1. Minimally invasive mitral and tricuspid valve surgery Prof. Parwis Massoudy Klinikum Passau, Germany Clinic for Cardiac Surgery Head of Department

2. What does ‚minimally invasive‘ mean in the context of mitral and tricuspid valve surgery?

3. Standard Sternotomy

4. Right Anterolateral Incision  positioning of the patient (right side up)  Incision (5-8 cm)

5. Set up for minimally invasive

6. Access for Cardiopulmonary Bypass  small incision in the groin  but safe access to both vessels  Seldinger technique

7. Intraoperative setup  open pericardium Protect phrenic nerve  use CO 2 to prevent air embolism

8. Why small and lateral incisions ?  Reduction of surgical trauma  Stability of chest is not compromised  Better cosmetic result  Direct view on the mitral valve

9. Where is the mitral valve?

10. MV-anatomy

11. Functional unit  Annulus  Leaflets  Chordae  Papillary Muscle  Myocardium

12. MV-disease Prolaps syndrom Degeneration (chordal rupture)

13. MV-disease Elongation after infarction PM I AIAI

14. MV-disease Ischemic MR / DCM „Functional MR“ Secondary alteration caused by surrounding structures

15. Aims of Surgery  Correction of annular dilatation  Restoration of annular geometry  Elevation of anterior / posterior annulus  Improvement of leaflet coaptation  Verification of normal valve physiology

16. Annuloplasty (Ring support) (Physio, Cosgrove, Rigid Saddle, 3D-Profile) Resection of prolaps Chordal replacement (Loop-technique) „Edge to edge repair“ (Alfieri) Patchplastic (leaflet defects) Decalcification of leaflet / annulus Techniques of MV repair

17. Annuloplasty in functional regurgitation Cardinal System (Valtech)Encor SQ (Micardia) In secondary or functional mitral valve regurgitation, the problem of the disease is the dilatation of the mitral valve annulus. Even after correction with a ring, there is a certain recurrence rate. A new generation of mitral rings was created that allows for readjustment of the ring at the time of clinical follow up.

18. Operation videos / photographs Prolapse of anterior leaflet of the mitral valve Prolapse of posterior leaflet of the mitral valve Bileaflet prolapse of the mitral valve Bicommissural prolapse of the mitral valve Regurgitation of the tricuspid valve Calcification of the tricuspid valve Left atrial myxoma Endocarditis of the mitral valve

19. Techniques of MV repair AML prolaps

20. Techniques of MV repair PML prolaps

21. Techniques of MV repair Bileaflet prolaps

22. Techniques of MV repair bicommissural prolaps

23. Tricuspid valve repair

24. Tricuspid valve replacement

25. Other atrium pathology LA myxoma

26. Other leaflet pathology Endocarditis

27. Conclusion The minimally invasive access to the Mitral and Tricuspid valves (including any pathology in both atria) is an elegant technique wich offers fast recovery from surgery because of remained stability of the chest. Compared to conventional surgery with median sternotomy patients like the cosmetic result.