1. 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 November 2014

2. Presented 120 cases in ISMICS 2006 New York – Big Apple
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Background
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4. 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
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5. Minithoracotomies Background
Minimally Invasive Mitral Valve Surgery include:
Partial Sternotomies
Parasternal Incisions
Minithoracotomies
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Background
Presenting :
our experience with minimally invasive mitral valve surgery via an anterolateral minithoracotomy, avoiding any peripheral cannulation, and providing adequate mitral valve exposure.
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PATIENTS & METHODS
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8. 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
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9. 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
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10. 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
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11. 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
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RESULTS
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13. Results Mitral valve repaired = 89 (28%) Replaced = 231 (72%)
Tricuspid valve repair = 80 (25%)
Radiofrequency Ablation = 80 (25%)
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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
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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
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CONCLUSION
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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
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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
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19. Thank You For Your Attention