Sternal approach optimal in mitral valve surgeries

NEW YORK – The conventional sternal approach in treating mitral valve disease remains the safest and most flexible, said Dr. Patrick McCarthy, who used his talk at the AATS annual meeting’s adult cardiac surgery symposium, "Becoming a Master Valve Surgeon," to defend its virtues as the "gold standard" for mitral valve operations.

"Patients don’t have much pain, and most are concerned about the risks of open heart surgery, not the cosmetic aspects. Even so, the scar heals to a thin white line," Dr. McCarthy said in an interview. And with a sternal approach, compared with robotic or minimally invasive procedures, "you’re prepared to fix anything," he said.

"So if there’s a technical complication – an aortic dissection, unusual bleeding, a circumflex coronary injury – or you encounter unrecognized aortic valve disease, then you can safely treat it."

Dr. McCarthy said that his own practice has evolved to perform fewer, not more, minimally invasive mitral valve surgeries in recent years.

"Ten years ago about half of my mitral valve operations were minimally invasive, and over time I saw less and less benefit. The length of time on the heart-lung machine and the potential safety issues made me evolve away from that approach."

Many centers and individual surgeons do right thoracotomy or robotic surgery very well and safely, Dr. McCarthy said.

"But the national data would indicate that the perioperative risk of stroke is twice as high with those approaches," he said, and they are not performed as often as they are talked about.

Surgeons who elect not to perform a minimally invasive mitral valve procedure "should not feel that they’re somehow shortchanging the patient. For safety and long-term outcomes we need to focus less on how we approach the mitral valve and more on what operation we do. Can you do a good durable repair, and not a replacement? Can you minimize the risks of open heart surgery?" he said.

"Generations of cardiac surgeons worked hard to minimize those risks and optimize the outcomes of repair, to the point that we now operate with minimal risk on asymptomatic patients with normal ventricles and expect a 95% or greater chance for a durable repair. Don’t compromise the operation for a perceived cosmetic advantage," Dr. McCarthy said.

Also during the course, Dr. Marc Moon of Washington University School of Medicine in St. Louis, Missouri, discussed surgical triggers for patients with aortic stenosis in several nonstandard clinical scenarios. These scenarios include frail patients, patients with severe aortic stenosis, and asymptomatic patients who need major noncardiac surgery.

In addition to drawing from his own center’s experience, Dr. Moon attempted to condense and summarize the most recent guideline and surgical review recommendations for performing – or not performing – aortic valve replacement (AVR) in these and other tricky patient groups.

Patients with aortic stenosis (AS) are initially classed as asymptomatic or symptomatic based on a history and physical exam, and those with symptomatic aortic stenosis should undergo AVR, Dr. Moon said.

Asymptomatic patients can have normal ejection fraction (EF), but generally display left ventricle hypertrophy or diastolic dysfunction once AS becomes severe. In asymptomatic patients, once left ventricle EF falls below 50% (independent of associated coronary artery disease) or pulmonary hypertension appears, AVR should be considered."

However, frailty will make surgical intervention futile in some of these patients. Dr. Moon described new assessment tools to replace the "eyeball test" for frailty that surgeons have been using for years.

"A 6-minute walk test can predict a poor outcome in patients following AVR," he said, so long as the mobility limitations are not mainly due to the AS itself. Slow walkers, who need 6 seconds or more to walk 5 meters, have a significantly increased risk of morbidity or mortality independent of other factors affecting surgical risk.

Other measures of frailty include unintended weight loss of 10 pounds or more over a year, self-reported exhaustion, and weak grip strength.

Patients whose underlying AS is the main contributor to frailty can benefit from AVR, Dr. Moon said, but determining this can be difficult. One approach Dr. Moon and colleagues use is to begin with balloon aortic valvuloplasty in frail patients whose valves are amenable to BAV. For these patients, "we initiate an appropriate heart failure regimen, perform BAV, and reevaluate functional status in 4-6 weeks."

In these difficult cases, BAV is used to determine the contribution of aortic stenosis to the patient’s symptoms associated with underlying chronic lung disease, hepatorenal dysfunction, or poor left ventricular function, he said.

"If there is improvement after BAV, then AS is a contributing, causative factor to the patient’s disability and AVR is recommended. If there is no improvement in functional status, medical therapy is continued or hospice care initiated as appropriate."

