Minimally invasive valve sparing mitral valve repair-the loop technique-how we do it

Abstract

Mitral valve insufficiency is the second most common heart valve disease, with untreated regurgitation leading to enlargement of the left atrium (LA), atrial fibrillation and heart failure. Besides functional regurgitation, the main cause is degenerative valve disease with elongation of the chordae tendineae and prolapsing of the leaflets. Surgical repair is the gold standard therapy for mitral valve insufficiency today. Recently, the implantation of neochordae (the "loop-technique") has been established and is the preferred technique in many centres including ours. Results of surgical mitral valve repair are good with low rates of re-intervention and mortality. With minimally invasive techniques, patient satisfaction is high and hospital stay is short. In conclusion, mitral valve repair should be the preferred strategy in patients with symptomatic mitral valve insufficiency or with asymptomatic mitral valve insufficiency in accordance with the guidelines. Modern repair techniques like neo-chord implantation with the loop-technique combined with minimally invasive access routes result in low mortality and morbidity and short hospital stay as well as high patient satisfaction.

Keywords: Mitral valve repair; minimally invasive surgery; operative setup.

Figure 1

OR Setup.

Figure 2

Chest wall landmarks before any incisions are made.

Figure 3

Incision with soft-tissue retractor, transthoracic Chitwood clamp, Camera with CO₂ supply and arm for the atrial roof retractor.

Figure 4

Pericardial incision site after putting two pericardial sutures and a suture in the epicardial fat above the interatrial grove.

Figure 5

Cardioplegia insertion and cross clamp. Below the aorta, where suction is placed.

Figure 6

Left atriotomy to expose the mitral valve.

Figure 7

Segments of the mitral valve. A, anterior; P, posterior.

Figure 8

Estimation of necessary chordal length with a caliper.

Figure 9

Neo-chordae insertion and fixation at the free margin of P2.

Figure 10

Measurement of the necessary annuloplasty ring size after implantation of ring sutures (green).

Figure 11

Implanted annuloplasty ring with the sutures partially knotted.

Figure 12

Left atriotomy closure.