Minimally Invasive Mitral Valve Repair Surgery

Minimally invasive mitral valve repair surgery is an alternative procedure to a conventional median sternotomy for patients with mitral valves that are damaged but not severe enough to require replacement. This procedure requires a smaller incision and is associated with better cosmesis, quicker recovery, and fewer postoperative complications. This video presents the case of a fifty-one-year-old man with severe mitral regurgitation secondary to a flail P2 segment.

To begin the surgery, a right anterolateral minithoracotomy was performed and the patient was connected to a cardiopulmonary bypass machine. This was followed by a left atriotomy, which was performed via the Sondergaard’s groove.

Initially, annuloplasty sutures were placed, followed by valve analysis and leaflet repair, and finally implantation of an annuloplasty ring.

To enable correct and safe placement of the annuloplasty sutures, identification of adjacent landmark structures was necessary. The annuloplasty sutures were placed 1-2 mm away from the hinge of the mitral valve leaflets, which could be further revealed by grasping the leaflets with forceps and applying gentle traction.

Valve analysis was then performed in a segmental manner and revealed a flail broad segment P2 with ruptured chordae tendinae. Two stay sutures were placed on the free edge of the prolapsing leaflet and the prolapsed portion of the leaflet, along with the chordae tendinae, were excised up to the annulus using a blade in a triangular fashion.

Leaflet continuity was restored using 4-0 Prolene sutures in a semicontinuous manner. Next, the first of the Prolene sutures were placed at the edge of the resected leaflet and tied down using a knot pusher. Once the leaflet continuity was restored with the placement of the final sutures, the annuloplasty ring size was assessed against the anterior leaflet. In this case, a 36 mm Physio II ring was deemed appropriate.

The annuloplasty sutures were then carefully placed through the ring, which was mounted onto a delivery device. The ring was then parachuted down onto the mitral annulus and the annuloplasty sutures were tied down using an automated suture fastening system.

Saline was injected into the ventricle to evaluate the competence of the mitral valve. In this case, adequate repair of the valve had not yet been achieved. The surgeon then decided to place sutures in the posterior medial commissure to further reduce mitral regurgitation. An additional suture was placed to further secure the continuity of the resected leaflet.

A repeated saline test demonstrated that adequate mitral valve repair had been achieved. Transesophageal echocardiography showed restored mitral valve competence.

In summary, minimally invasive mitral valve repair surgery can be advantageous compared to conventional mitral valve repair surgery with better postoperative outcomes. This procedure can involve several surgical techniques including triangular resection, commissuroplasty, and annuloplasty, which were demonstrated in this operative video.

References

1. Vohra HA, Salmasi MY, Chien L, Baghai M, Deshpande R, Akowuah E, Ahmed I, Tolan M, Bahrami T, Hunter S, Zacharias J; British and Irish Society for Minimally Invasive Cardiac Surgery. BISMICS consensus statement: implementing a safe minimally invasive mitral programme in the UK healthcare setting. Open Heart. 2020 Oct;7(2):e001259. doi: 10.1136/openhrt-2020-001259. Erratum in: Open Heart. 2020 Oct;7(2): PMID: 33020254; PMCID: PMC7537434.

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