Minimally invasive mitral valve surgery via minithoracotomy and direct cannulation M.H. Nezafati Associate Professor of Cardiac Surgery Mashhad University of Medical Sciences 3rd International Congress on Cardiovascular Diseases Mashhad – Iran 12-14 November 2014

Presented 120 cases in ISMICS 2006 New York – Big Apple Medicine is an ever-changing science

Medicine is an ever-changing science Background Medicine is an ever-changing science

Better Patient Satisfaction Background Minimally Invasive of Mitral valve surgery, since 1990s. Same quality as conventional BUT Surgical trauma Pain Recovery time Cosmetic outcome SO Better Patient Satisfaction Medicine is an ever-changing science

Minithoracotomies Background Minimally Invasive Mitral Valve Surgery include: Partial Sternotomies Parasternal Incisions Minithoracotomies Medicine is an ever-changing science

Medicine is an ever-changing science Background Presenting : our experience with minimally invasive mitral valve surgery via an anterolateral minithoracotomy, avoiding any peripheral cannulation, and providing adequate mitral valve exposure. Medicine is an ever-changing science

Medicine is an ever-changing science PATIENTS & METHODS Medicine is an ever-changing science

Patients & methods - through a 6-7cm right submammary skin … From July 2001 to December 2013 320 patients Male / Female = 181/139 All intubated with a double-lumen endotracheal tube Placed in the supine position with the arms tucked and right shoulder slightly elevated Chest was prepared and draped to enable a sternotomy (should this become necessary) Right lung deflated and a small thoracotomy performed in the 4th intercostal space through a 6-7cm right submammary skin Right chest retractor placed and gradually opened Right Internal Mammary Artery carefully identified and protected from any trauma Pericardium incised longitudinally anterior to the phrenic nerve Medicine is an ever-changing science

Patients & methods - Aorto-bicaval cannula … Aorto-bicaval cannula (arterial cannula, straight tip with flange; Maquet) and a right atrial cannula (DLP malleable single stage venous cannula; Medtronic) a suction-vent cardioplegia catheter conventionally sited directly through the thoracotomy and cardiopulmonary bypass initiated Medicine is an ever-changing science

Patients & methods - Intermittent antegrade blood cardioplegia … After cooling to 32C, the aorta was crossclamped using a standard aortic clamp through the thoracotomy Intermittent antegrade blood cardioplegia used to provide superb myocardial protection The mitral valve approached through the interatrial groove (Cooley atrial retractor, USA pattern; Geister) and repaired or replaced as deemed necessary Medicine is an ever-changing science

Patients & methods - Ablation … Performed when necessary Cobra device (Boston Scientific Corporation) Ablation undertaken using radiofrequency for 1 min on each lesion Left atrium closed routinely after the main procedures performed Patient weaned from cardiopulmonary bypass following rewarming to 37 A single drain with 2 additional lateral holes inserted through the 7th intercostal space on the midaxillary line Chest closed in layers and intercostal block carried out by Marcaine injection Medicine is an ever-changing science

Medicine is an ever-changing science RESULTS Medicine is an ever-changing science

Results Mitral valve repaired = 89 (28%) Replaced = 231 (72%) Tricuspid valve repair = 80 (25%) Radiofrequency Ablation = 80 (25%) Medicine is an ever-changing science

Medicine is an ever-changing science results Mean cross-clamp time = 43.0 ± 13.4 min Mean CPB time = 55.3 ± 17.0 min Mean ventilation time = 6.4 ± 2.8 hrs Mean length of ICU stay = 37 ± 8.7 hrs Mean legend of hospital stay = 8.1 ± 2.2 days Mortality = 0 Re-operation = 8 (2.5%) Excessive postoperative bleeding or mitral insufficiency Complication Conversion to sternotomy = 3 (0.94%) Inability to obtain satisfaction arterial cannulation Infection = 0 Medicine is an ever-changing science

Medicine is an ever-changing science Other studies Soltesz et al. (2007) : Minimally invasive valve surgery is a safe and effective procedure with similar if not improved morbidity and mortality rates compared to conventional valve surgery Burfeind et al. (2002) : The potential advantages of approaching the mitral valve through a right thoracotomy in the reoperative setting are the avoidance of patent bypass grafts including the left internal mammary artery, less dissection, improved mitral exposure, and less bleeding El-Fiky et al. (2000) : One of the disadvantages of this minimally invasive approach through a right thoracotomy is that there is a learning curve for the surgeon and team to be able to perform the procedure through a smaller incision with a right chest retractor, suitable aortic clamp, and arterial and venous cannulae Medicine is an ever-changing science

Medicine is an ever-changing science CONCLUSION Medicine is an ever-changing science

Medicine is an ever-changing science Conclusion Advantages Disadvantages Shorter ICU stay BMI greater than 32 kg/m2 Less blood loss (sternotomy elimination) Learning curve Less pain Less chest tube drainage Femoral cannualtion complications avoidance Right Internal Mammary artery protection Eradicating the risk of deep sternal infection Better reoperative setting Medicine is an ever-changing science

Medicine is an ever-changing science Conclusion minimally invasive direct mitral valve surgery through a right minithoracotomy using standard cardiopulmonary bypass is a good alternative to the conventional open surgical method Excellent cosmetic results and avoidance of sternal complications are the major advantages This technique deserves a place in the surgical armamentarium for mitral valve treatment, to improve patient satisfaction Medicine is an ever-changing science

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