Mitral Valve Repair Quality Of Life 5 Yrs Aftewards?

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• Open Access
• Published: 28 July 2022

Health-related quality of life following minimally invasive totally endoscopic mitral valve surgery

Journal of Cardiothoracic Surgery volume 15, Article number:194 (2020) Cite this article

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Abstract

Background

To compare the touch of two different types of mitral valve surgery on health-related quality of life, we conducted a retrospective study comparing modified totally endoscopic mitral valve surgery with median sternotomy mitral valve surgery.

Methods

A total of 163 patients who underwent mitral valve surgery at our institution between January 1, 2022 and Dec 31, 2022 were enrolled. For these 163 patients, mitral valve surgery was performed using either a modified totally endoscopic approach or median sternotomy approach. We used the numerical rating calibration and the Scar Cosmesis Assessment and Rating Scale to measure pain intensity and the aesthetic appearance of the surgical incision and used the MOS 36-particular Short-Form Wellness Survey to appraise health-related quality of life.

Results

Lxx-eight patients underwent the modified totally endoscopic mitral valve surgery, and lxxx-five patients underwent the median sternotomy mitral valve surgery. The two groups of patients were similar in terms of demographics and echocardiography findings. The number of bioprosthetic valve replacements performed was significantly college in the totally endoscopic group than in the median sternotomy group (p = 0.04), whereas the subvalvular apparatus was less preserved in just 33 cases in the totally endoscopic grouping (p = 0.01). The rate of postoperative adverse events was similar between the two groups. The pain was balmy and aesthetic appearance was significantly better in the totally endoscopic approach group than in the sternotomy arroyo group. Pregnant differences in the scores for the bodily pain and mental health subscales of the MOS 36-item Short-Class Health Survey were establish betwixt the two groups.

Conclusions

Compared with median sternotomy mitral valve surgery, totally endoscopic mitral valve surgery has an equally good treatment upshot, improving patient'southward health-related quality of life with a ameliorate cosmetic advent and a lower pain intensity. Our study suggested that the totally endoscopic approach is superior to the median sternotomy approach in terms of pain intensity, aesthetic appearance and health-related quality of life.

Peer Review reports

Introduction

Minimally invasive mitral valve surgery (MIMVS) has been performed in clinical practice since Cosgrove [1] and Cohn [2] performed the first minimally invasive valve surgery in 1996, and Carpentier [3] and Chitwood [four] later on performed video-assisted mitral valve surgery. In China, due to advancements in technology and a significant increase in the demand for minimally invasive approaches from patients, an increasing number of centres are choosing minimally invasive approaches to mitral valve repair and replacement. In recent years, the totally endoscopic approach has become known as a commonly performed and rubber technique for mitral valve surgery in our institution. Due to improvements in relevant surgical techniques, the mortality and morbidity rates of these approaches are the same equally those of the median sternotomy arroyo [5, 6]. We reviewed the literature and found that few studies have focused on totally endoscopic mitral valve surgery in terms of pain intensity, cosmetic appearance and health-related quality of life (HRQoL). Therefore, we conducted a retrospective cohort written report including 163 patients who had undergone mitral valve surgery using either the modified totally endoscopic approach or median sternotomy approach at our establishment and compared the aesthetic appearance of the surgical incision and the HRQoL and hurting intensity of these patients. In this report, we performed the modified minimally invasive totally endoscopic approach for mitral valve surgery with cardiopulmonary bypass through the femoral avenue and femoral vein merely with a single 2-stage femoral venous cannula.

Materials and methods

Patient selection and information drove

A total of 163 consecutive patients who underwent mitral valve surgery at our institution from January 1, 2022 to Dec 31, 2022 were enrolled. Mitral valve surgery was performed using either a modified totally endoscopic arroyo or median sternotomy approach. All patients either returned to the outpatient department for follow-up visits or were contacted past smartphone to confirm all the data that were collected. All patients were followed up, and all the data were bachelor in the patient files. All participants were requested to consummate the relevant questionnaires in different ways.

