Filip P A Casselman, Marcus D Lance, Aamer Ahmed, Alice Ascari, Juan Blanco-Morillo, Daniel Bolliger, Maroua Eid, Gabor Erdoes, Renard Gerhardus Haumann, A

Background— There is an increasing interest in minimally invasive cardiac surgery. Methods and Results— Since February 1, 1997 till April 1, 2002, 306 patients underwent endoscopic mitral valve surgery (226 repair, MVP; 80 replacement, MVR). Predominant valve pathology was degenerative in MVP (83.6%) and rheumatic in MVR (65%). Mean age was 61.5±12.9 years. Median preoperative functional class (MVP+MVR) and mitral regurgitation (MVP) were II and 4+. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19.6±17.3 months and complete. The procedure was successfully performed in all but 6 patients. Hospital mortality included 3 patients (1%) and was technology related in one. Postoperative morbidity included aggressive re-exploration (8.5%), new onset atrial fibrillation (17.0%), and pacemaker implantation (2.3%). There were 1 early and 10 late reoperations, 5 of which were because of endocarditis. Freedom from mitral valve reoperation at 4 years was 91±3.5%. No risk factors for reoperation could be detected. Echocardiographic follow-up showed a median degree of mitral regurgitation (MVP) of 0 and a small paravalvular leak in four patients (MVR). Ninety-four percent of the patients reported no or mild postoperative pain and 99.3% felt they had an esthetically pleasing scar. Ninety-three percent would choose the same procedure again and 46.1% were back at work within 4 weeks. Conclusions— Endoscopic mitral valve surgery can be performed safely but definitely requires a learning curve. Good results and a high patient satisfaction are guaranteed. It is now our exclusive approach for isolated atrioventricular valve disease.

Background— The purpose of this study was to evaluate the feasibility and effectiveness of a right video-assisted approach for atrioventricular valve disease after previous cardiac surgery. Methods and Results— Between December 1st 1997 and May 1st 2006, 80 adults (mean age 65±12 years; 56% female) underwent reoperative surgery using a video-assisted approach without rib spreading. Previous cardiac operations included mitral valve (39%), CABG (29%), congenital (10%), and other (23%). For 25% of patients, this was at least their third cardiac operation. Mean time to redo surgery was 15±12 years. Femoral vessel cannulation and endoaortic clamping were routinely used. Mean preoperative Euroscore was 9.0±2.7 (5 to 20) and predicted mortality was 16.0±14.2% (4 to 86). Median preoperative NYHA class was II and mean follow-up was 25±22 months. Lung adhesions necessitated sternotomy in 4 cases and cannulation problems in another patient. Total operative mortality was 3.8% (n=3), O/E for mortality being 0.24. Procedures were mitral valve repair (45%; n=36), replacement (50%; n=40) and tricuspid valve replacement (5%; n=4). Additional procedures were performed in 44% (n=35). Mean aortic crossclamp and procedure time were 92±37 and 267±64 minutes. Mean postoperative blood loss was 815±1083 mL. Postoperative morbidity included 2 strokes (2.5%). Mean hospital stay was 10.7±6.7 days. Survival at 1 and 4 years was 93.6±2.8% and 85.6±6.4%. There was 1 late reoperation at 5 years. Median NYHA class at follow-up was II. When comparing, all but 1 patient (98.8%) preferred their minimally invasive approach when considering perioperative pain, postoperative rehabilitation, and final esthetic result. Conclusions— Video-assisted minimal access correction of atrioventricular valve disease after previous cardiac surgery is not only feasible but had lower than predicted mortality and strong patient satisfaction. It should therefore be used more frequently in today’s practice.

BACKGROUND: Previous studies comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary disease not involving the left main have shown significantly lower rates of death, myocardial infarction (MI), or stroke after CABG. These studies did not routinely use current-generation drug-eluting stents or fractional flow reserve (FFR) to guide PCI. METHODS: FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) is an investigator-initiated, multicenter, international, randomized trial involving patients with 3-vessel coronary artery disease (not involving the left main coronary artery) in 48 centers worldwide. Patients were randomly assigned to receive FFR-guided PCI using zotarolimus drug-eluting stents or CABG. The prespecified key secondary end point of the trial reported here is the 3-year incidence of the composite of death, MI, or stroke. RESULTS: A total of 1500 patients were randomized to FFR-guided PCI or CABG. Follow-up was achieved in >96% of patients in both groups. There was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI compared with CABG (12.0% versus 9.2%; hazard ratio [HR], 1.3 [95% CI, 0.98–1.83]; P =0.07). The rates of death (4.1% versus 3.9%; HR, 1.0 [95% CI, 0.6–1.7]; P =0.88) and stroke (1.6% versus 2.0%; HR, 0.8 [95% CI, 0.4–1.7]; P =0.56) were not different. MI occurred more frequently after PCI (7.0% versus 4.2%; HR, 1.7 [95% CI, 1.1–2.7]; P =0.02). CONCLUSIONS: At 3-year follow-up, there was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI with current-generation drug-eluting stents compared with CABG. There was a higher incidence of MI after PCI compared with CABG, with no difference in death or stroke. These results provide contemporary data to allow improved shared decision-making between physicians and patients with 3-vessel coronary artery disease. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02100722.