Minimally Invasive Mitral Valve Surgery: The Evidence

It was a very good discussion on minimally invasive Mitral valve surgery. Everyone is talking about a right sided mini thoracotomy. For the Mitral valve, we forget that the Mitral valve is a left sided structure and the Left Atrium is a posterior structure. We, particularly in India have been used to approaching the Mitral through the left side for a Closed Mitral Valvotomy. Now we can accomplish arterial and venous return through excellent groin cannulation available today. Since most of the Mitral valve patients are relatively young, the concern for atherosclerosis emboli should be minimal. When one does the procedure through the left side, the Mitral valve is closer to the surgeon and the surgery can be accomplished through routine instruments. One does not need knot tiers and knot pushers. From the right side, the Mitral valve is at a fair distance from the incision and one loses the tactile sensation. Advantages of approaching the Mitral valve through the left side are 1. Easy and secure excision of the Left Atrial appendage. 2. We can accomplish an excellent Maze procedure. 3. What is more important is that we can reduce the size of the Left Atrium (which in our patients, a large Left Atrium is very common and interferes with establishing a sinus rhythm), in an easy manner. Reduction of the Left Atrial size from a right sided incision is impossible and from the mid sternotomy, very difficult. 4. Now with increasing popularity of a Beating Heart Mitral Surgery, if one chooses to do a beating heart Mitral operation, one can evaluate the Mitral anatomy better and see the immediate results of the Mitral valve repair. One has to flood the left chest with CO2 to reduce any possibility of an air embolus. We have done 3 cases in our unit with excellent haemodynamic and cosmetic results. So, we should remember that the Mitral valve is a left sided structure and approaching it through the left side would be a better and more rational way to deal with it.