This was a retrospective cohort written report that included 163 patients and reported astringent events according to the guidelines for reporting mortality and morbidity later cardiac valve interventions that were published in 2008 [7]. The inclusion and exclusion criteria were discussed with and modified according to the expert's stance [8]. The inclusion criteria were every bit follows: (1) primary mitral valve affliction; (2) no prior right thoracic surgery; (iii) no hearing disorders; (4) complete a whole-course follow-up. The exclusion criteria were as follows: (i) the inability to complete a routine examination; (two) the disability to finish the questionnaires; (3) pregnant peripheral vascular illness; (4) severe cardiac insufficiency; (five) severe pectus excavatum and kyphoscoliosis; (6) additional aortic valve regurgitation and coronary artery disease requiring surgical interventions.

Surgical technique

Amazement and surgical training

The anaesthesia protocols for the 2 different approaches to mitral valve surgery were generally the same, but the minimally invasive approach relied more on perfusion and anaesthesia techniques. Nosotros preferred to have patients intubated with a double-lumen endotracheal tube or a single-lumen endotracheal tube with a bronchial blocker to deflate the right lung during surgery. Transoesophageal echocardiography (TEE) is of nifty importance for cannulation and cannula placement. The radial or brachial arterial pressure was monitored. A non-invasive finger pulse oximeter was placed in the right arm to monitor the oxygen saturation level.

Patients undergoing correct minithoracotomy were placed in a supine position, with a pillow under the right scapula to slightly drag the correct hemithorax. The right elbow was bent, and the right forearm was immobilized on the tabular array to expand the axillary space and allow admission to the anterior axillary line. Defibrillator pads were placed in the standard positions outside of the operative field.

Surgical incisions

A longitudinal incision was fabricated forth the vertical management of the inguinal ligament to expose the femoral artery and femoral vein, and then, cannulation of the femoral artery and vein was performed with a purse-string suture made of v–0 polypropylene. After full heparinization [activated clotting time (ACT) > 480 due south], the modified Seldinger technique was performed, with an 18-estimate needle and a guide wire [Radifocus® Guidewire M (.35 in., 260 mm), Terumo®] to proceeds admission to the femoral vein. Under TEE guidance, ii distal perforated sections of a unmarried two-stage femoral venous cannula [femoral venous cannulae (22 to xxx Fr), Kangxin Medical Instruments Co. Ltd.] were then correctly positioned into both venae cavae (Fig. 1). An arterial cannula was installed through the right femoral artery. The amount of venous drainage from the vena cava was frequently sufficient when the cannula was placed properly and vacuum-assisted venous drainage was performed [9, ten].

Fig. i

A unmarried ii-stage femoral venous cannula

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The modified endoscopic approach was performed via endoscopic right minithoracotomy. The primary incision was a two–four cm longitudinal incision at the axillary midline in the fourth or fifth intercostal space (usually quaternary), depending on the position of the hilum of the right lung on the chest film. We used soft tissue retractors to protect the incision without fracturing the rib cage [WOUND PROTECTORS RETRACTORS, Kangxin Medical Instruments Co. Ltd.]. The chief incision was made to place the thoracoscope, the left heart venting catheter, cardioplegic needle, CO2 line, caval tapes and transthoracic cantankerous-clench. We used a Chitwood aortic clamp for transthoracic aortic occlusion [11]. Two boosted thoracic ports measuring approximately ii–4 cm were installed in the secondary and 5th intercostal spaces for surgical manipulation and insertion of the valve prosthesis (Fig. two).

Fig. 2

Surgical incisions for totally endoscopic mitral valve surgery

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Surgical process

The anterior pericardium was opened as shut to the sternum every bit possible to create a large flap. The flap was retracted by stay sutures that were inserted in the chief incision, and they held the lung back, creating a big cavity for performance. When full bypass flows and moderate hypothermia were achieved, caval tapes were used to secure the vena cava, and and then, the Chitwood clamp was used to occlude the ascending aorta. So, antegrade HTK solution was administered, and the right atrium was opened. Later, stay sutures were used to retract the margins of the correct atrium and were fixed on the chest wall. Then, sutures were used to retract and identify the femoral venous cannula in the correct position until we could come across the atrial septum (Fig. 3). The left atrium was accessed through the atrial septum, and ii groups of stay sutures were used to concur the margin of the atrial septum, were pulled out of the port, and secured properly. Afterwards the valve was assessed, mitral valve surgery and the tricuspid valve process were performed. After the center was carefully de-aired and evaluated past TEE, cardiopulmonary bypass was terminated, and all incisions were closed.

