Minimally invasive approach associated with lower resource utilization after aortic and mitral valve surgery

Abstract

Objective: To investigate the effect of minimally invasive cardiac surgery (MICS) on resource utilization, cost, and postoperative outcomes in patients undergoing left-heart valve operations.

Methods: Data were retrospectively reviewed for patients undergoing single-valve surgery (eg, aortic valve replacement, mitral valve replacement, or mitral valve repair) at a single center from 2018 to 2021, stratified by surgical approach: MICS vs full sternotomy (FS). Baseline characteristics and postoperative outcomes were compared. Primary outcome was high resource utilization, defined as direct procedure cost higher than the third quartile or either postoperative LOS ≥7 days or 30-day readmission. Secondary outcomes were direct cost, length of stay, 30-day readmission, in-hospital and 30-day mortality, and major morbidity. Multiple regression analysis was conducted, controlling for baseline characteristics, operative approach, valve operation, and lead surgeon to assess high resource utilization.

Results: MICS was correlated with a significantly lower rate of high resource utilization (MICS, 31.25% [n = 115] vs FS 61.29% [n = 76]; P < .001). Median postoperative length of stay (MICS, 4 days [range, 3-6 days] vs FS, 6 days [range, 4 to 9 days]; P < .001) and direct cost (MICS, $22,900 [$19,500-$28,600] vs FS, $31,900 [$25,900-$50,000]; P < .001) were lower in the MICS group. FS patients were more likely to experience postoperative atrial fibrillation (P = .040) and renal failure (P = .027). Other outcomes did not differ between groups. Controlling for stratified Society of Thoracic Surgeons predicted risk of mortality, cardiac valve operation, and lead surgeon, FS demonstrated increased likelihood of high resource utilization (P < .001).

Conclusions: MICS for left-heart valve pathology demonstrated improved postoperative outcomes and resource utilization.

Keywords: high-resource utilization; left heart valve surgery; minimally-invasive surgery.

Graphical abstract

High-resource utilization overall and by definition stratified by operative approach.

Figure 1

Comparison of high-resource utilization overall and separated by definition: direct procedure cost higher than the third quartile or either postoperative length of stay (LOS) ≥7 days or 30-day readmission between patients who underwent valve operations stratified by operative approach (full sternotomy vs minimally invasive surgery). By both separate definitions and composite high resource utilization, we find that patients who underwent full sternotomy cardiac valve operations experienced significantly higher rates of high resource utilization. HRU, High resource utilization; OR, odds ratio.

Figure 2

Comparison of (A) postoperative length of stay, and (B) total direct cost of patients who underwent valve operations stratified by operative approach. Patients who underwent full sternotomy experienced both significantly longer postoperative length of stay and higher direct costs.

Figure 3

Postoperative complications, mortality, and readmission rates after left-heart valve surgery in patient cohorts stratified by operative approach. No significant difference was observed in mortality, readmission, and postoperative complications. Patients who underwent the full sternotomy approach were more likely to experience postoperative atrial fibrillation and renal failure. ICU, Intensive care unit.

Figure 4

Forest plot of nominal logistic regression depicting full sternotomy (FS) vs minimally invasive cardiac surgery (MICS) and their respective odds of patients experiencing high resource utilization (HRU) controlled for lead surgeon, operation (aortic valve replacement [AVR], mitral valve replacement [MVR], or mitral valve [MV] repair), and Society of Thoracic Surgeons predicted risk of mortality score stratified into low, medium, and high risk defined as 1% to 4%, 4% to 8%, and ≥8% risk, respectively. The model showed that patients who underwent FS had 3.28 times the odds of HRU compared with their counterparts undergoing MICS (FS OR, 3.28; 95% CI, 1.76-6.13 vs MICS OR, 0.30; 95% CI, 0.16-0.57; P < .001).

Figure 5

Outcomes of minimally invasive approach to left-heart valve surgery. Our results show that minimally invasive cardiac surgery (MICS) approach correlated with lower rates of high resource utilization, shorter length of stay (LOS), and lower direct cost relative to full sternotomy with no concomitant increase in postoperative complication rate. AVR, Aortic valve replacement; MVR, mitral valve replacement; MV, mitral valve.