Transmitral Septal Myectomy and Complex Mitral Valve Repair for HOCM Through Periareolar Minimally Invasive Access

Procedure

Through a partial superior periareolar skin incision, a small right anterolateral thoracotomy was performed at the 4th intercostal space and a 5 mm 0° thoracoscope was introduced through the same intercostal space 7 cm laterally. A 2 cm skin incision was used to gain access to the femoral artery and vein and then the Seldinger technique was used for cannulation of the vessels for cardiopulmonary bypass. Once extracorporeal circulation was established, the ascending aorta was clamped with a Cygnet clamp (Vitalitec, Balgheim, DE) and the heart stopped with infusion or cold crystalloid cardioplegia (Custodiol) in the aortic root. The left atrium was opened and retracted using a standard MICS atrial retractor; a Crown FlexTM atrial retractor was also installed (Geister, Tuttlingen, DE) to improve the visualization of the mitral valve. The midline of the anterior mitral annulus and the trigons were signed with a skin marker, the insertion of the anterior leaflet was cut between the commissures, and the leaflet fixed to the posterior annulus with a 4/0 prolene. Transmitral myectomy of the interventricular septum was performed and extended distally to the origin of the papillary muscles. The anterior head of the accessory bifid papillary muscle was identified and isolated with the help of a surgical hook and then cut 2-3 mm distally from the base of insertion on the body of the muscle. The chordae that branched out from the head was cut at the distal end on the insertion on the anterior leaflet of the valve. A bovine eterologous pericardial patch was cut in a costume-made size on the basis of the measure of the intertrigone distance that the cardiologist had previously taken performing the TEE. The patch was then sutured using a 4/0 prolene running suture to the anterior annulus from the center to one and then the other trigone to avoid distortion. Another running suture with a 4/0 prolene was perfomed from the opposite site of the patch to the detached portion of the anterior leaflet. This procedure was made to extend the surface of the anterior leaflet and move backward the coaptation of the mitral valve, thus the risk of systolic anterior motion is averted. Two 4/0 GoreTex (W.L. Gore and Assoc, Inc, Flagstaff, AZ, USA) neochords were implanted on the anterolateral and posteromedial papillary muscles and lead to the free margin of the anterior leaflet. The length of the neochords was assessed by a fine-tuning hydrostatic test, filling the left ventricle with saline solution. 

The postoperative period passed regularly and the patient was discharged on eighth postoperative day. At the time of discharge, echocardiography revealed no intraventricular gradient or mitral regurgitation. At six months, cardiac MRI showed the left ventricular volume was fully restored without any residual outflow obstruction, the mitral valve appeared competent with a deep, posteriorized coaptation, and there was normal movement of the leaflets.

References 

1. Sakaguchi T, Totsugawa T, Tamura K, Hiraoka A, Chikazawa G, Yoshitaka H. Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic obstructive cardiomyopathy. Gen Thorac Cardiovasc Surg. 2018 Jun;66(6):321-326.
2. Musharbash FN, Schill MR, Hansalia VH, Schuessler RB, Leidenfrost JE, Melby SJ, Damiano RJ Jr. Minimally invasive versus full-sternotomy septal myectomy for hypertrophic cardiomyopathy. Innovations (Phila). 2018 Jul/Aug;13(4):261-266.
3. Musharbash FN, Schill MR, Henn MC, Damiano RJ Jr. Minimally invasive septal myectomy for hypertrophic obstructive cardiomyopathy. Innovations (Phila). 2017 Nov/Dec;12(6):489-492.
4. Kim HR, Yoo JS, Lee JW. Minimally invasive Ttans-mitral septal myectomy to treat hypertrophic obstructive cardiomyopathy. Korean J Thorac Cardiovasc Surg. 2015 Dec;48(6):419-421.
5. Gilmanov DSh, Bevilacqua S, Solinas M, Ferrarini M, Kallushi E, Santarelli P, et al. Minimally invasive septal myectomy for the treatment of hypertrophic obstructive cardiomyopathy and intrinsic mitral valve disease. Innovations (Phila). 2015 Mar-Apr;10(2):106-113.
6. Mazine A, Ghoneim A, Bouhout I, Fortin W, Berania I, L'Allier PL, et al. A novel minimally invasive approach for surgical septal myectomy. Can J Cardiol. 2016 Nov;32(11):1340-1347.
7. Mohr FW, Seeburger J, Misfeld M. Keynote lecture-transmitral hypertrophic obstructive cardiomyopathy (HOCM) repair. Ann Cardiothorac Surg. 2013 Nov;2(6):729-732.

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