NEW YORK – The conventional sternal approach in treating mitral valve disease remains the safest and most flexible, said Dr. Patrick McCarthy, who used his talk at the AATS annual meeting’s adult cardiac surgery symposium, "Becoming a Master Valve Surgeon," to defend its virtues as the "gold standard" for mitral valve operations.

"Patients don’t have much pain, and most are concerned about the risks of open heart surgery, not the cosmetic aspects. Even so, the scar heals to a thin white line," Dr. McCarthy said in an interview. And with a sternal approach, compared with robotic or minimally invasive procedures, "you’re prepared to fix anything," he said.

"So if there’s a technical complication – an aortic dissection, unusual bleeding, a circumflex coronary injury – or you encounter unrecognized aortic valve disease, then you can safely treat it."

Dr. McCarthy said that his own practice has evolved to perform fewer, not more, minimally invasive mitral valve surgeries in recent years.

"Ten years ago about half of my mitral valve operations were minimally invasive, and over time I saw less and less benefit. The length of time on the heart-lung machine and the potential safety issues made me evolve away from that approach."

Many centers and individual surgeons do right thoracotomy or robotic surgery very well and safely, Dr. McCarthy said.

"But the national data would indicate that the perioperative risk of stroke is twice as high with those approaches," he said, and they are not performed as often as they are talked about.

Surgeons who elect not to perform a minimally invasive mitral valve procedure "should not feel that they’re somehow shortchanging the patient. For safety and long-term outcomes we need to focus less on how we approach the mitral valve and more on what operation we do. Can you do a good durable repair, and not a replacement? Can you minimize the risks of open heart surgery?" he said.

"Generations of cardiac surgeons worked hard to minimize those risks and optimize the outcomes of repair, to the point that we now operate with minimal risk on asymptomatic patients with normal ventricles and expect a 95% or greater chance for a durable repair. Don’t compromise the operation for a perceived cosmetic advantage," Dr. McCarthy said.

Also during the course, Dr. Marc Moon of Washington University School of Medicine in St. Louis, Missouri, discussed surgical triggers for patients with aortic stenosis in several nonstandard clinical scenarios. These scenarios include frail patients, patients with severe aortic stenosis, and asymptomatic patients who need major noncardiac surgery.

In addition to drawing from his own center’s experience, Dr. Moon attempted to condense and summarize the most recent guideline and surgical review recommendations for performing – or not performing – aortic valve replacement (AVR) in these and other tricky patient groups.

Patients with aortic stenosis (AS) are initially classed as asymptomatic or symptomatic based on a history and physical exam, and those with symptomatic aortic stenosis should undergo AVR, Dr. Moon said.

Asymptomatic patients can have normal ejection fraction (EF), but generally display left ventricle hypertrophy or diastolic dysfunction once AS becomes severe. In asymptomatic patients, once left ventricle EF falls below 50% (independent of associated coronary artery disease) or pulmonary hypertension appears, AVR should be considered."

However, frailty will make surgical intervention futile in some of these patients. Dr. Moon described new assessment tools to replace the "eyeball test" for frailty that surgeons have been using for years.

"A 6-minute walk test can predict a poor outcome in patients following AVR," he said, so long as the mobility limitations are not mainly due to the AS itself. Slow walkers, who need 6 seconds or more to walk 5 meters, have a significantly increased risk of morbidity or mortality independent of other factors affecting surgical risk.

Other measures of frailty include unintended weight loss of 10 pounds or more over a year, self-reported exhaustion, and weak grip strength.

Patients whose underlying AS is the main contributor to frailty can benefit from AVR, Dr. Moon said, but determining this can be difficult. One approach Dr. Moon and colleagues use is to begin with balloon aortic valvuloplasty in frail patients whose valves are amenable to BAV. For these patients, "we initiate an appropriate heart failure regimen, perform BAV, and reevaluate functional status in 4-6 weeks."

In these difficult cases, BAV is used to determine the contribution of aortic stenosis to the patient’s symptoms associated with underlying chronic lung disease, hepatorenal dysfunction, or poor left ventricular function, he said.

"If there is improvement after BAV, then AS is a contributing, causative factor to the patient’s disability and AVR is recommended. If there is no improvement in functional status, medical therapy is continued or hospice care initiated as appropriate."

