Surgical repair of mitral valve prolapse through a minimal right vertical infraaxillary thoracotomy

Abstract Background: Minimally invasive mitral valve surgery has been proven a safe and cosmetic alternative to the conventional median sternotomy approach. The aim of this study is to retrospectively evaluate the clinical outcome of mitral valve repair for leaflet prolapse through a minimal right vertical infraaxillary thoracotomy (RVIAT). Methods: From January 2003 to December 2011, 68 patients with mitral regurgitation (MR) due to leaflet prolapse underwent mitral valve repair through a RVIAT approach. There were 37 males and 31 females. The mean age of the patients was 37.8 ± 10.5 years. Of the 68 patients, 45 had posterior leaflet prolapse and 23 had anterior leaflet prolapse. Results: The mean incision length was 7.3 ± 1.8 cm (range 5.5 to 10.0 cm). Mitral valve repair technique included quadrangular resection with or without sliding repair (40 cases), edge to edge technique (six cases), artificial chordae (18 cases), chordal transfer (four cases), and ring annuloplasty was performed in all 68 patients. There was no severe morbidity and operative mortality. Echocardiography after operation demonstrated absence or trivial mitral regurgitation in 52 patients and mild regurgitation in 16 patients. During the 3 months ～8 years' follow-up period, one patient (1.5%) underwent mitral valve replacement through the median sternotomy due to recurrent severe MR. Other patients were in good condition. Conclusion: Surgical repair of mitral valve prolapse can be successfully performed through the RVIAT approach achieving excellent cosmetic and clinical results. (J Card Surg 2012;27:533-537).     

Gore-tex chordoplasty in degenerative mitral valve repair

Mitral valve repair with Gore-Tex (W.L. Gore & Assoc, Inc, Flagstaff, AZ) neochordae is of increasing interest. In 2000, the loop technique using premeasured Gore-Tex neochordae was introduced by our group. Herein, we report our experience with this technique in minimally invasive mitral valve repair (MVR) for degenerative disease. Between 1999 and 2006, 468 patients (328 men and 140 women) underwent elective MVR using neochordae at our institution. The mean age of the patients was 58 +/- 12.3 years. All patients had significant mitral valve regurgitation, and the mean severity was 3.5 +/- 0.6. Prolapse of the posterior leaflet was diagnosed in 393 patients (84%), and prolapse of the anterior leaflet was diagnosed in 250 patients (53.4%). Mean left ventricular function was 64.8 +/- 12.3%. All patients were operated on with the minimally invasive approach via a right lateral mini-thoracotomy, femoral cannulation for cardiopulmonary bypass, and the transthoracic direct clamp technique. Mean duration of cardiopulmonary bypass was 136 +/- 40 minutes, and mean aortic clamp time was 87 +/- 31 minutes. Gore-Tex neochordae were used in 149 patients (32%) on both leaflets, in 224 patients (47.7%) on the posterior leaflet only, and in 95 patients (20.3%) on the anterior leaflet only. A mean number of 2.7 +/- 1 loops at a mean length of 21 +/- 3.3 mm were used on the A2 segment. On the P2 segment, a mean number of 3.2 +/- 1 loops at a mean length of 14.3 +/- 3.1 mm were applied. The intraoperative course was uneventful in all patients. Early reoperation for bleeding had to be performed in 18 patients (3.9%). Mean duration of hospital stay was 11.9 +/- 13 days. The 30-day mortality rate was 1.5% (7 patients), and 1-year mortality rate was 2.6% (12 patients). MVR with neochordae and the loop technique is an easy and effective treatment for degenerative mitral valve disease. The procedure is reliable and reproducible, leading to low morbidity and mortality. Thus, use of Gore-Tex neochordae has become the standard technique for MVR at our institution.     

