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.