Past, present, and future of minimally invasive mitral valve surgery

Minimally invasive mitral valve surgery (mini-MVS) has evolved into a safe and efficient surgical option for many patients. The overall complication rate is reduced, patient satisfaction increased, and hospital costs are lower with this approach, while providing safe and durable surgery. The repair/replacement of mitral valves via a minimally invasive technique represents a significant recent paradigm shift in cardiac surgery. The rapid development and refinement of minimally invasive valve surgery has enabled the repair of complex valves and, most importantly, has yielded similar results to those provided by standard surgical approaches.     

Minimally invasive mitral valve repair with and without robotic technology in the elderly

An increasing number of elderly persons require mitral valve surgery, primarily for mitral regurgitation. Minimally invasive mitral valve repair, including robotic surgery, has been shown to be feasible and safe in the general population. Minimally invasive cardiac surgery is especially beneficial in the elderly because it decreases trauma and speeds recovery. The authors conducted a retrospective review of 123 cases of minimally invasive mitral valve repair in elderly patients aged 70 years and older and five robotic mitral valve repairs using the da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) in one octogenarian. The authors review their 9 years of experience with minimally invasive mitral valve repair in the elderly and compare and contrast other forms of surgery in the elderly, including robotic mitral valve repair.     

Minimally invasive mitral valve surgery

Like many other surgical specialties, cardiac surgery is evolving toward more minimally invasive approaches. Mitral valve surgery has been shown to be feasible and safe when performed through smaller incisions or with the aid of robotic manipulation. Recent technologic advances allow complex mitral valve reconstruction to be carried out through these small incisions with avoidance of a full sternotomy and its untoward effects on pain and blood loss. Percutaneous mitral valve repair has been in development for some years and has begun to show promise for certain lesions. Finally, completely percutaneous mitral valve replacement also is beginning to evolve. This review assesses the status of various minimally invasive mitral valve approaches, including robotic techniques, and speculates about forthcoming advances.     

Future directions in cardiac surgery

The future of cardiac surgery is interesting, challenging, and changing. In coronary artery disease, operations are becoming more difficult due to previous stent placement and population aging, but there is a sense that volume is increasing, especially in centers that perform operations for diffuse disease and those that can perform truly minimally invasive procedures with robotic takedown of mammary arteries and perform anastomoses thoracoscopically. In valve disease, there will be increasing numbers of elderly patients requiring surgery, especially for aortic valve disease; a combination of minimally invasive surgery, hybrid procedures, and perhaps percutaneous valve placement in the truly high risk will be required. Mitral valve repair will become increasingly used as well as some percutaneous valve devices. In 5 years, most thoracic aneurysms will be treated by endovascular stenting and adults with congenital disease will be a small but growing population of patients.     

Minimally invasive mitral valve surgery: from Port Access to fully robotic-assisted surgery

Currently, there is a growing interest in minimally invasive cardiac surgery, and despite early criticisms, it has become the preferred method of mitral valve repair and replacement in many institutions worldwide with excellent results. The interest in performing cardiac valve operations through minimal incisions was stimulated by Port Access technology and has evolved to include robotically assisted video-enhanced valve surgery. Robotic assistance has led to shorter operating times and represents an ideal tool to prepare for fully robotic-assisted cardiac procedures. This report will highlight minimally invasive mitral valve surgery with its evolution from Port Access techniques to fully robotic-assisted surgery. The nuances, strengths, and shortcomings, as well as the potential to enhance the valvular procedure, the promise to reduce hospital stay, earlier return to normal activity, less pain, better cosmesis, and the rethinking of surgical dogma that wide surgical exposure is essential for such complex intracardiac surgery are discussed.     

Will minimally invasive valve replacement ever really be important?