Minimally invasive mitral surgery: mitral valve repair with a right-sided partial sternotomy

We describe our concept and the results of mitral valve repair using a right-sided partial sternotomy. We performed mitral valve repair using this method in 50 patients with severe MR between April 1997 and October 1998. In 10 patients in whom good exposure was not attained, we changed to the ordinary full-sternotomy or T-shaped partial sternotomyprocedure. Forty patients with good exposure underwent successful mitral valve repair. The sites of repair were anterior in 15 cases, posterior in 16, and both in 9. There was no mortality, and intraoperative TEE performed in all 40 patients revealed that all had trivial or no regurgitation. The right-sided partial sternotomy (open door method) is a safe and useful method for minimally invasive valve Surgery. A better quality of life compared with traditional median sternotomy can be ensured for patients undergoing minimally invasive cardiac surgery only when receive the best-quality Surgery is performed.     

Loop technique for mitral valve repair

A new artificial chordal reconstruction technique has been developed using several expanded polytetrafluoroethylene (ePTFE) loops. This technique differs from conventional artificial chordal reconstruction in the use of premeasured ePTFE loops. The loop technique involves several steps: (1) assessment of the corresponding papillary muscle; (2) measurement of the required ePTFE loop length; (3) making a loop set of the premeasured length; (4) anchoring the loop set to the papillary muscle; (5) fixing the ePTFE loops to the prolapsing leaflet; (6) adjusting the loop length if necessary; and (7) ring implantation. Favorable early and mid-term results of this loop technique have been reported in patients undergoing mitral valve repair through mini-thoracotomy and via median sternotomy, with 3-year survival and re-operation-free rates of 94.8 and 97.4 %, respectively. The loop technique using ePTFE chordal reconstruction with premeasured loops thus appears to be a safe, reliable, and reproducible technique for mitral valve repair. In addition, it is suitable for both minimally invasive and conventional sternotomy approaches, and represents a useful technique for treating posterior, anterior, and especially bi-leaflet prolapses.     

The role of the minimally invasive beating heart technique in reoperative valve surgery

Abstract Objective: We reviewed our experience to assess potential advantages of minimally invasive surgery without aortic clamping over conventional median sternotomy and cardioplegic arrest during reoperative valve surgery. Methods: From August 2008 to August 2010, 22 reoperative valve procedures were performed through a minimally invasive approach without aortic cross‐clamping [no‐clamp group (NCG)]. Postoperative results were compared to a matched population in terms of sex, age, and type of surgery, and operated through median sternotomy with aortic cross‐clamping and cardioplegic arrest [clamp group (CG)]. Results: We performed 17 mitral valve replacements (MVRs), one mitral valve repair, one MVR associated to a tricuspid plasty (TVP), and three isolated TVP in both groups. Cardiopulmonary bypass (CPB) time was 166 and 163 minutes in NCG and CG, respectively. Intra‐aortic balloon pump was necessary in two (NCG) and three (CG) patients. Two patients died in both groups from multiorgan failure. Biochemical analysis showed no significant differences in perioperative lactate or creatine kinase‐MB values. Conclusions: Redo valve surgery with an unclamped aorta is feasible, effective, and at least as safe as surgery using cardioplegic arrest. There was, however, no difference in biochemical or clinical outcomes from conventional surgery using aortic clamping and cardioplegic techniques. (J Card Surg 2012;27:24–28)     

Hemisternotomy approach for aortic and mitral valve surgery

After exploring several less invasive approaches for cardiac valve surgery, we have concluded that the partial upper sternotomy is the incision of choice for minimally invasive aortic and mitral valve surgery. From March 1997 to January 1999, 827 patients had cardiac valve surgery using this approach; 462 had mitral valve procedures and 365 had aortic valve procedures. Of those having mitral valve surgery, 87% had mitral valve repair. Aortic valve surgery included replacement with stented bioprostheses (38%), allografts (29%), and mechanical prostheses (10%); in addition, 23% had aortic valve repair. Operative mortality was 0.8%. Conversion to full sternotomy was necessary in 2.4%. Blood use was low with 80% of patients receiving no blood transfusions. We conclude that all primary mitral and aortic procedures can be accomplished safely via partial upper sternotomy.     

Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay

BACKGROUND: Robotic-assisted minimally invasive mitral valve reconstruction has gained popularity recently. Initial reports suggest that this approach can be used with relative safety and efficacy. Direct comparisons with a traditional sternotomy approach have not yet been explored extensively. METHODS: All mitral valve procedures that were performed by a single surgeon during a 3-year period of time were analyzed (n = 142 procedures). Patients whose condition required concomitant coronary artery bypass grafting or aortic valve surgery were excluded subsequently from analysis, because all of these patients were approached obligatorily by sternotomy (n = 71 patients). Six patients underwent right thoracotomy mitral valve procedures without robotic assistance, and 1 patient in cardiogenic shock underwent emergent mitral valve reconstruction by sternotomy. Of the remaining 64 patients who were eligible theoretically for sternotomy or robotic-assisted minimally invasive surgery, 39 patients underwent sternotomy, and 25 patients underwent right chest minimally invasive robotic-assisted surgery. Randomization between these 2 approaches would be almost impossible in the United States. The primary determinant for the choice of approach was request of the referring physician or patient. Multiple perioperative outcomes were then compared. RESULTS: Patients who underwent sternotomy and robotic-assisted surgery exhibited equivalent preoperative characteristics and experienced an equivalent degree of correction of mitral regurgitation in repairs and in need for replacement. Complex mitral valve repairs that entailed leaflet resection and reapproximation, annular plication, sliding annuloplasty, chordal transfer, and GoreTex neochordal construction were accomplished successfully with the robotic system. Cross-clamp and bypass times were longer for patients in the minimally invasive group (110 vs 151 minutes; P = .0015; 162 vs 239 minutes; P < .001, respectively). Mean packed red blood cell transfusion was lower among patients who underwent robotic-assisted surgery (5.0 vs 2.8 units; P = .04). Patients who underwent robotic-assisted surgeries experienced shorter mean duration of postoperative hospitalization (10.6 vs 7.1 days; P = .04). There was 1 death among the patients who underwent sternotomy, and no deaths among the patients who underwent robotic-assisted surgery. CONCLUSION: Patients can undergo mitral valve reconstruction with minimally invasive robotic assistance, avoid a sternotomy, require less blood product transfusion, and experience shorter hospitalization.     

Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease

OBJECTIVE: We began minimally invasive mitral valve surgery in August, 1996, to reduce hospital costs, to improve patient recovery, cosmetic appearance, and to decrease trauma, yet maintain the same quality of surgery. To validate this approach we reviewed our entire experience through May 2002. METHODS: From August 1996 to May 2002, we performed 413 minimally invasive mitral valve operations including 51 mitral valve replacements and 362 mitral valve repairs. Excluding 4 robotically assisted repairs, we evaluated 358 patients, using the mitral valve repairs as the basis for this retrospective survey. These operations were performed through a 6- to 8-cm minimally invasive incision, beginning with parasternal and, most recently, lower ministernotomy (181 patients). The mitral valve reparative techniques include repair of 94 prolapsed anterior leaflets, posterior leaflet resection, leaflet advancement, commissuroplasty, Polytetrafluoroethylene (PTFE; Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) chordal placement, and ring annuloplasty. Cannulation sites varied but primarily utilized a miniaturized system of 24F catheters in both the inferior and superior venae cavae with assisted venous suction. The Cosgrove ring was used in 95% of the patients undergoing this procedure. RESULTS: The operative mortality was 0/358. Perioperative morbidity included a 26% incidence of new atrial fibrillation, 2% incidence of pacemaker implantation, 0.5% incidence of deep sternal wound infection, and 1.9% incidence of stroke after an operation. There were 10 arterial and 3 venous complications. The mean length of stay was 6 days and 208 patients stayed < or =5 days. Only 25% of the patients underwent homologous blood transfusion. The mean follow-up was 36 months with 1.4% lost to follow-up. There were 12 late deaths and a survival at 5 years of 95%. There were 21 valves requiring reoperation for structural valve failure of 5.8%. The probability of freedom from reoperation at 5 years was 92%. CONCLUSION: This study documents the safety of minimally invasive mitral valve repair surgery in 358 patients. It also documents a low incidence of homologous blood use, requirement for post-hospital rehabilitation, and general morbidity.     