Fig. 3

Intraoperative view of the patient with the mechanical valve installed, and correctly position of the single two-stage femoral venous cannula

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Conventional open mitral valve surgery was performed via median sternotomy.

Questionnaire survey

The assessments were initiated in the 3rd month later surgery. The clinical parameters in the two groups included the surgical technique, postoperative morbidity, length of infirmary stay and costs. Severe events were divers according to guidelines published by Akins [vii]. The Chinese version of the MOS 36-Item Short-Class Health Survey(SF-36) was selected as the main clinical assessment tool for HRQoL, and two sets of questionnaires, including the Scar Cosmesis Assessment and Rating (SCAR) Scale and numerical rating scale (NRS), were used to evaluate pain intensity and the cosmetic advent of the scar in all participants.

The MOS 36-Item Brusk-Class Health Survey is the nearly commonly used assessment tool for HRQoL [12]. We used the Chinese version of the SF-36 to assess health status. This SF-36 is suitable for assessing the wellness of clinical populations with various diseases. The questionnaire consists of 36 items and measures 8 health domains (general wellness, mental health, bodily pain, concrete role, physical function, vitality, role emotional and social role) [xiii, 14]. A higher score for a given subscale suggests a higher QoL regarding that domain.

Some patients were illiterate and elderly and may have had visual and cerebral functional impairments. We used the NRS as a simple and valid alternative cess of hurting intensity [15, 16]. We used the 11-signal numerical rating scale (NRS-11) for the assessment of pain intensity, where 0 = no pain and 10 = the most astringent hurting imaginable. The NRS-11 provides a sufficient level of bigotry for patients to describe pain intensity [17].

All the surgical wounds eventually developed into scars. Post-surgical scars with corrective issues cause functional and psychosocial impairments. The evaluation of postsurgical scar formation is very important. The SCAR calibration is a valid and reliable scale for the assessment of postsurgical linear scars. The scale includes six questions with vi parameters scored by a clinician (scar spread, erythema, dyspigmentation, suture marks, hypertrophy/atrophy, overall impression) and two questions requiring only a yeah/no response from the patient [18, 19]. Scores can exist determined by directly ascertainment and evaluation or by using loftier-quality images. The patients' responses to the questions may be either verbal or written [20].

Statistical analysis

SPSS 22.0 was used as statistical software, and P-values < 0.05 were defined as statistically significant. The mean ± standard deviation was calculated for quantitative information with a normal distribution; for nonnormally distributed data, the Mann-Whitney U-test was used. We used the independent samples t-test or assay of variance for continuous variables. For the categorical data, the χ2 test was applied. We used Spearman's correlation coefficient for ranked information to appraise the correlation between hurting intensity or the SCAR scale scores and the SF-36 scores.

Results

A full of 163 consecutive patients underwent mitral valve surgery (78 patients underwent the modified totally endoscopic approach (EA, n = 78), and 85 patients underwent the median sternotomy approach (SA, due north = 85)) were included. At that place were no significant differences in the demographics or echocardiography findings betwixt the ii groups (Table 1). There was a trend towards fewer mitral valve repair (p = 0.13) and fewer tricuspid valve plasty (p = 0.10) procedures being performed in the EA grouping. The number of bioprosthetic valve replacements was significantly higher in the EA grouping (p = 0.04), whereas the subvalvular apparatus was preserved more ofttimes in the SA group (p = 0.01).

Tabular array ane Demographic and Intra-operative data compared betwixt EA group and SA group

Full size table

The postoperative complications are shown in Table ii. The rate of postoperative adverse events was similar betwixt the 2 groups. Serious complications did not occur, and reoperations were not needed during the follow-up period. The length of intensive care and postoperative hospital stay did not statistically significantly differ betwixt groups. One case of inguinal lymphatic leakage and a case of right femoral vein thrombosis were detected in patients after minimally invasive surgery. Immediately after the patient was diagnosed, she was transferred to the vascular surgery department for catheter-directed thrombolysis combined with stent placement for acute femoral vein thrombosis, and warfarin anticoagulation was continued.