PURPOSE OF REVIEW: Most cardiac surgical centers worldwide have instituted some form of minimally invasive surgery into their operative armamentarium. However, skepticism still remains whether minimally invasive valve replacement will ever really be important. This review first addresses the definition of minimally invasive surgery and then analyzes the possible advantages and disadvantages of minimally invasive valvular surgery. RECENT FINDINGS: The nomenclature for minimally invasive surgery is ill defined. Minimally invasive valve replacement is a safe and effective procedure compared with total sternotomy. The advantages of minimally invasive valve replacement are the length of stay and disposition after discharge, postoperative bleeding, cosmesis, and postoperative pain, whereas the main disadvantage involves the operative times early in the learning curve. SUMMARY: Minimally invasive valve replacement is beneficial and will continue to evolve as an important treatment option for patients with valvular heart diseases.     

Robotic cardiac valve surgery: transcending the technologic crevasse!

"The man with a new idea is a crank until the idea succeeds."--Mark Twain. With the profound public stress for minimally invasive surgery that guided General Surgery, Cardiothoracic Surgery has progressed with warranted enthusiasm. The explosion of technological advancements in optics, instrumentation and cardiopulmonary bypass has permitted minimally invasive cardiac procedures to be performed with safety, efficiency, and efficacy.In this chapter, we review the evolution of minimally invasive cardiac valve surgery. The articles of leading minimally invasive valve surgeons, both European and American, are reviewed. The indications for minimally invasive surgery are explained. Furthermore, the present day state of "robotic" mitral valve surgery is described.     

A single center experience with minimally invasive approaches in congenital cardiac surgery

BackgroundCardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved.MethodsWe performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range).ResultsBetween September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14–47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7–37.8) than those who were not (24.2, 20.8–29.3) (P=0.009).ConclusionsMinimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.     

Minimally invasive transaortic mitral valve repair during aortic valve replacement

Herein, we report the case of a 77-year-old man who presented with congestive heart failure. Echocardiography and cardiac catheterization revealed severe aortic stenosis with severe mitral regurgitation and a left ventricular ejection fraction of 0.20. Because of comorbidities, the patient was considered to be at high risk for double-valve surgery. In order to reduce the operative risk, a minimally invasive aortic valve replacement was performed together with a transaortic edge-to-edge repair (Alfieri stitch) of the mitral valve. We discuss the surgical technique and note the positive outcome. To our knowledge, this is the 1st report of minimally invasive aortic valve replacement and transaortic mitral valve repair with use of the Alfieri stitch.     

Minimally invasive valve surgery

Minimally invasive heart valve surgery has evolved significantly over the past 10 years and now comprises safe and efficient operations for most patients. The main goals of minimally invasive heart valve surgery are to reduce surgical trauma, increase patient satisfaction, reduce morbidity, and lower costs while still providing durable and safe valve repair or replacement. After a decade of refinements, studies have shown that minimally invasive heart valve surgery is a safe and effective procedure with similar if not improved perioperative morbidity and mortality rates compared with conventional valve surgery. Patients derive a variety of tangible benefits from these new surgical approaches, including less pain, shorter lengths of hospital stay, and faster return to preoperative functional levels. Minimally invasive heart valve surgery should be an option for any patient undergoing heart valve surgery today.     

Robotic mitral valve surgery: a review and tips for safely negotiating the learning curve

Totally endoscopic robotic mitral valve repair represents the least invasive surgical therapy for mitral valve disease. Comparative results for robotic mitral valve surgery against sternotomy are impressive, repeatedly demonstrating shorter hospital stay, faster return to normal activities, less morbidity and equivalent mortality and mid-term durability. We lack data comparing robotic approaches to totally endoscopic minimally invasive mitral valve surgery using 3D vision platforms. In this review, we explore the advantages and disadvantages of robotic mitral valve surgery and share technical tips that we have learned to help teams embarking on their robotic journey. We consider factors necessary for the successful implementation of a robotic programme including the importance of training a dedicated team, with the common goal to avoid any compromise in either patient safety or repair quality during the learning curve. As experience grows with robotic techniques and more cardiac surgeons become proficient with this innovative technology, the volume of robotic cardiac procedures around the world will increase helped by the introduction of new robotic systems and patient demand. Well informed patients will increasingly seek out the opportunity of robotic valve reconstruction in reference centres in the hands of a few highly experienced robotic surgeons.     

