Right Anterior Minithoracotomy versus Median Sternotomy Surgery for Native Mitral Valve Infective Endocarditis

Background and aim of the study: While concomitant medical and surgical therapy has improved the treatment of infective endocarditis (IE), mortality and postoperative complications remain high. A minimally invasive approach to mitral valve surgery has been associated with decreased morbidity and mortality in high-risk populations. The study aim was to analyze the feasibility of a minimally invasive approach to valve surgery for native mitral valve IE. Methods: All heart operations performed between January 2008 and April 2013 at the authors' institution were reviewed retrospectively. The operative times, intensive care unit (ICU) and hospital lengths of stay, postoperative complications, and in-hospital mortality of patients who underwent minimally invasive surgery via a right anterior minithoracotomy for native mitral valve IE were compared to those of a cohort which underwent median stemotomy. A Kaplan-Meier analysis was performed to compare long-term survival between the cohorts. Results: A total of 50 patients was identified (22 minithoracotomy, 28 median sternotomy). The baseline characteristics, mitral valve pathology and disease burden (annular abscess, cusp perforation, vegetation size, chordal rupture) were similar between the groups. There was no difference in the rate of active versus healed disease. Patients who underwent a minithoracotomy had fewer postoperative composite complications (41% versus 75%, p = 0.02), mainly driven by a decreased incidence of sepsis (0% versus 21%, p = 0.02), as well as less use of intraoperative blood products (59% versus 93%, p = 0.004), higher rates of mitral valve repair (55% versus 25%, p = 0.03), and a shorter ICU length of stay (56 versus 114 h, p = 0.009). Repair of the mitral valve was associated with a decreased risk of postoperative composite complications (OR 0.16, 95% CI 0.04-0.71, p = 0.02). At 2.5 years postoperatively, survival was estimated at 80% and 68% in the minithoracotomy and median sternotomy groups, respectively (p = 0.33). Conclusion: A right anterior minithoracotomy approach for native mitral valve IE provides a safe and feasible alternative to conventional median sternotomy surgery, with improved outcomes conferred by valve repair compared to replacement.