Minimally invasive mitral valve surgery

Minimally invasive mitral valve surgery (MIC-MVS) was introduced into clinical practice in the mid 1990s. Since then it has evolved as the standard technique at some specialized centers. The routine technique includes femoral access for extracorporeal circulation, a right lateral minithoracotomy and direct aortic clamping using special instruments. Different techniques leading to some variations have been described. There is no prospectively randomized trial comparing minimally invasive with conventional mitral valve surgery. However, several series including large patient numbers and up to 8 years of follow-up have been published. Literature results as well as different aspects of minimally invasive MVS are discussed in this review, including the development, the current technique and future perspectives. Regarding MIC-MVS the word is that it is a safe and effective operation. Lateral minithoracotomy access offers excellent exposure, visualization can be further enhanced when using endoscopic cameras. All different mitral valve repair procedures can be performed even in the presence of complex pathologies. The repair rate is excellent and reaches 75%. Patient recovery is fast leading to a significant improvement in individual quality of life. MIC-MVS can now be considered the standard approach and will reach more widespread clinical application.     

Reexamining contraindications for minimally invasive mitral valve surgery

Historically, contraindications to minimally invasive or robotic mitral valve surgery have included prior mastectomy, thoracic reconstruction, or chest radiation. However, we believe that by granting flexibility in the choice of skin incision site while performing careful dissection, surgeons can provide these patients the outstanding results afforded by a minithoracotomy. We present a patient who had undergone a prior mastectomy and radiation treatment in whom we performed a minimally invasive mitral valve repair through a right-sided minithoracotomy using the previous mastectomy incision.     

Minimally invasive, robotic, and off-pump mitral valve surgery

A significant transformation is occurring in the management of mitral valve disease. Earlier surgery is now recommended. Mitral valve repair is the standard of care, and newer methods of reconstructing the mitral valve are developing. Surgery with videoscopic assistance can be effectively performed without sternotomy. Robotics systems are gaining wider adoption. Implantable devices to repair or replace the mitral valve off-pump and percutaneously are emerging.     

Examination of mitral valve repair with port-access method—Aiming at early and less invasive mitral valve repair—

Objective  We reviewed the results of mitral valvuloplasty by port-access minimally invasive cardiac surgery to examine the validity of operating during an early phase. Methods  From 1988 through March 2007, a total of 126 patients requiring mitral valvuloplasty were treated with port-access minimally invasive cardiac surgery. Their mean age was 51 ± 13 years, and 88 were male. The operative procedures were resection-suture in 51 cases, artificial chordal replacement in 5 cases, chordal translocation in 3 cases, leaflet plication in 3 cases, and artificial chordal reconstruction by the loop technique in 64 cases. Results  There was one hospital death, and two patients required reoperation at 1 and 21 postoperative days because of hemolysis and intractable systolic anterior motion, respectively. Except for the two patients undergoing reoperation, the duration of the postoperative hospital stay was 9.7 ± 3 days. The results of the other cases were satisfactory during each follow-up period. Conclusion  Complete valvuloplasty with port-access MIS is thought to be an increasingly important procedure for treating mitral regurgitation. This study was presented at the 60th annual scientific meeting of the Japanese Association for Thoracic Surgery.     

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.     

Minimally invasive direct access mitral valve surgery.