Table 2 Postoperative Information

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The patients were followed upwardly in the 3rd month later the operation. Nosotros assessed HRQoL in the ii groups using the MOS SF-36, which demonstrated meaning differences in the scores for the actual pain and mental health subscales (Table three). The NRS scores and the SCAR scores were evaluated in both groups (Table four). The difference in the SCAR scores between the two groups was pregnant, with the EA group being more satisfied with the artful appearance of the incision (P<0.05). There were significantly fewer complaints of postoperative pain in the EA group than in the SA group. The scores were significantly lower (P < 0.05). Evaluation on hurting intensity and aesthetics showed a pregnant correlation (P < 0.05) with the SF-36 subscale evaluation results. The rank correlation coefficient between the SF-36 scores and the NRS and SCAR scores is shown in Tabular array 5. The high correlation coefficient and depression p-value indicate that the correlation is highly significant. The correlation coefficient between the score of the actual hurting subscale of the SF-36 and the NRS score was − 0.819, with a p-value less than 0.001 (see Tabular array five). The correlation coefficient between the score of the mental health subscale of the SF-36 and the SCAR scale score was − 0.791, with a p-value less than 0.001 (see Table 5). We observed that bodily pain was strongly correlated with the NRS score. Moreover, the mental health score was correlated with the SCAR scores. These findings bespeak that patients who obtained a college score on the NRS demonstrated lower SF-36 scores on the bodily pain subscale and those who obtained a higher score on the SCAR scale demonstrated lower SF-36 scores on the mental wellness subscale.

Table 3 SF-36 scores were compared between the ii groups at iii months after surgery

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Tabular array four assessment of unlike pain intensity and scar scale

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Table 5 The coefficient of rank correlation between the SF-36 scores and the NRS and SCAR calibration scores

Full size tabular array

Table 3 shows that the EA grouping had higher scores on the bodily pain and mental health subscales than did the SA group, and a higher score represents less bodily pain and better mental health. Table 4 shows that the EA group had lower full scores on the NRS and SCAR scales than did the SA group, and a lower score represents less severe pain and a improve cosmetic appearance. Co-ordinate to the relationship shown in Table 5, bodily pain was strongly correlated with the NRS score. Moreover, the mental health score was correlated with the SCAR scores. The EA group accomplished a reduction in hurting and better aesthetic outcomes, and the related HRQoL in the EA group was improve than that in the SA group.

Discussion

As several literature reviews have mentioned, MIMVS has been successfully performed with techniques modified over the past twenty years and has recently been proven to be a safety and constructive handling [21, 22]. Compared to conventional approaches, MIMVS is rubber and yields similar results. Reviewing all the studies on mortality with MIMVS, the majority of studies showed no difference between the minimally invasive approach and the median sternotomy approach [23, 24]. Many authors have shown that the morbidity and mortality rates of MIMVS are similar to those of the traditional sternotomy approach for mitral valve surgery just that MIMVS yields a shorter recovery fourth dimension, shorter hospital stay, less astringent pain and meliorate cosmesis [21, 24, 25]. With the desire to reduce the mortality and morbidity rates associated with mitral valve surgery, the minimally invasive techniques accept continued to evolve and achieve excellent results. MIMVS has equally good outcomes as well every bit shorter hospital stays and better resources utilization [26, 27].

Different from common totally endoscopic approach, we performed mitral valve surgery with a modified, minimally invasive, totally endoscopic arroyo. Cardiopulmonary bypass was established only through the femoral artery and femoral vein with a single two-phase femoral venous cannula. This technique avoids the demand for the insertion of a right internal jugular vein cannula, which can lead to many complications, such every bit haemorrhage, pneumothorax, carotid artery injury and haematoma. In add-on, the time required to set the patient preoperatively is greatly reduced because jugular vein cannulation is not needed. Although some individuals may argue that air may be entrained in the venous cannula when the right atrium is open up, this issue can exist safely avoided if the two perforated segments are positioned correctly. Some other issue may be that the not-perforated section of the cannula crosses the right atrium, which may limit exposure of the heart valve. All the same, as shown in Fig. 3, the non-perforated segment of the cannula is located at the septum and does non obstruct the valve view. In conclusion, a unmarried two-stage cannula can be safely used during surgery in the right atrium, and information technology allows the pump to function properly when the left atrium is retracted during mitral valve surgery or when the right atrium is opened during tricuspid valve surgery. In fact, it is our preferred method of venous render during totally endoscopic surgery.

