Putting UK Mini Mitral in Context for US Patients Needing Mitral Valve Repair скачать в хорошем качестве

Putting UK Mini Mitral in Context for US Patients Needing Mitral Valve Repair

Cardiothoracic surgeons Tom Nguyen and Joanna Chikwe discuss the UK Mini Mitral trial of minimally invasive vs sternotomy-based mitral valve repair and where transcatheter options fit. https://www.medscape.com/viewarticle/... -- TRANSCRIPT -- Tom C. Nguyen, MD: Welcome. My name is Tom Nguyen. I'm the chief of cardiothoracic surgery at UCSF in San Francisco. It's a pleasure to be joined by Dr Joanna Chikwe, a good friend down the street from us in Los Angeles. She's the chair of the Department of Cardiothoracic Surgery at Cedars-Sinai and also the editor of one of our major journals, Annals of Thoracic Surgery. We wanted to discuss an important trial that recently was published and presented at the ACC 2023. It's a topic that's very near and dear to our hearts, no pun intended. Essentially, the trial looked at randomizing patients to minimally invasive vs sternotomy surgery in the United Kingdom. US Better Results vs UK Mini Mitral Nguyen: As a very broad overview, there's a debate over the best approach for patients with mitral regurgitation who need mitral valve repair — whether they should get a sternotomy or a minimally invasive approach. There are many questions about the minimally invasive approach. Can you repair as many cases? Can you repair them as well? Is it safe? This is a huge trial. It's actually one of the first large, multicenter, randomized trials in the world. What the authors found was pretty interesting. I'll start off with the background of the trial. About 1100 patients were initially evaluated; 330 patients were randomized, with 164 in the sternotomy arm and 166 in the minimally invasive arm. They looked at functional status after surgery from baseline to 12 weeks and essentially found that there was no difference in functional status. They did find that functional status improved much faster with the minimally invasive approach. In patients with the minimally invasive approach, from baseline to 6 weeks, they recovered much faster. As expected, or maybe not so as expected, patients in the mini group had reduced postoperative length of stay and they were discharged earlier. Both arms had super-high repair rates of about 96%, with very little residual mitral regurgitation at 1 year. Lastly, when looking at the outcomes of death, heart failure, and reoperation, they were pretty similar. I want to engage in some discussion with my colleague, Dr Chikwe. What does this mean to our patients and what does this mean to our providers? What's your interpretation of this trial? Joanna Chikwe, MD: I think that some of the aspects of the trial really highlight the importance of experience and expertise. Although we're focusing on the fact that there wasn't a significant difference in the primary outcome measures — essentially quality of life at 1 year — some of the things that struck me were the surprisingly high mortality in the trial and the surprisingly high replacement rates in the trial. When we look at STS national data for the US, most recently published in JACC and the Annals of Thoracic Surgery, over an 8-year time span, the mortality of mitral valve repair in the US for most centers and most surgeons across an all-comers national database was zero. Obviously, it's not zero, but if you look at every single patient that had a degenerative mitral valve repair in the US, the average mortality is less than 0.3%, and 90% of patients can expect mortality less than 1%. I think comparing that to the outcomes in this trial, where good surgeons and good centers had one death out of 166 patients in mini-thoracotomy arm and four deaths out of 163 patients in the sternotomy arm — that's 2.5% operative mortality overall in these relatively low-risk cohorts, and eight patients in the mini-thoracotomy arm and five in the sternotomy arm needed replacements in a selected degenerative cohort. That's an interesting snapshot of practice. My first takeaway is that certainly for patients in the US going to experienced centers, you can actually expect much better outcomes. I would ask the question, does that maybe translate into a greater benefit that our patients receive at these expert centers if they're having minimally invasive approaches that maybe this trial wasn't powered to define? Experience Matters Nguyen: That's a great point. The trial actually did try to make sure that the surgeons were experienced. One of the criteria was that the surgeons must have completed at least 50 procedures prior to surgery. You and I know that 50 mitral surgeries really isn't much to be an experienced mitral surgeon. Then they divided the surgeons that did sternotomy vs minimally invasive, and maybe not surprisingly, the number of operations performed prior to surgery was higher in the sternotomy group: about 162, vs in the minimally invasive group, at 86. https://www.medscape.com/viewarticle/...