Minimally invasive mitral valve surgery through right mini-thoracotomy: recommendations for good exposure, stable cardiopulmonary bypass, and secure myocardial protection

Abstract

An apparent advantage of minimally invasive mitral surgery through right mini-thoracotomy is cosmetic appearance. Possible advantages of this procedure are a shorter ventilation time, shorter hospital stay, and less blood transfusion. With regard to hard endpoints, such as operative mortality, freedom from reoperation, or cardiac death, this method is reportedly equivalent, but not superior, to the standard median sternotomy technique. However, perfusion-related complications (e.g., stroke, vascular damage, and limb ischemia) tend to occur more frequently in minimally invasive technique than with the standard technique. In addition, valve repair through a small thoracotomy is technically demanding. Therefore, screening out patients who are not appropriate for performing minimally invasive surgery is the first step. Vascular disease and inadequate anatomy can be evaluated with contrast-enhanced computed tomography. Peripheral cannulation should be carefully performed, using transesophageal echocardiography guidance. Preoperative detailed planning of the valve repair process is desirable because every step is time-consuming in minimally invasive surgery. Three-dimensional echocardiography is a powerful tool for this purpose. For satisfactory exposure and detailed observation of the valve, a special left atrial retractor and high-definition endoscope are useful. Valve repair can be performed in minimally invasive surgery as long as cardiopulmonary bypass is stable and bloodless exposure of the valve is obtained.

Axillary venous drainage in redo aortic root surgery

“…The common femoral vein is the standard peripheral venous cannulation site for CPB. Modern femoral venous cannulas with multiholes usually provide sufficient drainage for full‐flow CPB with the aid of a vacuum assist . However, two venous cannulas may provide better drainage than one, and bicaval drainage is occasionally necessary .…”

“…Modern femoral venous cannulas with multiholes usually provide sufficient drainage for full‐flow CPB with the aid of a vacuum assist . However, two venous cannulas may provide better drainage than one, and bicaval drainage is occasionally necessary . A right jugular venous drainage is added through the cannula placed percutaneously from the neck in patients undergoing minimally invasive cardiac surgery.…”

Robotic‐assisted cardiac surgery without lung isolation utilizing single‐lumen endotracheal tube intubation

“…Nevertheless, right‐sided unilateral pulmonary edema developed in several patients. With the goal of providing better outcomes, the studies and alternative techniques in minimally invasive cardiac surgery were reviewed 1‐26 . The literature on robotic cardiac surgery presented no recommendations about the use of SL endotracheal tubes without lung isolation.…”

“…The literature on robotic cardiac surgery presented no recommendations about the use of SL endotracheal tubes without lung isolation. However, some authors used SL endotracheal intubation without lung isolation in minimally invasive cardiac operations 20‐22 . Ito 20 noted that although lung isolation is important but not essential for minimally invasive cardiac surgery.…”

“…However, some authors used SL endotracheal intubation without lung isolation in minimally invasive cardiac operations 20‐22 . Ito 20 noted that although lung isolation is important but not essential for minimally invasive cardiac surgery. The authors suggested that ventilation could be held or made intermittent both before cardiopulmonary bypass (CPB) and at its conclusion to permit exposure.…”