Totally Endoscopic Mitral and Aortic Valve Surgery

This video describes one of the authors’ initial series of combined mitral and aortic valve surgery and highlights the steps involved for an endoscopic approach. The authors hypothesize that this technique could result in lower ventilation times, less blood loss, less postoperative pain, and fewer ICU and hospital stays, as seen with endoscopic single valve surgery. They also highlight the long learning curve and the expertise required to use this technique in combined mitral and aortic valve surgery. 

The Surgery 

The patient was referred for aortic valve replacement with the referral echocardiogram showing moderate mitral valve incompetence. She had a previous history of a coarctation repair at the age of eleven. The surgery was delayed for a few months because of the impact of the COVID pandemic on elective procedures. An up-to-date echocardiogram was performed prior to surgery and showed progression of the mitral valve disease to severe. The mitral valve pathology was mainly a restriction of the P1 component of the posterior mitral leaflet and overriding of the A1 component of the anterior mitral leaflet. The aortic valve was calcific degenerative in nature in functionally bicuspid valve. A CT aortic angiogram showed suitable arterial vasculature for minimally invasive surgery.  

Because of this, the patient was positioned in supine position with an inflatable bag behind the back at the level of the fourth right intercostal space. This helped position the patient with a 30-degree tilt to the left and spreading of the intercostal spaces. Anesthetists routinely insert a single lumen endotracheal tube with right bronchial blocker to deflate the right lung. The authors routinely use 3D endoscopes to give a better perception of movements.  

Antegrade cold blood cardioplegia was also given after cross-clamping using the Chitwood clamp. The authors then used premeasured chordae and a 32 mm mitral incomplete band for repairing the mitral valve. Aortic valve was replaced using a 21 mm tissue valve. Before aortotomy, the aortic root cannula was removed to create a space for the incision. De-airing was then performed using the left ventricular vent prior to removal of the cross-clamp. The total cardiopulmonary bypass time was 217 minutes and cross-clamp time was 172 minutes. This patient was extubated two hours after surgery, discharged to the ward within twenty-four hours, and sent home on day five. An eight-week follow-up showed a well-healed peri-areolar incision and well-functioning valves. The patient reported no postoperative pain and a good exercise tolerance. 

The authors have performed more than six hundred endoscopic cardiac valve procedures. They were mainly isolated mitral valve surgery with or without tricuspid valve surgery. In some cases, they added AF ablation and/or PFO closure. This also includes surgeries for cardiac tumors. The authors moved to endoscopic techniques for isolated aortic valve surgeries after performing more than one hundred cases through a right anterior mini thoracotomy. In this case, they have utilized their expertise to perform both valves and obtain the postoperative advantages of the endoscopic cardiac surgery. 

Conclusions 

Endoscopic cardiac surgery is a safe option for combined mitral and aortic valve surgery when done by experienced teams. The relative longer bypass and cross-clamp times do not reflect negatively on postoperative patient recovery. It is known that there is a learning curve in this surgery; with more procedures, that would improve, resulting in shorter operative times. 

References

1. Abdelbar A, Zacharias J. Minimally Invasive Totally Endoscopic Beating Mitral Valve Repair. May 2020. doi:10.25373/ctsnet.12350867
2. Abdelbar A, Saravanan P, Zacharias J. Four Sternotomies, Three MitraClips: Now What?. September 2020. doi:10.25373/ctsnet.12909704
3. Abdelbar A, Laskawski G, Zacharias J. Respecting The Mitral With Homemade Loops. May 2021. doi:10.25373/ctsnet.14589135

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