We reviewed our experience with minimally invasive direct-access mitral valve surgery in 207 patients through February 1999. Three patients underwent associated procedures, a coronary artery bypass graft (CABG) with right internal mammary artery to right carotid artery (RIMA-RCA), a left ventricular outflow tract (LVOT) debridement for endocarditis, and a primum atrial septal defect (ASD) repair, and were excluded from analysis. Of the 204 remaining patients, 120 (59%) patients were men, aged 58.7 +/- 13.2 years, functional class of 2.3 +/- 0.5. The cause was myxomatous in 162 (79%) patients, rheumatic in 28 (14%) patients, endocarditis in 8 (4%) patients, congenital in 3 (2%) patients, and ischemic in 3 (2%) patients. Mean preoperative EF was 60% +/- 10%, with 184 (90%) patients showing ejection fraction (EF) greater than 50%. The valve was approached through a 5- to 8-cm right parasternal (n = 180, 88%) or right inframammary (n = 24, 12%) incision. One hundred nineteen (58%) patients had open femoral artery-femoral vein cannulation, and 85 (42%) patients had direct cannulation of the aorta and percutaneous cannulation of the femoral vein. One hundred seventy (83%) patients underwent successful valve repair, and 34 (17%) patients required valve replacement. The mean duration of aortic clamping and cardiopulmonary were, respectively, 100 +/- 34 and 146 +/- 44 minutes. There were 2 (1%) surgical deaths. Nonfatal perioperative complications included 3 (1.5%) ascending aortic complications, 3 (1.5%) reoperations for bleeding, 4 (2%) strokes, 2 (1%) transient ischemic attacks (TIAs), 2 (1%) myocardial infarctions, 3 (1.5%) pericardial effusions requiring drainage, 9 (4.5%) vascular complications, and 3 (1.5%) wound complications. Mean length of stay (LOS) was 6.1 +/- 3 days, with 63 (31%) patients being discharged in less than 5 days. One hundred twenty-nine (63%) patients did not require blood transfusions. Follow-up was complete in 165 (81%) patients, with mean follow-up of 13.2 +/- 8 months. Late complications included 1 (0.5%) myocardial infarction, 3 (1.5%) reoperations, all converting repairs to replacements, 3 (1.5%) wound hernias requiring reoperation and repair with mesh, 5 (2.5%) thromboembolic events, and 3 (1.5%) deaths of suicide, pneumonia, and sudden death, respectively. Mean follow-up New York Heart Association (NYHA) functional class was 1.2 +/- 0.5. We conclude that minimally invasive direct-access mitral valve surgery is safe, effective, and applicable for most patients presenting for isolated mitral valve surgery. We now consider it the standard of care for selected patients.     

Anesthetic considerations during minimally invasive mitral valve surgery

Advances in instruments and visualization tools as well as circulatory systems for cardiopulmonary bypass during the late 1990s have stimulated widespread adoption of minimally invasive mitral valve surgery (MIMVS). Today, MIMVS is the standard approach for many surgeons and institutions. There are multiple benefits of MIMVS. Patient satisfaction and improved cosmesis are important. Additionally, studies have consistently shown faster recovery times and less associated pain with MIMVS. Statistically significant improvement in bleeding, transfusion, incidence of atrial fibrillation, and time to resumption of normal activities with MIMVS has also been shown when comparing MIMVS with conventional mitral surgery. Most important, these benefits have been achieved without sacrificing perioperative safety or durability of surgical repair. Although a steep learning curve still exists given the high level of case complexity, continued development fueled by increasing patient demand may allow for even further expansion in the use of minimal invasive techniques.     

Robotic-assisted instruments enhance minimally invasive mitral valve surgery

BACKGROUND: The potential for totally endoscopic mitral valve surgery has been advanced by the development of minimally invasive techniques. Recently surgical robots have offered instrument access through small ports, obviating the need for a significant thoracotomy. This study tested the hypothesis that a microsurgical robot with 5 degrees of freedom is capable of performing an endoscopic mitral valve replacement (MVR). METHODS: Dogs (n = 6) were placed on peripheral cardiopulmonary bypass; aortic occlusion was achieved with endoaortic clamping and transesophageal echocardiographic control. A small left seventh interspace "service entrance" incision was used to insert sutures, retractor blade, and valve prosthesis. Robotically controlled instruments included a thoracoscope and 5-mm needle holders. MVR was performed using an interrupted suture technique. RESULTS: Excellent visualization was achieved with the thoracoscope. Instrument setup required 25.8 minutes (range 12 to 37); valve replacement required 69.3+/-5.39 minutes (range 48 to 78). MVR was accomplished with normal prosthetic valve function and without misplaced sutures or inadvertent injuries. CONCLUSIONS: This study demonstrates the feasibility of adjunctive use of robotic instrumentation for minimally invasive MVR. Clinical trials are indicated.     

Comparison between port-access and less invasive valve surgery.