Minimally invasive approach for redo mitral valve surgery: a true benefit for the patient

OBJECTIVES: Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. MATERIAL AND METHODS: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59+/-13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. RESULTS: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168+/-73 [redo] vs 168+/-58 min and 52+/-21 [redo] vs 58+/-25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. CONCLUSION: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Minimally Invasive Approach for Redo Mitral Valve Surgery: A True Benefit for the Patient

ABSTRACT Objectives Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. Material and Methods: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59 ± 13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. Results: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168 ± 73 [redo] vs 168 ± 58 min and 52 ± 21 [redo] vs 58 ± 25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. Conclusion: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.

OBJECTIVE: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. SUMMARY BACKGROUND DATA: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. METHODS: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. RESULTS: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. CONCLUSIONS: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.     

Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results

BACKGROUND: This study compares intermediate-term outcomes of mitral valve reconstruction after either the standard sternotomy approach or the new minimally invasive approach. Although minimally invasive mitral valve operations appear to offer certain advantages, such as reduced postoperative discomfort and decreased postoperative recovery time, the intermediate-term functional and echocardiographic efficacy has not yet been documented. METHODS: From May 1996 to February 1999, 100 consecutive patients underwent primary mitral reconstruction through a minimally invasive right anterior thoracotomy and peripheral cardiopulmonary bypass and Port-Access technology (Heartport, Inc, Redwood City, Calif). Outcomes were compared with those for our previous 100 patients undergoing primary mitral repair who were operated on with the standard sternotomy approach. RESULTS: Although patients were similar in age, the patients undergoing the minimally invasive approach had a lower preoperative New York Heart Association classification (2.1 +/- 0.5 vs 2.6 +/- 0.6, P <.001). There was one (1.0%) hospital mortality with the sternotomy approach and no such case with the minimally invasive approach. Follow-up revealed that residual mitral insufficiency was similar between the minimally invasive and sternotomy approaches (0.79 +/- 0.06 vs 0.77 +/- 0.06, P =.89, 0- to 3-point scale); likewise, the cumulative freedom from reoperation was not significantly different (94.4% vs 96.8%, P =.38). Follow-up New York Heart Association functional class was significantly better in the patients undergoing the minimally invasive approach (1.5 +/- 0.05 vs 1.2 +/- 0.05, P <.01). CONCLUSIONS: These findings demonstrate comparable 1-year follow-up results after minimally invasive mitral valve reconstruction. Both echocardiographic results and New York Heart Association functional improvements were compatible with results achieved with the standard sternotomy approach. The minimally invasive approach for mitral valve reconstruction provides equally durable results with marked advantages for the patient and should be more widely adopted.     

Mitral regurgitation caused by an isolated mitral leaflet cleft

An isolated cleft of the mitral valve leaflet is rare cause of mitral regurgitation in adults. We report a successful minimally invasive mitral valve repair for severe mitral regurgitation caused by an isolated cleft of the anterior mitral leaflet. During the operation, we found a large cleft measuring 5×8 mm in the center of the anterior mitral leaflet. We closed the cleft directly and performed annuloplasty with a 30-mm Carpenter-Edwards Physio Ring (Edwards Lifesciences, Irvine, CA). The mitral valve is very well visualized with the video-assisted minimally invasive approach through the right chest.     

Mitral valve repair robotic versus sternotomy.