Videoscope-assisted cardiac surgery

Videoscope-assisted cardiac surgery (VACS) offers a minimally invasive platform for most cardiac operations such as coronary and valve procedures. It includes robotic and thoracoscopic approaches and each has strengths and weaknesses. The success depends on appropriate hardware setup, staff training, and troubleshooting efficiency. In our institution, we often use VACS for robotic left-internal-mammary-artery takedown, mitral valve repair, and various intra-cardiac operations such as tricuspid valve repair, combined Maze procedure, atrial septal defect repair, ventricular septal defect repair, etc. Hands-on reminders and updated references are provided for reader’s further understanding of the topic.     

Minimally invasive resection of benign cardiac tumors

Primary cardiac tumours for which surgical resection is the main stay of treatment are rare and present both diagnostic and management challenges. The majority of patients are asymptomatic and one third of those who have symptoms present with vague constitutional symptoms which further complicates the process of early diagnosis. The current state-of-the art multi-modality imaging, routine use of intra-operative transoesophageal echocardiogram (TOE) in most cardiac centres and the tremendous advances of endoscopic adjuncts greatly enhances both the diagnosis and management of those group of patients. The surgical burden of median sternotomy and the contemporary trend towards less invasive surgery urged the necessity for adopting minimally invasive surgery in general and cardiac tumours are no exception. Despite the rarity of theses tumours, minimally invasive resection is successful in the hands of experienced minimally invasive surgeons who employ the same minimal access valve surgery platform to access the tumours in various cardiac chambers and valves with no compromise to the oncological clearance and hence achieve the benefits of minimally invasive surgery without compromising long term outcomes.     

Minimal access reoperative mitral and aortic valve surgery

Minimally invasive cardiac surgery has allowed surgeons to perform valve procedures with a morbidity and mortality comparable with conventional resternotomy approaches while reducing postoperative ventilatory and intensive care unit requirements and overall hospital length of stay. Additionally, patient satisfaction with rapid recovery, earlier return to work, and improved cosmetic results has pushed the pendulum of reoperative valve surgery towards minimally invasive techniques. We reviewed our institutional data consisting of 129 patients requiring reoperative valve surgery over the past 4 years, which was accomplished using these minimally invasive approaches.     

Choosing the Ideal Candidate for a Robotic Valve Intervention

Robotic cardiac surgery addressing the mitral and tricuspid valves is a highly developed field offering multiple potential advantages regarding postoperative complications, valve repair rates, hospital length of stay, and rapid functional recovery compared with the conventional sternotomy approach for select patients. The unparalleled stereoscopic view within the heart and precision of robotic arms make robotic surgery a highly attractive minimally invasive approach, facilitating repair of even the most complex valvular pathology. Careful candidate selection and surgical planning are paramount to optimising the outcomes of those who undergo robotic valve surgery. As a team’s experience grows, the technique can be applied to a wider range of patients that may derive even greater benefit, such as those with significant comorbid conditions, ventricular dysfunction, and previous sternotomy. The goal of this review is to provide clinicians with a practical overview of the factors influencing a patient’s candidacy for robotic valve surgery. We discuss key issues such as preoperative diagnostic assessment, concerns regarding demographics and surgical pathology, and additional considerations relating to surgical exposure, cardiopulmonary bypass, and myocardial protection. Diligent patient assessment and a strong team-based approach are paramount to developing and maintaining a successful robotic valve surgery program, with the most seasoned teams being able to safely offer the technique to the vast majority of patients referred for mitral or tricuspid valve repair or replacement.     

