title: Fifteen-year experience with minimally invasive approach for reoperations involving the mitral valve.
abstract: OBJECTIVE
  Reoperative sternotomy to address mitral valve pathology carries substantial risk, especially with patent bypass grafts or an aortic valve prosthesis. We previously reported our early experience with minimally invasive right thoracotomy and peripheral cannulation as an alternative strategy, and we recently reviewed our cumulative 15-year hospital outcomes with this approach.
  
  
  METHODS
  Between June 1996 and April 2010, we performed right minithoracotomy for reoperations involving the mitral valve on 167 patients, 85 (51%) of these since 2006. Seventy-one percent had undergone previous coronary artery bypass grafting and 38% a previous valve procedure. Fibrillatory arrest was used in 77% and aortic clamping and root cardioplegia in 23%. Nineteen procedures were performed with robotic assistance.
  
  
  RESULTS
  Mitral repair frequency increased during each 5-year interval of our experience (1996-2000, 43%; 2001-2005, 53%; 2006-2010, 72%; P = .019), including 80% of native mitral valves without stenosis. Concomitant procedure frequency, most commonly atrial fibrillation ablation, also increased during each 5-year interval (0%, 21%, 48%; P < .0001). Thirty-day mortality was 3.0% (5/167), 0% since 2005. There were no conversions to sternotomy or aortic dissections. Stroke, in 2.4% (4/167), was statistically unrelated to fibrillatory arrest. Increased New York Heart Association functional class (odds ratio, 5.6; 95% confidence interval 1.1-27.8; P = .037) was the only independent predictor of mortality in multivariable analysis.
  
  
  CONCLUSIONS
  Our updated experience confirmed the effectiveness of minimally invasive right thoracotomy to treat mitral pathology while avoiding reoperative sternotomy risk. We found fibrillatory and cardioplegic arrest methods to be safe myocardial preservation strategies with this approach.
authors.affiliation: Department of Cardiovascular Sciences, East Carolina University, 600 Moye Blvd, Greenville, NC 27858, USA.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Arcidi
authors.forename: Evelio
authors.initials: E
authors.lastname: Rodriguez
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Elbeery
authors.forename: L Wiley
authors.initials: LW
authors.lastname: Nifong
authors.forename: Jimmy T
authors.initials: JT
authors.lastname: Efird
authors.forename: W Randolph
authors.initials: WR
authors.lastname: Chitwood
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D005260:Female; D006324:Heart Arrest, Induced; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D058386:Mitral Valve Annuloplasty; D015999:Multivariate Analysis; D009657:North Carolina; D016017:Odds Ratio; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012371:Robotics; D056346:Sternotomy / Q000009:adverse effects / Q000401:mortality; D025321:Surgery, Computer-Assisted; D013908:Thoracotomy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome