As several literature reviews have mentioned, minimally invasive mitral valve surgery (MIMVS) has been successfully performed with modified in techniques in the past twenty years and now is proved to be a safe and effective treatment21–22. Compared to conventional approaches, MIMVS provides safe and familiar results. Reviewing all the studies on mortality with MIMVS, majority studies shown no difference between the minimally invasive approach and the median sternotomy approach23–24. Many authors shown that MIMVS has similar morbidity and mortality rates compared with the traditional sternotomy approach mitral valve surgery but with accelerated recovery time, shorter hospital stay, decreased pain and better cosmesis21,24−25. With the desire to reduce the mortality and morbidity from mitral valve surgery, minimally surgery has non-stop evolved and achieved an excellently results. MIMVS has an equally good outcomes while improving in such as hospital stay, and resource utilization26–27. In our study, the morbidity rates after cardiac valve interventions in two group were similar. No structural valve deterioration and no valve thrombosis were observed in either group. There were no differences in major adverse events such as reoperation for bleeding, operated valve endocarditis, or reintervention.
In addition, we found there is a similar cost for total thoracoscopic mitral valve surgery compared to median sternotomy mitral valve surgery(100980.24 vs 101309.91rmb,p༞0.05). Although it can reduce intensive care unit days and postoperative hospital stays, but this technique is accompanied by appreciable medical consumables costs. Consumables such as HTK solution, femoral artery and femoral vena cava cannula were associated with a significant increase in medical costs26,28.
Although mortality and morbidity after totally thoracoscopic mitral valve surgery have been reported in previous studies, the effect of totally thoracoscopic mitral valve surgery on the HRQoL has been rarely studied, especially in Chinese population. It may be influenced by factors such as the mental state of the patient, the pain intensity and even the patient’s recognition of cosmesis can be participate in. Operation safety and postoperative outcomes of totally thoracoscopic mitral valve surgery and median sternotomy mitral valve surgery have proven to be equivalent. Thus, the effect of the totally thoracoscopic mitral valve surgery on the HRQoL should be taken into consideration when evaluating and selecting the surgical approach.
In this study, we aimed to compare the effect of totally thoracoscopic approach and that of median sternotomy approach on the HRQoL of patients who had undergone mitral valve surgery. We also focused on the effect of two different approaches with respect to the pain intensity and cosmetic appearance, and the correlation between pain intensity and cosmetic appearance and HRQoL in patients. Through our literature search we could not find any research to compare QoL in patients undergoing mitral valve surgery by different surgical approach. There are also no comparative studies of the pain intensity and cosmetic appearance between the two surgical approaches, and no studies of the impact of pain intensity and cosmetic appearance on quality of life.
We assumed that the totally thoracoscopic mitral valve surgery and median sternotomy mitral valve surgery had similar impacts on the HRQoL of patients.
All patients in the study completed the SF-36 and provided information on the pain intensity and the SCAR scale. We used the Chinese version of the SF-36 to assess HRQoL. We found that the SF-36 scores of the minimally invasive group were superior to the median group in two subscales. We detected significant differences in bodily pain and mental health between the MI group and SI group. Moreover, scores on the other six subscales (including physical functioning, general healthy, role physical, vitality, social role functioning, and emotional role functioning) were higher in MI group than in the SI group.
The impact of pain intensity and cosmetic appearance on a patient's health-related quality of life, different from severe complications, is often underestimated by surgeons. R.P. Alston reported that chronic post-sternotomy pain, occurs in 40–50% of patients. Of these, 33–66% had pain lasting more than 3 months29. Pain after cardiac surgery is still underestimated and can be a problem. J Meyerson also reported that 28% of patients who underwent median sternotomy for cardiac surgery could suffer with non-cardiac pain. Mild pain was present in the majority of patients and severe pain was present in 1% of patients30. Chronic pain associated with the sternotomy incision is a well-recognized complication that have an important impact on the patient's daily life31. Chronic pain usually has a negative influence on mood and can restrict the patient's activities29. In a study targeted to investigate persistent pain after cardiac surgery ,7% of the 244 patients reported interference with everyday life32.
The cause of persistent post-sternotomy pain includes rib fracture, scar formation, tissue destruction, steel wire suture, intercostal nerve trauma, infection in sternal and sternal dehiscence33. This totally thoracoscopic incision, which avoided divided the sternum and cracking of ribs may reduce patient distress and pain. our study proved that the postoperative pain intensity of TA was different from that of SA, and the pain intensity of TA was significantly lower than that of SI group. This change is consistent with other previously reported results.
Another apparently advantage of totally thoracoscopic mitral valve surgery is cosmetic appearance compare with median sternotomy approach. In this study, we also compared the SCAR scores of the two groups, and our study proved that the SCAR scores of the TA group was significantly better than that of the SI group.
The coefficient of rank correlation between the SF-36 scores and the pain intensity and the SCAR scores indicate that: bodily pain was closely related to the pain intensity (NRS scores), and mental health was closely related to scar aesthetics (the SCAR scale scores). The other six levels were slightly correlated with pain.
According to the data summarized above, the TA group had a better impact on HRQoL, as well as a mild pain intensity and a better cosmetic appearance, which also had a better impact on HRQoL. The postoperative complications were similar between the two groups. Therefore, totally thoracoscopic mitral valve surgery is an alternative surgery in China, with no significant difference in related postoperative complications, but there are significant differences in pain intensity, cosmetic appearance and HRQoL.
The results of this study have some limitations. First,It was a retrospective study conducted in a single institution in China༌selection and recall bias may contribute to the findings. In spite of these limitations, we still believe that this study has some. Second༌the follow up times was short, the follow-up period was short, only about 3 months.