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This article describes the approach to mitral valve repair using ThruPort (Edwards Lifesciences, Irvine, CA) technology to facilitate peripheral cannulation, endoballoon clamping of the ascending aorta, and access to the mitral valve through a non-rib-spreading right minithoracotomy. Preoperatively, patients who met the indications for mitral valve repair were evaluated by cardiac catheterization, pulmonary function tests, and magnetic resonance imaging to exclude patients with whom this procedure is not deemed appropriate. Patients with severe peripheral vascular disease, a dilated ascending aorta >4.5 cm, or those with lung adhesions that might render the access impossible to the right hemithorax are excluded.
The successful conduct of endoscopic mitral valve repair surgery requires the coordination of perfusionists, nurses, anesthesiologists, and surgeons. The procedure is performed under general anesthesia with a double-lumen endotracheal tube. Transesophageal echocardiography (TEE) plays a vital role in venous cannulation, in EndoClamp (Edwards Lifesciences) balloon placement, and with assessing the valve both pre- and postcardiopulmonary bypass (post-CPB). Femoral-femoral CPB with separate drainage of the superior vena cava is utilized along with endo-aortic clamping with an EndoClamp balloon. Cold crystalloid cardioplegia is delivered in an antegrade fashion via a lumen on the EndoClamp. Long-shafted instruments are used to carry out the procedure, while a 5-mm endoscope is used to optimize visualization of the intrathoracic cavity and valvular apparatus. In our experience, a team approach with well-trained specialists has resulted in excellent results with mortality of <1% and a freedom from reoperation of >93% at 4 years.
Endoscopic approaches to mitral valve repair have resulted in reduced intensive care unit and hospital stays, accelerated recovery times, improved postoperative pulmonary function, improved quality of life, reduced rehabilitation requirements, and improved cosmesis.
Postoperatively, patients are monitored overnight in the intensive care unit. Chest tubes are removed on the second postoperative day. Patients' survival and freedom from reoperation are excellent and comparable to valves repaired using standard sternotomy approaches.
In our experience, the adherence of Carpentierian principles and the performance of all known repair techniques can be routinely performed using the thoracoscope, which provides optimal visualization.
Totally endoscopic mitral valve repair is designed to have similar characteristics to the least invasive cardiology interventions that result in minimal scarring, no pain, and immediate rehabilitation. By utilizing a non-rib-spreading endoscopic approach, we can come very close to this level of noninvasiveness by limiting the size of the scar and the magnitude of the physiologic response, and with this approach, afford the patient no pain and complete rehabilitation in 2 weeks. Cardiac surgeons who continue to perform sternotomy to manage repairable mitral valves with rehabilitation after 2 months are encouraging interventional cardiologists to continue their efforts to achieve percutaneous “repairs” without respect for the basic “Carpenterian” rules of mitral valve repair.
Van Slycke S.
Mitral valve surgery can now routinely be performed endoscopically.
Dr. F. Casselman reports receiving lecture fees from Medtronic, Edwards, and Atricure. Dr. F. Van Praet reports receiving consulting fees from Edwards and Intuitive Surgical and lecture fees from Edwards. Dr. H. Vanermen reports receiving consulting fees from Edwards, USB Medical, Valtech, and 4-Tech (Founder). Dr. H. Vanermen also receives royalties from Medtronic for inventing the Countour Tricuspid Annuloplasty Ring, and royalties from USB Medical. Drs. A. Vanermen, I. Deblier, K. Dossche, I. Degriek, R. Beelen, L. Maene, and F. Cooreman have no commercial interests to disclose.