Impact of Minimally Invasive Mitral Valve Surgery in Elderly Patients

Objective: An increasing number of elderly patients present with mitral valve disease. Minimally-invasive cardiac surgery (MICS) has evolved to become standard therapy for several cardiac pathologies. The goal of this study was to compare this technique to the conventional access via full median sternotomy in the elderly population.

Methods: This retrospective analysis included 424 consecutive patients receiving a mitral valve repair between 2012 and 2017 at the age of 70 or older. 213 patients underwent concomitant procedures while isolated mitral valve surgery was performed in 211 patients. 145 patients were operated via full median sternotomy (group I) while fully endoscopic MICS was performed in 72 cases (group II). According hospital protocol, anterolateral minithoracotomy was performed with femoral cannulation in 50 patients (group II-F). In the presence of systemic arteriosclerosis, as diagnosed by preprocedural CT-scan or a history of stroke, right axillary cannulation was implemented in 22 patients (group II-A).

Results: Patients in the II-F subgroup were significantly younger (I: 75 ± 4 years; II-A: 76 ± 3 years; II-F: 73 ± 2 years; p < 0.001). Preoperative variables were comparable between I and II-A subgroups. EuroSCORE II (I: 4.02 ± 2.89; II-A: 3.86 ± 2.78; II-F: 1.66 ± 1.58; p < 0.001) was significantly higher in group I / group II-A. Cardiopulmonary bypass time (I: 128 ± 41; II-A: 186 ± 58; II-F: 178 ± 51 minutes; p < 0.001) was significantly longer in both MICS groups. However, aortic cross clamp time did not differ significantly between group I and group II-A (I: 81 ± 28 versus II-A: 89 ± 25 minutes, p = 0.311). Procedural time was significantly longer in group II-A (I: 233 ± 79, II-A: 289 ± 77; II-F: 257 ± 69 minutes; p = 0.011). Perioperative stroke occurred in 2 patients in the Group I. No patient suffered a perioperative stroke in both MICS subgroups. There was no in-hospital mortality in both MICS subgroups. In group I, one patient died postoperatively due to a ventricular rupture.

Conclusion: Fully endoscopic minimally invasive mitral valve surgery is safe and feasible in elderly patients > 70 years. Even high-risk patients with the signs of systemic arteriosclerosis can be safely treated via minimally invasive approach using antegrade axillary artery perfusion. Given standardized risk assessment protocol and appropriate preprocedural imaging, fully endoscopic MICS mitral valve surgery does not seem to increase the perioperative neurological risk.