In our study, the morbidity rates later on cardiac valve interventions in the 2 groups were similar. No cases of structural valve deterioration or valve thrombosis were observed in either group. In that location were no differences in major agin events, such as reoperations for bleeding, operated valve endocarditis, or reintervention. In addition, we found that for the cost for total endoscopic mitral valve surgery is similar to that of median sternotomy mitral valve surgery (100,980.24 vs 101,309.91 RMB, p>0.05). Although previous written report shows that it can reduce intensive care unit of measurement days and postoperative hospital stays, this technique is accompanied by appreciable costs for medical consumables. Consumables such every bit HTK solution, femoral artery and femoral vena cava cannula were associated with a significant increase in medical costs [26, 28].

Although the mortality and morbidity afterwards totally endoscopic mitral valve surgery take been reported in previous studies, the upshot of totally endoscopic mitral valve surgery on HRQoL has rarely been studied, especially in the Chinese population. HRQoL may be influenced by factors such every bit the mental state of the patient, the pain intensity and even the patient's recognition of cosmesis. Operation safety and postoperative outcomes of totally endoscopic mitral valve surgery and median sternotomy mitral valve surgery accept been proven to be equivalent. Thus, the effect of totally endoscopic mitral valve surgery on HRQoL should be considered when the surgical approach is evaluated and selected.

In this written report, we aimed to compare the effect of the totally endoscopic approach and that of the median sternotomy arroyo on the HRQoL of patients who had undergone mitral valve surgery. We likewise focused on the effect of 2 different approaches with respect to hurting intensity, cosmetic advent, and the correlations between pain intensity and cosmetic advent and HRQoL in patients. In our literature search, we could not find any studies that compared HRQoL in patients undergoing mitral valve surgery with different surgical approaches. Moreover, no studies compared pain intensity and cosmetic advent betwixt the two surgical approaches, and no studies assessed the impacts of pain intensity and cosmetic appearance on quality of life. We assumed that totally endoscopic mitral valve surgery and median sternotomy mitral valve surgery have similar impacts on the HRQoL of patients.

All patients in the report completed the SF-36 and provided information on the pain intensity and the SCAR calibration. Nosotros used the Chinese version of the SF-36 to assess HRQoL. Nosotros establish that the SF-36 scores of the minimally invasive group were superior to those of the median group in the two subscales. We detected significant differences in bodily hurting and mental wellness between the totally endoscopic approach group and the median sternotomy arroyo group. Moreover, the scores on the other six subscales (including physical functioning, general healthy, role physical, vitality, social role performance, and emotional function functioning) were higher in the totally endoscopic approach group than in the median sternotomy approach grouping.

The affect of pain intensity and cosmetic advent on a patient's health-related quality of life, different from severe complications, is ofttimes underestimated past surgeons. R.P. Alston reported that chronic post-sternotomy pain occurs in 40–50% of patients. Of these patients, 33–66% had hurting lasting more than 3 months [29]. Pain after cardiac surgery is still underestimated and tin can be a problem. J Meyerson also reported that 28% of patients who underwent median sternotomy for cardiac surgery could suffer from non-cardiac hurting. Mild pain was present in the bulk of patients, and severe pain was present in 1% of patients [30]. Chronic pain associated with the sternotomy incision is a well-recognized complexity that severely impacts patients' daily life [31]. Chronic pain usually has a negative influence on mood and tin impair patients' ability to perform activities [29]. In a study that investigated persistent pain after cardiac surgery, 7% of the 244 patients reported experiencing interference with everyday life [32].

The crusade of persistent post-sternotomy pain includes rib fractures, scars, tissue impairment, steel wire sutures, intercostal nerve trauma, and infections in sternal and sternal dehiscence [33]. This totally endoscopic incision, which avoids dividing the sternum and bang-up of the ribs, may reduce patient distress and pain. Our study proved that the postoperative hurting intensity associated with EA was different from that associated with SA, and the hurting intensity of the EA group was significantly lower than that of the SA grouping. This consequence is consistent with those in previous studies [22, 24, 34].

Another apparent reward of totally endoscopic mitral valve surgery compared with the median sternotomy approach is the resulting cosmetic appearance. In this report, we besides compared the SCAR scores of the two groups, and our report proved that the SCAR scores of the EA group were significantly better than those of the SA grouping.

