Minimally invasive mitral valve repair

Abstract

Minimally invasive mitral valve (MV) repair is being increasingly performed over the last 2 decades due to the constantly growing patient demand, since it offers a shorter recovery, less restriction and faster return to normal physical activities, reduction in pain, and superior cosmetic results. However, such procedures have to be performed through small incisions which limit visualization and the freedom of movement of the surgeon, in contrast to conventional operations that are performed through a sternotomy. Therefore, special long surgical instruments are required, and visualization is usually enhanced with advanced port-access two-dimensional (2D) or three-dimensional (3D) thoracoscopic cameras. This makes performance of a minimally invasive MV repair more challenging for the surgeon and is thereby associated with a steep learning curve. Nonetheless, the vast majority of patients who require MV repair are usually good candidates for this less invasive technique, though adequate patient selection is of utmost importance for success. Concomitant cardiac procedures such as ablation surgery for atrial fibrillation or right-sided interventions such as tricuspid valve surgery, heart tumor resection, and atrial septal defect closure can easily be performed using this approach. Short- and long-term results after minimally invasive MV repair are excellent and comparable with those achieved through a sternotomy approach. There are few drawbacks associated with minimally invasive MV repair such as the high technical demands of working through a constrained space and development of complications associated with peripheral cannulation and seldom unilateral pulmonary edema. Nonetheless, high-volume centers have been able to achieve similar operating times, postoperative complication rates, and mid-/long-term outcomes to those obtained through conventional sternotomy. Up-to-date evidence is needed in order to improve recommendations supporting minimally invasive MV repair. Future innovations should concentrate on decreasing complexity and improving reproducibility of minimally invasive procedures in low-volume centers.

Keywords: Minimally invasive mitral valve repair; Three-dimensional; Two-dimensional.

Fig. 1

Patient position: 30° left lateral position. The axilla (black dot) has to be within the operative field. The left arm (black hatched line) is positioned downwards and outwards

Fig. 2

Femoral arterial and venous cannulation

Fig. 3

The inframammary incision in females (black hatched arrow)

Fig. 4

The pericrdial incision: 3–4 cm anterior to phrenic nerve (white double-headed arrow), extends up to the diaphragm and further posteriorly to the inferior vena cava (yellow arrows)

Fig. 5

The setup shows the incision and soft tissue retractor (blue hatched circle), the thoracoscope port (black hatched arrow), the entry site of the transthoracic aortic clamp (black arrow), the left atrial retractor and holding arm (yellow hatched arrows), and the left atrial vent (yellow line)

Fig. 6

The water test. The line of coaptation should be located in the posterior third of the mitral valve orifice and should be parallel to the posterior mitral annulus

Fig. 7

The closed incision in males (blue circle) with drains and a pacing wire (yellow arrow)

Fig. 8

a P₂ prolapse. b Measurement of length of loops. c Loops attached to the antero-lateral papillary muscle. d, e PTFE sutures passed through the loops and then through the free margin of P₂