OBJECTIVE: Robotically assisted mitral valve repair were compared with sternotomy mitral valve repair. Prospectively we evaluated safety and efficacy in performing simple mitral repairs. METHODS: Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system. They were matched retrospectively with 25 patients who underwent the same repair via a median sternotomy. The minimal invasive repairs were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Repair was performed with two ports and a 4-cm intercostals lateral incision in the right chest for access. All patients had posterior leaflet resection and placement of a ring annuloplasty. RESULTS: All patients had successful valve repairs. There were no deaths. There was one conversion to an extended thoracotomy in the minimal invasive group due to a bleeder on the left atrial appendage. Overall mean study times showed a longer aortic cross-clamp (range, 96.1 min vs 69.6 min) and cardiopulmonary bypass (range, 122.1 min vs 85.7 min) for the minimal invasive group. Length of stay was less for the minimal group (7 days vs 9 days). At postoperative echocardiography two patients in both group developed 2+ mitral regurgitations. All other patients had a competent mitral valve repair with no insufficiency. CONCLUSIONS: Simple mitral valve repair can be successfully performed with the da Vinci robotic system. This approach is as safe as a sternotomy and long-term follow-up is needed to determine the durability of the mini invasive repair.     

One thousand minimally invasive valve operations: early and late results

OBJECTIVE: We sought to evaluate the potential benefits of minimally invasive approaches for treatment of isolated aortic and mitral valve disease. METHODS: From 7/96 to 04/03, we performed 1000 minimally invasive valve operations: 526 aortic (AV) procedures (64 years; mean, 25-95) and 474 mitral (MV) procedures (58 years; mean, 17-90). RESULTS: In the AV group, an upper ministernotomy was used in 492/526 patients (93%) and a right parasternal approach in 34 (7%). Sixty-three patients had reoperative aortic valve replacements. In the MV group lower sternotomy was used in 260/474 (55%), right parasternal in 200/474 (42%), and a right thoracotomy in 14 patients. MV repair was performed in 416 and MV replacement in 58 patients. Operative mortality was 12/526 (2%) in the AV and 1/474 (0.2%) in the MV group. Freedom from reoperation at 6 years was 99% and 95% in the AV and MV group, respectively. Late mortality was 5% in the AV and 3% in the MV group, respectively. CONCLUSIONS: Minimally invasive valve surgery can be performed at very low levels of morbidity and mortality, with results equal to or better than conventional techniques. All forms of valve repair and replacement operations can be performed. Long-term survival and freedom from reoperation are excellent.     

Minimally invasive valve surgery

BACKGROUND: Cardiac surgery has been the last area of clinical surgery to adopt and embrace minimally invasive surgical techniques. Since the onset of arterial embolectomy in 1965, arthroscopic knee surgery performed in 1975 and laparoscopic cholecystectomy in 1985, huge advances in videoscopic, thorascopic and small incision surgery has taken place in all specialties which now allow change in the traditional approaches to cardiac valve surgery. In 1996, the Brigham and Women's Hospital, along with other units, began minimally invasive cardiac valve surgery for patients who had isolated valve pathology without coronary disease. Our experience now totals 689 patients, including 353 minimally invasive mitral valve repair/replacements and 336 minimally invasive aortic valve replacements, including root replacement and reoperations. METHODS: This new operative approach involves smaller incisions, the mandatory use of transesophageal echocardiogram for the monitoring of operation quality and air removal, newer perfusion techniques and some modifications in the standard valve repair/replacement techniques. With this blending of TEE, better perfusion techniques and new exposure, the safety and quality of valve operations by these techniques have been excellent. RESULTS AND CONCLUSION: The operative mortality is equal to (AVR) or less than (MVP) conventional open sternotomy cases and there is a shorter length of stay in the ICU and post-ICU, leading to a lower cost than conventional procedures. There are also less blood transfusions, atrial fibrillation and posthospital rehabilitation requirements, and patients have indicated that there is a faster return to normality over the conventional operative approaches. This brief report summarizes our experience from July, 1996 to January 2001.     

