How to Set Up a Minimally Invasive Mitral Valve Surgery: A Step-by-Step Approach

This video demonstrates the setup for a minimally invasive mitral valve surgery in a step-by-step approach. Femoral cannulation is done through an oblique incision in the right groin.

Both the femoral vein and femoral artery are exposed, and a purse string suture 5-0 Prolene is taken in both vessels. The Seldinger technique is used where a wire is passed and echocardiographic guidance in a bicaval view is used to visualize the wire all the way up to the SVC. Once that is confirmed, the venous cannula is inserted and again visualized into the SVC. A venous line is connected. The venous line is fixed with another stitch and snared with a tourniquet to allow adjustment during the case if needed. A similar technique is used for arterial cannulation. A hybrid cannula is inserted over a wire, and the wire also has to be visualized in the descending thoracic aorta. The arterial line is fixed. Once femoral cannulation is achieved, a 4-5 cm incision is made just anterior to the left axillary line, and then the soft tissue and fat are dissected all the way down to the intercostal space. The mini-thoracotomy is performed in the fourth intercostal space, the soft tissue retractor is placed, and the low-profile intercostal retractor is placed over the soft tissue retractor. Then a 5-mm 30-degree scope is placed.

The first step done after the thoracotomy is placement of a retraction stitch in the tendinous part of the diaphragm for retraction caudally during the operation. This stitch is passed through the outside using a Carter-Thomason device, and fixed to the skin using a hemostat. A multilevel intercostal nerve block is performed under direct visualization at the beginning of the case using a long-acting local anesthetic. Prior to any dissection in the pericardium, the phrenic nerve is marked the entire course so as to be kept under direct visualization throughout the case. The thymic fat is dissected all the way up until you visualize the inferior border of the innominate vein. Pericardiotomy is then performed and extended all the way down to the IVC and then all the way up to when you visualize the pericardial reflections. Posterior pericardial sutures are placed, passed to the outside using the Carter-Thomason device, and fixed with hemostat outside the incision. Then anterior pericardial sutures are placed and sutured to the anterior part of the incision in the soft tissue retractors. In order to place the clamp as high as possible, the dissection plane is started between the right pulmonary artery and the aorta, directed to the left shoulder. This is also done anteriorly. A trial of clamping is attempted to make sure you are high enough and across the aorta.

Next a spot for the cardioplegia needle is chosen. Then a 4-0 stitch is taken in preparation for the cardioplegia needle insertion. Once this is accomplished, the Sondergaard groove is prepared for the mitral valve surgery. A cross-clamp is inserted through the same incision. The flow is dropped, the aorta is retracted upward using the suction, and the cross- clamp is placed. Once we have good arrest, the clamp is retracted to be away from the incision. After that you place two right atrial retraction sutures. Those sutures are brought out through the incision and fixed with a hemostat. Left atriotomy is performed and then a left atrial lift system is inserted as illustrated here. Segmental analysis of the valve is performed, and the lesion is identified. Artificial chordae are placed with the help of a 31-valve sizer to expose the subvalvular apparatus. The artificial chordae are placed in the prolapsed leaflets. After performing a water test, those chordae are slid down as needed and then tied down using a knot pusher. After that, a flexible mitral valve ring is placed and sutured using 3-0 Prolene. Once this is done, the mitral valve is tested with a suction irrigator as a final test.

The left atriotomy is closed using 4-0 Prolene sutures on both sides, and they are tied in the middle. To have adequate exposure, it is extremely important to place a temporary epicardial pacemaker wire before unclamping while the heart is still arrested. The cross-clamp is removed after de-airing. The patient is weaned from cardiopulmonary bypass, and the echo hopefully shows very good repair results. Decannulation is performed. The cardioplegia needle is removed under direct vision and secured with the Cor-Knot device. Intercostal spaces are approximated using number 2 Vicryl sutures, and then the rest of the incision is closed in a regular fashion. The chest tube is inserted at the same site as the camera port.

References

1. Ramlawi B, Gammie JS. Mitral Valve Surgery: Current Minimally Invasive and Transcatheter Options. Methodist Debakey Cardiovasc J. 2016 Jan-Mar;12(1):20-6. doi: 10.14797/mdcj-12-1-20. PMID: 27127558; PMCID: PMC4847963.
2. Pope NH, Ailawadi G. Minimally invasive valve surgery. J Cardiovasc Transl Res. 2014 Jun;7(4):387-94. doi: 10.1007/s12265-014-9569-1. Epub 2014 May 6. PMID: 24797148; PMCID: PMC4191712.

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