Discussion
Mitral valve surgery represents an important frontier for cardiovascular
medicine that needs a surgical approach since trans-catheter
implantation valve models are still in their “start” and the results
with the ”clip” procedures have recorded contrasting results (8).
Despite a simple design, our study aims to demonstrate that, in our
cardiac surgery center, a policy focused on the use of a minimally
invasive approach in all comers is effective in providing satisfactory
clinical and echocardiographic results, even at long-term follow-up.
Our results are consistent with recent data from the United States:
successful surgical mitral valve repair is necessarily associated with
the volume of interventions that can be performed annually in a cardiac
surgery center (9).
Routinely practicing a minimally invasive mitral valve procedure allows
speeding up technical preparation times for the patient, as well as
cardiac ischemia time, making the procedure as a whole “less
invasive”. This aspect has an impact on the patient’s postoperative
outcome due to reduced surgical times (10). We previously showed in
complex valve reconstructions that surgical time, with a rapid learning
curve, could be reduced to less than 1 hour of aortic clamping (7).
Obviously, this advantage in terms of lower surgical time was made
possible by the simplification of the surgical technique which, despite
its simplicity of application, also proved to be effective in
maintaining good valve continence at follow-up (7).
However, minimally invasive surgery of the mitral valve was not shown to
be superior a superiority to complete sternotomy (6)., This could also
be due to patient selection. In selected populations of low-risk
patients, except an outcome improvement with the minimally invasive
approach was limited the esthetic result or a shorter hospital stay. It
is our belief, however, that in more ”frail” and higher risk patients,
avoid opening the sternum and performing a ”complete” minimally invasive
approach that also includes ”minimally invasive” anesthesia and
”minimally invasive” extracorporeal circulation can be an important
advantage.
In our study, only age affected long-term mortality, which is
physiological in a study population that included elderly patients
(Figure 8). However, the most relevant data consisted in the better
quality of life of these patients, as demonstrated by a significant
improvement in NYHA class which was maintained at follow-up (Figure 6).
One of the limitations of our study is that we were unable to
demonstrate the reproducibility of the procedure being a “single
surgeon” case series, but our study is in line with what has recently
been reported as a vision for the future by Dreyfus and Windecker: the
results are good only if the procedure is done in a center with highly
specialized surgeons on a specific procedure (11). Perhaps in a
speculative sense, it would be necessary to think of ”heart” facilities
that focus more on the type of pathologies treated rather than the
treated apparatus: a center with highly trained specialists, for
example, to which all patients with heart valve disease can refer to
(11).
In conclusion, our study wants to be an example for this type of
specialization path. In a center with high qualitative and quantitative
capabilities, minimally invasive mitral valve surgery can be performed
in all patients with surgical indication, with excellent clinical and
valve continence results that are maintained at follow-up.