Mitral Valve Infective Endocarditis: Transareolar Endoscopic Complex Mitral Valve Repair

This video demonstrates the feasibility of a MV repair, also one in the setting of destruent infective process, and proposes a physiological technique to restore the natural geometry of the valve. In experienced centers, complex and extensive repair are doable in a completely endoscopic fashion.

A fifty-five-year-old man with past medical history consistent for heart failure with reduced ejection fraction, neuropathy, beta thalassemia trait, recent COVID 19 infection, COPD requiring BiPAP, severe morbid obesity with a BMI of 41.5, and recent acute kidney injury presented in severe sepsis requiring pressors. Blood cultures grew Serratia and a transthoracic echocardiogram (TEE) revealed a 13x10 mm vegetation for the PML with mild mitral regurgitation (MR). A conservative strategy was chosen.

One month later, the patient was admitted with intermittent fever, lower limb swelling and shortness of breath. Deep vein thrombosis was diagnosed and a new TEE demonstrated a worsening of the infective process with a vegetation actually 10x25 mm and severe MR. Patient was considered for an endoscopic mitral valve (MV) repair versus replacement.

Endoscopic setup did not differ from the one for standard elective cases and consisted of a periareolar working port at the fourth intercostal space, two 5 mm miniports at the second and and fifth intercostal spaces for the 30° thoracoscope and the LV venting line respectively. Peripheral veno-arterial cannulation was achieved, and in this specific patient—because of his BMI—a internal jugular vein cannula was added to improve venous drainage.

Through a transareolar completely endoscopic fashion, a complex reconstruction of the posterior leaflet with a bovine pericardium patch from P1 to P3, replacing the entire P2 scallop, was achieved. Two pairs of GTX neochords for the neoleaflet were implanted. A custom-made pericardial band was also trimmed and implanted. Because of annular dilatation, a tricuspid valve repair under beating heart was performed.

Patient was extubated six hours after surgery and stepped down on postoperative day two. The postop TEE showed a well-functioning MV with a very physiological behave of the neo posterior leaflet with no residual MR.

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