Minimally Invasive Mitral Valve Replacement and Left Atrium Plication

This video presents a case of minimally invasive mitral valve replacement, left atrial appendage closure and left atrium plication. The patient is a sixty-eight-year-old woman with a history of rheumatic heart disease. She had symptoms of dyspnea and permanent atrial fibrillation. On the echocardiograph, surgeons observed severe mitral valve stenosis. Her ejection fraction was 45 percent with left atriomegaly 91 mm in diameter. Her coronary arteries were without lesions. 

Preoperatively, the surgical team performed computer tomography for better planning of their minimally invasive operation, which helped to detect the possibility of peripheral cannulation for cardiopulmonary bypass (CPB) and exclude the ascending aortic calcification for aortic cross-clamp.
To begin, the patient was positioned with an inflatable pillow under the right chest and the right arm at a 45-degree angle off to the side of the bed. The operation plan followed the team’s usual setup for minimally invasive mitral valve surgery. It consisted of right jugular vein cannulation for CPB by anesthesiologist after central line administration, a right lateral thoracotomy in the fourth intercostal space, cannulation of the right femoral artery and vein for CPB, transthoracic aortic cross-clamp, antegrade cardioplegia into the aortic root, mitral valve replacement, left atrial appendage closure, and left atrium paraanular plication.

On an arrested heart, surgeons first opened the left atrium and exposed the mitral valve with a mitral valve lifting system. The mitral valve commissures were fused, and the edge of the valve was found to have fibrosis and calcinosis. The anterior and posterior leaflets were then removed and secondary chords to posterior leaflet were preserved. To preserve the LV geometry, one additional artificial chordae was placed from the posteromedial papillary muscle to the posterior annulus of the mitral valve.

For mitral valve implantation, surgeons placed inverted sutures with pledgets on the atrial side. They then inserted a 25 mm biological prosthesis. All knots were tied with a knot-pusher device. Because of the large left atrium, the team decided to perform volume reduction to improve atrial flow, minimize the risk of thrombus formation, and minimize the risk of structure compression. A paraanular plasty of the left atrium was then performed with elimination of its appendage, and a separate line was performed between the left and right pulmonary veins’ ostias. Plication of the atrium was performed using 4-0 monofilament continuous sutures. The left atriotomy was then closed.

Postoperative TEE showed good mitral valve prosthesis function and a 50 mm left atrium diameter. At six-month follow up, the patient was doing well with good function of the mitral valve prosthesis.

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