Is a port-access mitral valve repair superior to the sternotomy approach in accelerating postoperative recovery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether port-access mitral valve repair reduces the recovery period of patients compared to the conventional sternotomy approach. Using the reported search, 778 papers were identified. Thirteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The 13 papers demonstrated that patients who undergo minimally invasive mitral valve repair have a shorter ICU and total hospital stay than those who undergo the sternotomy approach. Results vary but mean hospital stays range from 5.6 to 13 days in port-access groups compared to 6.25-15 days in sternotomy groups. Other advantages over the sternotomy approach were reduced postoperative bleeding and pain, shorter time to extubation and a quicker return to daily activities. However, it is consistently reported that operative time is longer, with the increase in bypass time being around 30 min. We conclude that in several cohort studies minimally invasive mitral valve repair is reported to result in a shorter ICU and hospital stay, reduced postoperative bleeding and pain and a shorter time to resuming normal activities. This is at the expense of longer bypass and operative times.     

A case report of surgical correction for congenital mitral regurgitation with subvalvular apparatus abnormality

We report a successful complex mitral valve plasty using port access minimally invasive cardiac surgery for congenital mitral regurgitation that presented as an abnormality of the subvalvular apparatus. A 16-year-old male patient received a diagnosis of mitral regurgitation resulting from tethering of the anterior mitral leaflet and posterior mitral leaflet caused by an abnormality in papillary muscle insertion and a hypoplastic chordae tendineae. The posterior leaflet was closely tethered to the tips of the papillary muscle with essentially no chordae tendineae. The flexibility of the leaflet was restored by surgically removing the abnormal chordae, and reconstruction of chordae tendinae of the anterior leaflet was carried out using three loops and of the posterior leaflet using one loop with a loop technique method. As an additional procedure for persistent regurgitation, an edge-to-edge technique to the posterior commissure side was performed, after which the mitral regurgitation disappeared.     

Mini-Reoperative Mitral Valve Surgery

BACKGROUND: Reoperative surgery involving the atrioventricular valves places the patient at risk for cardiac or bypass graft injury upon reoperative sternotomy. Standard right thoracotomy can avoid these problems but is associated with a large incision and possibly more pulmonary complications. METHODS AND RESULTS: An alternative, minimally invasive approach for reoperative atrioventricular valve surgery was studied in 22 patients. Patient age was 66 +/- 10 years. Postoperative mitral regurgitation was 3.4 +/- 0.3 and New York Heart Association (NYHA) Class was III/IV, despite a mean ejection fraction of 44 +/- 14%. These patients had 1-4 prior procedures a mean of 5 years previously. An anterior 5th interspace incision of 5- to 10-cm was performed. A 1-cm segment of 5th rib was removed to facilitate exposure. Cardiopulmonary bypass was performed via ascending aorta or femoral artery cannula and bicaval venous cannulae. Systemic cooling (25 degrees) and fibrillatory arrest was used. Operations performed included mitral valve repair (12), mitral valve replacement (5), prosthetic mitral valve rereplacement (4), repair of perivalvular leak (3), tricuspid valve repair (5), and atrial septal defect closures (7). Mean bypass time was 109 +/- 21 minutes with a mean fibrillatory time of 62 +/- 12 minutes. There was no intraoperative or 30-day mortality. Patients were weaned from ventilation at a mean of 5 hours postoperatively and received 1.3 +/- 1 unit of blood. There were no wound complications or re-explorations for bleeding. At a mean follow-up of 15 +/- 8 months, survivors are NYHA Class I-II. When interviewed, all patients felt their recovery was more rapid and less painful than their original sternotomy. CONCLUSION: This minimally invasive approach to reoperative atrioventricular valve surgery is safe and technically feasible. It has become our preferred approach to the atrioventricular valves in patients with a previous sternotomy.     

Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience

BACKGROUND: Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. METHODS: Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. RESULTS: Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. CONCLUSIONS: The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.