May 2023 | Issue 69
6
Equivalent recovery times shown between minimally invasive and conventional surgery for mitral valve repair The largest randomised controlled trial to date to compare minimally invasive and conventional mitral valve surgery—UK Mini Mitral—has found outcomes and quality of life to be similar in patients who received either technique for at 12 weeks.
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resented at the American College of Cardiology (ACC) annual Scientific Session (4–6 March, New Orleans, USA), lead author Enoch Akowuah (Newcastle University, Newcastle upon Tyne, UK) investigated patients with severe degenerative mitral valve regurgitation to assess recovery and subsequent complications. The study included 330 patients treated at 10 centres across the UK—the cohort’s average age was 67 years—30% of whom were women. Participants were randomly assigned to undergo mitral valve repair by either sternotomy or mini-thoracotomy. Expertise randomisation was a focal area of the study—28 surgeons were approved by the Trial Steering Committee and were required to have performed at least 50 procedures—and Akowuah stated that this was based on patient feedback prior to the study’s design to “remove the learning curve” and assure patients would receive a “high-quality procedure” regardless of group designation. The researchers outlined their primary endpoint as the change in patients’ physical functioning and ability to carry out day-to-day activities at 12 weeks post-procedure. This was measured by changes in SF-36v2 quality-of-life and physical functioning scale from baseline. Akowuah et al assessed changes through periodic questionnaires and updates via an accelerometer that patients wore on their wrists. Defining their secondary endpoint, the
researchers included physical function at six weeks, physical activity and sleep efficiency measure via accelerometery at both six and 12 weeks, MVr rates, quality of mitral valve repair and adverse events, such as death, stroke, heart failure and repeat intervention. When assessed at 12 weeks, Akowuah and colleagues found physical function levels pre- and post-surgery were similar in both groups. Although at six weeks, they noted, who underwent minithoracotomy had recovered physical function compared to pre-surgery, whereas patients who received a sternotomy had not.
At one year follow-up, Akowuah et al recorded that all secondary outcomes were not significantly different between the two groups. Despite one mini-thoracotomy patient requiring a secondary operation due to bleeding, the researchers found mini-thoracotomy patients typically spent a median of five days in hospital—compared to six days for sternotomy patients—and were more likely to be discharged early. Reflecting on the significance of their findings, Akowuah highlighted that speed of recovery to ultimately regain physical function and return to normal activities is important for patients. “Our results show that at three months, physical recovery is equivalent in both groups of patients,” he said. “In addition, we show that when both surgical procedures are performed by expert surgeons, minimally invasive mitral valve surgery is as safe and effective as conventional surgery.” Answering focal questions about the effectiveness of approaches, the authors state their study confirms the valve repair rate and the quality and durability of valve repair when using mini-thoracotomy. Akowuah asserted: “Valve repair rates were excellent [at 96%] and similar to those obtained with sternotomy. Moreover, at one year after surgery more than 92% of patients in both groups had no or mild valve leakage.”
We hope that the results of this trial will give confidence to both clinicians and patients and drive uptake of the mini approach.”
Enoch Akowuah
female sex with CABG operative there are clear differences in baseline “Urgent” action needed to improve ofoutcomes over time. anatomical and clinical characteristics Asserting their primary and secondary between men and women—such as the outcomes in women undergoing endpoints as operative mortality and pattern of ischaemic heart disease— combined mortality and morbidity alluding to revascularisation being less coronary artery bypass surgery respectively, Gaudino et al found their beneficial in some cases.
Women have been found to have significantly higher risk of operative mortality and postoperative complications after isolated coronary artery bypass (CABG) when compared with men. Results from a retrospective cohort study of over a million US patients were released today, revealing the “essentially unchanged” excess operative risk for women between 2011 and 2020. PUBLISHED ONLINE IN JAMA Surgery, the investigators assert theirs is the first to provide “contemporary nationwide analysis” in operative mortality and morbidity trends for women undergoing CABG in the US. Women, the authors preface, are more commonly older and have a higher prevalence of cardiovascular risk factors when presenting for CABG. However, despite a national upward trend in CABG outcomes over the past decades, it is “unclear” why this improvement has remained static for
women, the researchers state. Led by Mario Gaudino (Weill Medical College, New York, USA) the authors reviewed data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STSACSD), comparing outcomes between men (979,488 [75.5%]) and women (317,716 [24.5%]). Spanning 110 participating centres, the STS-ACSD represents over 95% of the US cardiac surgical volume, and was evaluated by the authors using the primary analytic method to estimate the association
primary endpoint revealed significantly higher unadjusted mortality when compared with men (2.8% vs 1.7%; p<0.001). Their secondary endpoint also yielded significant results, showing the overall incidence of the composite of operative mortality and morbidity to be 22.9% for women (95% CI, 22.7–23.0) and 16.7% for men (95% CI, 16.6–16.8) (p<0.001). Regarding trends over time, Gaudino and colleagues report that unadjusted mortality in women increased from 2.9% in 2011 to 3.3% in 2020, while adding the operative risk attributable to female sex varied from 1.28% in 2011 to 1.41% in 2020, showing no improvement over time. “The reason for the lack of improvement in outcomes for women in the last decade is unclear,” the authors write. However, they recognise
The authors point out, however, that current diagnostic and therapeutic protocols for coronary revascularisation, including studies comparing coronary artery bypass with percutaneous coronary intervention (PCI) are “all informed by data derived from studies performed prevalently in men”, and so provide “inadequate” generalisability to women. Addressing the larger significance of their results, the authors believe a “multifactorial” approach is required to reduce mortality in women after CABG. They affirm that it is important that sex disparities are evaluated in basic science research and women enrolled in clinical trials, and Gaudino et al conclude that “further investigation in the determinants of operative outcomes in women is urgently needed”.