Mitral Valve Surgery Can Now Routinely Be Performed Endoscopically

Abstract

Background— There is an increasing interest in minimally invasive cardiac surgery. Methods and Results— Since February 1, 1997 till April 1, 2002, 306 patients underwent endoscopic mitral valve surgery (226 repair, MVP; 80 replacement, MVR). Predominant valve pathology was degenerative in MVP (83.6%) and rheumatic in MVR (65%). Mean age was 61.5±12.9 years. Median preoperative functional class (MVP+MVR) and mitral regurgitation (MVP) were II and 4+. Statistical analysis included Kaplan-Meier and Cox regression methods. Mean follow-up was 19.6±17.3 months and complete. The procedure was successfully performed in all but 6 patients. Hospital mortality included 3 patients (1%) and was technology related in one. Postoperative morbidity included aggressive re-exploration (8.5%), new onset atrial fibrillation (17.0%), and pacemaker implantation (2.3%). There were 1 early and 10 late reoperations, 5 of which were because of endocarditis. Freedom from mitral valve reoperation at 4 years was 91±3.5%. No risk factors for reoperation could be detected. Echocardiographic follow-up showed a median degree of mitral regurgitation (MVP) of 0 and a small paravalvular leak in four patients (MVR). Ninety-four percent of the patients reported no or mild postoperative pain and 99.3% felt they had an esthetically pleasing scar. Ninety-three percent would choose the same procedure again and 46.1% were back at work within 4 weeks. Conclusions— Endoscopic mitral valve surgery can be performed safely but definitely requires a learning curve. Good results and a high patient satisfaction are guaranteed. It is now our exclusive approach for isolated atrioventricular valve disease.

Cirurgia cardíaca videoassistida

“…A complication of aortic endoclamping much reported in the literature [40,45,46] also occurred in our series. A dissection of the atrioventricular groove and rupture of the left ventricle were observed in a patient with mitral valve surgery in advance on which we used the method.…”

Initial experience with minimally invasive cardiac operations

“…Data from the Society of Thoracic Surgery (STS) show that less than 20% of valve surgeries are performed by minimally invasive incisions, and there are few centers that make these surgeries more routine [1,2,9]. In our country, that number should be even lower, given the small number of publications on minimally invasive valve surgery, and with relatively small case series [10][11][12][13].…”

“…With the development of the technique, our dissection of the intercostal spaces is minimal and corresponding for the size of the incision in the skin, and the removal of the intercostal space is limited, avoiding trauma to the ribs and thereby decreasing postoperative pain. Some centers advocate the use of video or robotic systems for performing these surgeries [4,9,11]. In Brazil, Poffo et al [11] reported their experience of minimally invasive surgeries with the aid of video, including being performed a pioneering procedure by periareolar access.…”

“…For anesthesia, the selective intubation should be avoided, since the possibility of occurrence of unilateral pulmonary edema which is a complication of complex handling [23]. The use of TEE is essential for the proper positioning of the arterial, venous and retrograde cardioplegia cannulas, as well as for monitoring various steps of the surgery, during the removal of air from the heart chambers and to monitor ventricular function and appropriate management of inotropic drugs, since we have no visualization of the heart as in the conventional surgeries [7,9]. In our series, we had a case of injury to the right ventricle through the tip of the venous cannula that could have been avoided with proper TEE control which was not available in this case.…”

Evolution of a minimally invasive mitral valve program

“…The minimally invasive access advanced from partial sternotomy to anterolateral minithoracotomy and from direct vision via endoscopic guidance to totally endoscopic procedures (2)(3)(4).…”