The coefficient of rank correlation between the SF-36 scores and the pain intensity and the SCAR scores betoken that bodily pain was closely related to pain intensity (NRS scores) and that mental health was closely related to scar aesthetics (the SCAR scale scores).

According to the data summarized above, the EA grouping had a improve impact on HRQoL, as well as mild pain and a better cosmetic appearance than did the SA group, leading to a better impact on HRQoL. The postoperative complications were similar between the two groups. Therefore, totally endoscopic mitral valve surgery can be performed as an alternative surgery in People's republic of china, as it does not yield whatever significant differences in related postoperative complications but does yield significant differences in pain intensity, cosmetic advent and HRQoL.

This written report has some limitations. Starting time, this was a retrospective study conducted in a single institution in Cathay, and selection and recall bias may contribute to the findings. Second, the cohort was small, and the follow-up flow was short. Despite these limitations, nosotros nonetheless believe that this study has some significance.

Conclusions

The results of this study showed that modified totally endoscopic mitral valve surgery has an every bit treatment outcome every bit does traditional median sternotomy mitral valve surgery. The totally endoscopic arroyo mitral valve surgery has higher scores on the bodily pain and mental wellness subscales of the SF-36 than did median sternotomy, besides, the endoscopic approach group had lower full scores on the NRS and SCAR scales than did the median sternotomy grouping, indicating the totally endoscopic mitral valve surgery tin reach reductions in hurting and better aesthetic outcomes, and the related HRQoL in the totally endoscopic approach group was better than that of the median sternotomy approach group. Our written report suggested that the totally endoscopic approach was superior to the median sternotomy in terms of pain intensity, artful appearance and health-related quality of life. It is recommended that the type of arroyo to be used for mitral valve surgery is selected in each centre on the ground of the actual state of affairs. Boosted studies with longer follow-up periods are recommended to assess the HRQoL of patients who undergo these surgeries with these two different approaches.

Availability of information and materials

Data sharing not applicable to this commodity every bit no data sets were generated or analyzed during the current report.

Abbreviations

HRQoL:

Wellness-related quality of life

SCAR:

Scar Cosmesis Assessment and Rating

NRS:

Numerical Rating Scale

MIMVS:

Minimally invasive mitral valve surgery

TEE:

Transesophageal echocardiography

SF-36:

The MOS 36-Item Short-Form Health Survey

NYHA course:

New York Heart Association functional classification

BMI:

Body mass index

LVED:

Left ventricular end diastolic

LVEF:

Left ventricular ejection fraction

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Acknowledgements

We highly admit the contribution by the participating doctors: Xue-shan Huang, Feng Lin, Qi-min Wang, Han-fan Qiu, Dong-shan Liao.

Funding

There is no financial back up for this work.

Author information

Affiliations

1. Department of Cardiovascular Surgery, Union Infirmary, Fujian Medical University, Fuzhou, 350001, People's Commonwealth of Cathay

   Ling-chen Huang, Dao-zhong Chen, Liang-wan Chen, Qi-chen Xu, Zi-he Zheng & Xiao-fu Dai

Contributions

X-FD and L-CH designed the study, participated in the operation, and drafted the manuscript. Q-CX and Z-HZ collected the clinical information and performed the statistical analysis. L-WC and D-ZC provide technical support. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xiao-fu Dai.

Ethics declarations

Ethics blessing and consent to participate

This study complied with the requirements of the Ethics Committee of Fujian Medical Academy [approval ID: No. 2022KY069], and adhered to the Declaration of Helsinki. Written informed consent was also obtained from the patient or a relative of the patient.

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Huang, Lc., Chen, Dz., Chen, Lw. et al. Wellness-related quality of life following minimally invasive totally endoscopic mitral valve surgery. J Cardiothorac Surg 15, 194 (2020). https://doi.org/x.1186/s13019-020-01242-eight

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• Received: xviii May 2022

• Accepted: twenty July 2022

• Published: 28 July 2022

• DOI : https://doi.org/10.1186/s13019-020-01242-8

Keywords

• Minimally invasive
• Quality of life
• Mitral valve surgery
• SF-36

Source: https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-020-01242-8

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