Long-term outcomes of minimally invasive concomitant mitral and tricuspid valve surgery with surgical ablation

Abstract

Objectives: We compared the outcomes of a right mini-thoracotomy (RMT) versus those of a sternotomy for concomitant mitral and tricuspid valve surgery and surgical ablation.

Methods: We analysed patients who underwent concomitant mitral and tricuspid valve surgery and surgical ablation at a single institution (mean follow-up: 7 years) after propensity score matching. The primary and secondary outcomes were all-cause death, composite major adverse events (including stroke, reoperation, readmission, permanent pacemaker insertion) and recurrence of atrial fibrillation (A-fib). A subgroup analysis was performed.

Results: A total of 797 procedures (mean age: 61.6 years; RMT: 45.2%; female: 66.5%; mitral valve repair: 33.6%) were done; 267 pairs were matched. The 5- and 10-year overall survival in the matched cohort was 92.7% and 86.9% for the RMT group and 92.1% and 83.1% for the sternotomy group (P = 0.879). Significant differences were not observed in major adverse events (P = 0.273; hazard ratio: 0.76) and A-fib recurrence (P = 0.080; hazard ratio: 0.72). The RMT group had lower rates of postoperative low cardiac output syndrome (P = 0.019) and acute renal failure (P = 0.003). Atrial fibrillation high-risk factors (including long-standing A-fib, enlarged left atrium, old age) exhibited significant interactions (P for interaction = 0.002) with the approach regarding A-fib recurrence.

Conclusions: In this study, an RMT exhibited no significant differences in long-term outcomes compared to a sternotomy, but it could remain a clinically reasonable option. Patients with a high risk of A-fib may have favourable ablation outcomes with a sternotomy.

Keywords: Long-term outcome; Minimally invasive cardiac surgery; Surgical ablation.

Graphical abstract

Figure 1:

Right mini-thoracotomy versus sternotomy. Kaplan–Meier plots of whole (A) and matched (B) cohorts showing all-cause mortality. CI: confidence interval; HR: hazard ratio; RMT: right mini-thoracotomy.

Figure 2:

Right mini-thoracotomy versus sternotomy. Kaplan–Meier plots of whole and matched cohorts showing major adverse events-free rate (A and B). Atrial fibrillation recurrence-free rate (C and D). A-fib: atrial fibrillation; CI: confidence interval; HR: hazard ratio; MAEs: major adverse events; RMT: right mini-thoracotomy.

Figure 3:

Adjusted hazard ratio of atrial fibrillation recurrence with right mini-thoracotomy compared to sternotomy according to the selected variables. A-fib: atrial fibrillation; COPD: chronic obstructive pulmonary disease; HR: hazard ratio; LA: left atrium; LVEF: left ventricular ejection fraction; LVIDd: left ventricular internal dimension/diastolic.