:677–82. 13. Bolotin G, Kypson AP, Reade CC, et al. Should a video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery? J Heart Valve Dis 2004;13:155–8. 14. Vallabhajosyula P, Wallen T, Solometo L, Fox J, Vernick W, Hargrove WC III. Minimally invasive mitral valve surgery utilizing heart port technology: a single institution experience. J Heart Valve Dis 2014;29:384–8. 15. Arcidi JM Jr, Rodriguez E, Elbeery JR, Nifong LW, Efird JT, Chitwood WR Jr. Fifteen-year experience with minimally invasive approach for reoperations involving the mitral valve. J Thorac Cardiovasc Surg 2012;143:1062–8.
VALLABHAJOSYULA ET AL MINIMALLY INVASIVE MITRAL VALVE OPERATION
73
16. Cerfolio RJ, Orszulak TA, Pluth JR, Harmsen WS, Schaff HV. Reoperation after valve repair for mitral regurgitation: early and intermediate results. J Thorac Cardiovasc Surg 1996;111: 1177–84. 17. Burfeind WR, Glower DD, Davis RD, Landolfo KP, Lowe JE, Wolfe WG. Mitral surgery after prior cardiac operation: portaccess versus sternotomy or thoracotomy. Ann Thorac Surg 2002;74:S1323–5. 18. Crooke GA, Schwartz CF, Ribakove GH, et al. Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke in reoperative mitral valve procedures. Ann Thorac Surg 2010;89:723–9. 19. Gammie JS, Zhao Y, Peterson ED, O’Brien SM, Rankin JS, Griffith BP. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2010;90: 1401–10.
INVITED COMMENTARY Vallabhajosyula and colleagues [1] compare the results of minimally invasive port access versus redo sternotomy for reoperation on the mitral valve in 287 patients. The authors conclude that the port access approach can safely be adopted for reoperations on the mitral valve without compromising postoperative mortality or mitral function. Although the results are good and the data are new, this report does not address the elephant in the room, namely, “Why would anyone resort to port access for a redo mitral operation?”. Many of the previously reported advantages to the port access approach to the mitral valve were not addressed in this report, including marketability, cosmesis, transfusion and blood loss, pulmonary adverse events, and return to normal activity. In fact, for decades before port access began, the right anterior thoracotomy was a common approach for a reoperative mitral procedure, with the consensus that morbidity and mortality were less than for redo sternotomy. Although this report seems to deny any advantage in mortality or morbidity to the right thoracotomy versus the redo sternotomy approach to the mitral valve, the port access group may have been too small and the study underpowered to enable improved mortality to be clearly defined, for example. On the positive side, this study does tend to refute previous reports of increased risk (namely stroke, dissection, and failure to repair the mitral valve) with the right thoracotomy approach. However, this study could have been underpowered to detect these differences also.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Despite the limitations, these data confirm most prior single-center reports that the port access approach to a reoperative mitral valve procedure is indeed a reasonable option. The authors do hint at a learning curve and experience dependence of the femoral endoclamp technique predominantly used in this study. Whether the results would have been different with axillary artery or central arterial cannulation or whether they would have been different if ventricular fibrillation had been used instead of femoral endoclamping remains to be determined. Thus, the elephant in the room asking the question “Why would anyone resort to port access for a redo mitral operation?” will still have to await further investigation, perhaps in a prospective, multiinstitutional series. Donald Glower, MD Department of Surgery Duke University Medical Center Box 3851 Durham, NC 27710 e-mail: [email protected]
Reference 1. Vallabhajosyula P, Wallen T, Pulsipher A, et al. Minimally invasive port access approach for reoperations on the mitral valve. Ann Thorac Surg 2015;100:68–73.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.079
ADULT CARDIAC
Ann Thorac Surg 2015;100:68–73
VALLABHAJOSYULA ET AL MINIMALLY INVASIVE MITRAL VALVE OPERATION
73
16. Cerfolio RJ, Orszulak TA, Pluth JR, Harmsen WS, Schaff HV. Reoperation after valve repair for mitral regurgitation: early and intermediate results. J Thorac Cardiovasc Surg 1996;111: 1177–84. 17. Burfeind WR, Glower DD, Davis RD, Landolfo KP, Lowe JE, Wolfe WG. Mitral surgery after prior cardiac operation: portaccess versus sternotomy or thoracotomy. Ann Thorac Surg 2002;74:S1323–5. 18. Crooke GA, Schwartz CF, Ribakove GH, et al. Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke in reoperative mitral valve procedures. Ann Thorac Surg 2010;89:723–9. 19. Gammie JS, Zhao Y, Peterson ED, O’Brien SM, Rankin JS, Griffith BP. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2010;90: 1401–10.
INVITED COMMENTARY Vallabhajosyula and colleagues [1] compare the results of minimally invasive port access versus redo sternotomy for reoperation on the mitral valve in 287 patients. The authors conclude that the port access approach can safely be adopted for reoperations on the mitral valve without compromising postoperative mortality or mitral function. Although the results are good and the data are new, this report does not address the elephant in the room, namely, “Why would anyone resort to port access for a redo mitral operation?”. Many of the previously reported advantages to the port access approach to the mitral valve were not addressed in this report, including marketability, cosmesis, transfusion and blood loss, pulmonary adverse events, and return to normal activity. In fact, for decades before port access began, the right anterior thoracotomy was a common approach for a reoperative mitral procedure, with the consensus that morbidity and mortality were less than for redo sternotomy. Although this report seems to deny any advantage in mortality or morbidity to the right thoracotomy versus the redo sternotomy approach to the mitral valve, the port access group may have been too small and the study underpowered to enable improved mortality to be clearly defined, for example. On the positive side, this study does tend to refute previous reports of increased risk (namely stroke, dissection, and failure to repair the mitral valve) with the right thoracotomy approach. However, this study could have been underpowered to detect these differences also.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Despite the limitations, these data confirm most prior single-center reports that the port access approach to a reoperative mitral valve procedure is indeed a reasonable option. The authors do hint at a learning curve and experience dependence of the femoral endoclamp technique predominantly used in this study. Whether the results would have been different with axillary artery or central arterial cannulation or whether they would have been different if ventricular fibrillation had been used instead of femoral endoclamping remains to be determined. Thus, the elephant in the room asking the question “Why would anyone resort to port access for a redo mitral operation?” will still have to await further investigation, perhaps in a prospective, multiinstitutional series. Donald Glower, MD Department of Surgery Duke University Medical Center Box 3851 Durham, NC 27710 e-mail: [email protected]
Reference 1. Vallabhajosyula P, Wallen T, Pulsipher A, et al. Minimally invasive port access approach for reoperations on the mitral valve. Ann Thorac Surg 2015;100:68–73.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.079
ADULT CARDIAC
Ann Thorac Surg 2015;100:68–73