BACKGROUND: Valvular operations have followed coronary artery bypass grafting as procedures that are amenable to a minimally invasive approach. This study is a review of our brief experiences of less invasive valve surgery (LIVS) through a partial sternotomy approach and port-access valve surgery (PAVS) with an attempt to compare safety and cost-effectiveness of the surgical procedure and post-discharge follow-up. METHODS: Forty PAVS and 66 LIVS procedures performed between May 1996 and December 1998 were reviewed. The PAVS patients were younger, included more men, and had greater left ventricular function. Aside from these particular data points, there was no significant difference in preoperative variables between groups. RESULTS: Operating room time, surgery time, and cross-clamp time were significantly longer in the PAVS group. The operative mortality was 3% (LIVS) and 5% (PAVS). There was more new atrial fibrillation in LIVS (26% versus 5%, p = 0.009). Postoperative follow-up revealed 77% of LIVS and 76% of PAVS patients had returned to work and more than 95% of the retired patients in both groups had resumed their daily activities. Importantly, PAVS patients returned to work about 4 weeks sooner than LIVS patients did. CONCLUSIONS: Early clinical outcomes are comparable between the two approaches, which indicates safety and importance of appropriate patient selection. More follow-up is required to assess postoperative pain and cosmetic satisfaction. At the present time, LIVS appears to be more cost-effective. Early return to work in the PAVS group may be the most important finding to further support the port-access approach. However, with practice pattern changes and increased intraoperative efficiencies, each of these two surgical techniques may continue to have an important role in the minimally invasive valve surgery arena.     

Minimally invasive surgery of mitral valve (MIS-MV)

Following the revision of the therapeutic guideline of ACC/AHA in (Circulation 114:450–527, 2006), the incidence of mitral valve repair in asymptomatic patients with moderate or severe mitral valve regurgitation has increased. For mitral valve repair, the quality and outcomes as well as lower invasive procedure are important to obtain the confidence of cardiologists and ensure request of early phase operation from cardiologists. With recent innovations of technologies and the development of revolutionary techniques, minimally invasive surgery of the mitral valve (MIS-MV) has become a widespread surgical option of mitral valve repair. It is vital, however, that careful preoperative assessment, and planning of the approach and perfusion strategy are put in place to perform MIS-MV safely.     

Minimally invasive mitral valve surgery after failed transcatheter mitral valve repair in an intermediate-risk cohort

Open in a separate window OBJECTIVESAlthough clinical experience with transcatheter mitral valve interventions is rapidly increasing, there is still a lack of evidence regarding surgical treatment options for the management of recurrent mitral regurgitation (MR). This study provides guidance for a minimally invasive surgical approach following failed transcatheter mitral valve repair, which is based on the underlying mitral valve (MV) pathology and the type of intervention.METHODSA total of 46 patients who underwent minimally invasive MV surgery due to recurrent or residual MR after transcatheter edge-to-edge repair or direct interventional annuloplasty between October 2014 and March 2021 were included.RESULTSThe median age of the patients was 78 [interquartile range, 71–82] years and the EuroSCORE II was 4.41 [interquartile range, 2.66–6.55]. At the index procedure, edge-to-edge repair had been performed in 45 (97.8%) patients and direct annuloplasty in 1 patient. All patients with functional MR at the index procedure (n = 36) underwent MV replacement. Of the patients with degenerative MR (n = 10), 5 patients were eligible for MV repair after removal of the MitraClip. The 1-year survival following surgical treatment was 81.3% and 75.0% in patients with functional and degenerative MR, respectively. No residual MR greater than mild during follow-up was observed in patients who underwent MV repair.CONCLUSIONSMinimally invasive surgery following failed transcatheter mitral valve repair is feasible and safe, with promising midterm survival. The surgical management should be tailored to the underlying valve pathology at the index procedure, the extent of damage of the MV leaflets and the type of previous intervention.     

Minimally invasive mitral valve surgery: mini-sternotomy with extended transseptal approach.

A partial upper sternotomy and an extended transseptal incision provide excellent exposure for mitral valve surgery. From March 1997 to December 1998, 462 patients had mitral valve surgeries using this minimally invasive approach. Eighty-seven percent had mitral valve repair, and 13% had mitral valve replacement. Thirteen patients (3%) required conversion to full sternotomy, and all other patients had the procedure completed using the initial approach. Forty-eight percent of patients were extubated within 6 hours of surgery, and 47% of patients spent less than 24 hours in the intensive care unit (ICU). Mean hospital length of stay was 7.2 +/- 5.4 days. Eighty-six percent of patients received no blood products. There was 1 hospital death (0.2%). Morbidity included reexploration for bleeding (4%), respiratory insufficiency (1%), stroke (1%), myocardial infarction (0.2%), and wound infection (0.2%). We conclude that virtually all mitral valve procedures, including complicated repairs, can be accomplished via partial upper sternotomy with an extended transseptal incision. This approach provides excellent exposure of the mitral valve and results in a low rate of wound complications, low transfusion requirements, and excellent cosmesis.