Minimally Invasive Mitral Valve Repair Paul S. Massimiano MD Inova Heart and Vascular Institute Adventist Healthcare

I have no real or apparent conflicts of interest to report. Paul S. Massimiano, MD I have no real or apparent conflicts of interest to report.

Goals of Mitral Valve Repair Repair Rates of 90-100% for degenerative disease. Excellent Mortality = 0% Excellence in all quality measures *Decreased Complications *Decreased A-Fib *Decreased Blood Transfusions *Decreased Length of Stay *Decreased Cost *Increased Patient Satisfaction

Start with the Basics Broad consensus in the literature that repair is preferable to replacement for degenerative disease 2. Principles of Repair in Degenerative Mitral Valve Disease Establish Leaflet Coaptation Resection Neochord Construction Alfieri Maneuvers Restore Annular Geometry Rigid/Flexible Band or Ring

Overview of the current state of Mitral Valve Repair 2005 to 2007 28,507 patients undergoing mitral valve surgery Among surgeons performing mitral valve repair, mean rate of repair - 41% Median number of mitral valve operations per surgeon per year = 5 Probability of repair increased from 36.5% to 73.6% with increasing mitral case volume Bolling, S, et al Ann Thor Surg 2010; 90: 1904-1912

Current State of Mitral Valve Repair 2000 to 2007 – 47,126 patients Repair rate for isolated mitral regurgitation ranged from 51% to 69% -Gammie, JS et al, Ann Thor Surg 2009 87: 1431-1439 “…Ongoing ‘gap’ in best practice surgical care of patients with significant degenerative disease of at least 20%, which translates into a significant incidence of unnecessary mitral valve replacement” -Adams, DH, EUR Heart J (2010) 31, 1958-1967

Current State of Mitral Valve Repair Since most of the cases(80-90%) in these studies were performed with median sternotomy, how well are we really doing with that approach?

Minimally Invasive Mitral Valve Repair Hypothesis 1997 -Using the same principles of repair we can achieve at least the same repair rates and outcomes with a less invasive approach than with median sternotomy -Minimally invasive surgery has distinct advantages over sternotomy Less trauma = less pain Shorter length of stay Faster overall recovery Dramatically improved patient satisfaction

What is Minimally Invasive Mitral Valve Repair? Small right lateral thoracic incision (< 2 inches) with minimal or no rib-spreading Femoral arterial & venous cannulation Can be accomplished with a variety of techniques – all with excellent results Direct vision Robotic Thoracoscopic *Identical principles of repair as sternotomy

Evolution of Practice at the INOVA Heart & Vascular Institute Direct Vision  Robotic & Thoracoscopic  Direct Vision 1997 2011

Video

Minimally Invasive Incision 1 Week Post-Op

All Mitral Valve Repair and/or Cox-Maze III Surgical Ablation Results: Inova Heart and Vascular Institute All Mitral Valve Repair and/or Cox-Maze III Surgical Ablation 2007-2011

“Minimally Invasive Mitral Valve Surgery” and/or Cox-Maze III 2007 – 2011 continued: 239 patients 75 Stand Alone Maze 164 MV Repairs Overall Repair Rate 98.7% * -Repair Rate for Degenerative Disease 100% *(2 patients with Rheumatic MS/MR)

Results - Minimally Invasive Mitral Valve surgery and/or Cox-Maze III 2007 - 2011 Variables-Postoperative Data Patients (N=239) Postoperative low cardiac output 1 (0.4%) Patients w packed rbc transfusion Intra-op 5 (2.0 %) Patients w packed rbc transfusion post-op 6 (2.5%) Patients requiring no transfusion 228 (95.3%) Any Infection 2 (<1%) Myocardial Infarction Stroke TIA

Results - Minimally Invasive Mitral Valve surgery and/or Cox-Maze III 2007 - 2011 Acute Renal Failure Hemodialysis Prolonged Ventilator > 24 hours 9 (4%) Atrial Fibrillation 6 (2.5%) Reop for Bleeding 1 (0.4%) Reoperation for Mitral Valve Readmit ICU 4 (2%) ICU Hrs (mean/median) 33.6/19.6 Operative Mortality Days Length of Stay (mean/median) 4.1/3.0 Readmit < 30 days 17 (7%)

“Minimally Invasive Mitral Valve Surgery” and/or Cox-Maze III 2007 - 2011

Conclusions Minimally invasive Mitral Valve Repair is a safe & effective approach to Mitral Valve Disease Repair rates are comparable to median sternotomy in experienced hands Mitral Valve repair may offer a significant advantage in decreasing post-operative complications, length of stay, cost, and patient satisfaction

Conclusions The real issue is not the surgical approach, rather it is the fact that to achieve excellence in repair rates and quality measures, with either a sternotomy or mini approach, extensive training and on-going experience with a significant volume of repairs per surgeon per year is required.

But… Who will ultimately decide this debate?