胸腔镜辅助心脏手术352例

目的 总结胸腔镜辅助心脏手术352例的疗效。方法 先天性心脏病和风湿心脏病采用周围体外循环技术,全胸腔镜辅助下行房间隔缺损修补术155例,室间隔缺损修补术85例;胸腔镜辅助小切口行先天性心脏病矫治23例,二尖瓣置换81例。冠心病组采用胸腔镜辅助下取左乳内动脉行非体外循环冠状动脉旁路移植术8例。结果 无死亡病例。先天性心脏病、风湿心脏病组体外循环时间、升主动脉阻闭时间较传统手术方式略长,但全部患者术后呼吸机辅助时间短,术后胸腔引流量少,术后住院时间短。结论 胸腔镜心脏手术创伤小,恢复快,效果好。     

The Minimally Invasive Surgical Approach: A Critical Reappraisal

The use of minimally invasive techniques for cardiac surgery procedures has increased in the last 5 years. The term minimally invasive is used to describe cardiac procedures performed through a small incision or heart surgery performed without cardiopulmonary bypass. A review of the minimally invasive heart surgery literature is presented. According to the literature coronary bypass grafting without cardiopulmonary bypass can be carried out with similar early and mid-term results when compared to coronary bypass grafting with cardiopulmonary bypass. The same is true for LIMA to LAD bypass grafting performed through a lateral mini-thoracotomy. Controversial results are reported regarding morbidity after aortic and mitral valve surgery operated through a mini-incision. Some report less postoperative pain, earlier mobilization, shorter hospital stays, and lower costs. Others did not find any difference between full sternotomy and mini-incisions except a better cosmetic outcome. According to the literature there is no proven advantage of performing open heart surgery minimally invasively except in special situations, such as reoperation or polymorbid patients.     

Minimally invasive tricuspid valve surgery

Tricuspid valve disease carries a very unfavorable prognosis when medically treated. Despite that, surgical intervention is still underperformed for tricuspid valve disease due to the reported high morbidity and mortality from a sternotomy approach. This had led to a shift towards maximizing medical therapy for right ventricular failure and, as a result, a more significant delay in surgical referrals with surgical risks when patients are finally referred. Tricuspid valve patients usually have other co-morbidities resulting from their systemic venous congestion and low flow cardiac output. Minimally invasive tricuspid valve surgery provides less tissue injury and, as a result, less trauma during surgery. This provides a hope for both patients and treating doctors to be more open for providing this procedure with less complications. Isolated minimally invasive tricuspid valve surgery is still not performed as widely as expected. This can be partly due to the adverse outcomes historically labelled to tricuspid valve surgery or by the long journey of learning the surgical team would need to commit to with a minimal access approach. In this article we will review the perioperative pathway, and outcomes of isolated minimally invasive tricuspid valve surgery in the available English literature.     

New developments in cardiac surgery

In cardiac surgery new developments in the current area are mainly directed towards minimally invasive surgery techniques. New anastomotic devices for CABG are clinically available and will facilitate partial and total endoscopic CABG techniques. In valve surgery percutaneous techniques are already available for AVR and PVR. Single percutaneous mitral valve repair is not a too far away procedure. Tissue engineering will offer biocompatible heart valves. New developments for heart failure therapy are booming. The major drawback for the achievements of this amazing progress is the financial cost. An open debate between all the parties concerned in healthcare is urgently needed in order to maintain the quality of surgical care for the decades to come.     

经右胸微小切口微创心脏瓣膜手术

目的 探讨右胸微小切口（4～5 cm）微创心脏瓣膜手术的可行性和优越性.方法 回顾性分析经右胸微小切口（4～5 cm）微创心脏瓣膜手术89例的临床资料,其中男性38例,女性51例,对手术方法、主要并发症和手术适应证进行分析总结.结果 本组手术包括MVR 50例,MVP 11例,MVR＋TVP＋MAZE 2例,MVR＋PFO缝闭3例,MVR＋赘生物清除2例,MVR＋ASD修补＋TVP 3例,MVR＋TVP 8例;AVR 8例;MVR＋AVR 2例.右胸切口长度4～5 cm.术后并发症包括：二次开胸止血6例,伤口延迟愈合5例.无神经系统并发症,无肺部并发症,无肝肾功能不全.89例患者均痊愈出院.结论 掌握好手术适应证,经右胸微小切口行微创心脏瓣膜手术是安全可行的,疗效满意,创伤小,恢复快,切口美观,患者满意度高.