NEW YORK – The conventional sternal approach in treating mitral valve disease remains the safest and most flexible, said Dr. Patrick McCarthy, who used his talk at the AATS annual meeting’s adult cardiac surgery symposium, "Becoming a Master Valve Surgeon," to defend its virtues as the "gold standard" for mitral valve operations.

"Patients don’t have much pain, and most are concerned about the risks of open heart surgery, not the cosmetic aspects. Even so, the scar heals to a thin white line," Dr. McCarthy said in an interview. And with a sternal approach, compared with robotic or minimally invasive procedures, "you’re prepared to fix anything," he said.

"So if there’s a technical complication – an aortic dissection, unusual bleeding, a circumflex coronary injury – or you encounter unrecognized aortic valve disease, then you can safely treat it."

Dr. McCarthy said that his own practice has evolved to perform fewer, not more, minimally invasive mitral valve surgeries in recent years.

"Ten years ago about half of my mitral valve operations were minimally invasive, and over time I saw less and less benefit. The length of time on the heart-lung machine and the potential safety issues made me evolve away from that approach."

Many centers and individual surgeons do right thoracotomy or robotic surgery very well and safely, Dr. McCarthy said.

"But the national data would indicate that the perioperative risk of stroke is twice as high with those approaches," he said, and they are not performed as often as they are talked about.

Surgeons who elect not to perform a minimally invasive mitral valve procedure "should not feel that they’re somehow shortchanging the patient. For safety and long-term outcomes we need to focus less on how we approach the mitral valve and more on what operation we do. Can you do a good durable repair, and not a replacement? Can you minimize the risks of open heart surgery?" he said.

"Generations of cardiac surgeons worked hard to minimize those risks and optimize the outcomes of repair, to the point that we now operate with minimal risk on asymptomatic patients with normal ventricles and expect a 95% or greater chance for a durable repair. Don’t compromise the operation for a perceived cosmetic advantage," Dr. McCarthy said.

Also during the course, Dr. Marc Moon of Washington University School of Medicine in St. Louis, Missouri, discussed surgical triggers for patients with aortic stenosis in several nonstandard clinical scenarios. These scenarios include frail patients, patients with severe aortic stenosis, and asymptomatic patients who need major noncardiac surgery.

In addition to drawing from his own center’s experience, Dr. Moon attempted to condense and summarize the most recent guideline and surgical review recommendations for performing – or not performing – aortic valve replacement (AVR) in these and other tricky patient groups.

Patients with aortic stenosis (AS) are initially classed as asymptomatic or symptomatic based on a history and physical exam, and those with symptomatic aortic stenosis should undergo AVR, Dr. Moon said.

Asymptomatic patients can have normal ejection fraction (EF), but generally display left ventricle hypertrophy or diastolic dysfunction once AS becomes severe. In asymptomatic patients, once left ventricle EF falls below 50% (independent of associated coronary artery disease) or pulmonary hypertension appears, AVR should be considered."

However, frailty will make surgical intervention futile in some of these patients. Dr. Moon described new assessment tools to replace the "eyeball test" for frailty that surgeons have been using for years.

"A 6-minute walk test can predict a poor outcome in patients following AVR," he said, so long as the mobility limitations are not mainly due to the AS itself. Slow walkers, who need 6 seconds or more to walk 5 meters, have a significantly increased risk of morbidity or mortality independent of other factors affecting surgical risk.

Other measures of frailty include unintended weight loss of 10 pounds or more over a year, self-reported exhaustion, and weak grip strength.

Patients whose underlying AS is the main contributor to frailty can benefit from AVR, Dr. Moon said, but determining this can be difficult. One approach Dr. Moon and colleagues use is to begin with balloon aortic valvuloplasty in frail patients whose valves are amenable to BAV. For these patients, "we initiate an appropriate heart failure regimen, perform BAV, and reevaluate functional status in 4-6 weeks."

In these difficult cases, BAV is used to determine the contribution of aortic stenosis to the patient’s symptoms associated with underlying chronic lung disease, hepatorenal dysfunction, or poor left ventricular function, he said.

"If there is improvement after BAV, then AS is a contributing, causative factor to the patient’s disability and AVR is recommended. If there is no improvement in functional status, medical therapy is continued or hospice care initiated as appropriate."