Minimally Invasive Video Assisted Thoraco-Scopic Mitral Valve Surgery

Abstract

ver the last decade there has been a transformation in the way cardiac surgeons, cardiologists and patients decide the approach to cardiac therapies. Less invasive procedures were demanded but at the same time must be proven safety, efficacy and durability. There was no prior evidence to justify switching to minimally invasive mitral valve surgery, and all the reviewed evidences at that time demonstrated that minimally invasive mitral valve surgery was associated with equal mortality and morbidity to sternotomy despite longer cardiopulmonary bypass and aortic cross-clamp times. Through enhanced understanding of surgical bases and application of technological development which has sourced a breakthrough in minimally invasive approaches, the mitral valve can now be operated upon using a minimally invasive 6 to 8 cm right anterolateral mini thoracotomy incision with several proven advantages over routine median sternotomy. These advantages include better visualization of the mitral valve which aids in the performance of repair procedures easily, better cosmetic results, better stability of the thoracic bony cage due to more anatomical respect of the thorax, less post-operative blood loss and need for transfusions, less risk of wound infection and mediastinitis, less surgical trauma, less ICU and hospital stay, less post-operative pain, and faster return to normal activity. MIMVS technique is done through a 6 cm incision in the right side of the chest wall and depends on port access technology to introduce an optical video camera through one of the port access sites and the other is used for venting, passing pericardial stay sutures, CO2 insufflation, the mitral valve is reached through a left atriotomy incision which provides an excellent view of the mitral valve allowing repair procedures to be done easily. In this kind of procedure, we use specific group of instruments like long needle holders, long scissors and long clamps as most steps of the operation takes place under videoscopy as the surgical field is deeper than with sternotomy. Cardiopulmonary bypass is established via femoral venous & arterial cannulation, or direct aortic cannulation, and the aorta is cross clamped using a flexible aortic clamp. Despite the bypass time and cross clamp time were longer than with sternotomy, the outcome of the procedure was much better than sternotomy. Patients required less amount of blood or blood product transfusions, extubation was early, transfer from ICU to ward was rapid, ambulation and discharge from the hospital was much faster than with a sternotomy. Different studies were conducted worldwide to evaluate the procedure in comparison to sternotomy and the result was that a minimally invasive mitral valve surgery was associated with lower morbidity and mortality and better post-operative outcome than a sternotomy approach for he mitral valve. Also minimally invasive mitral valve surgery via right anterolateral mini thoracotomy had a prominent role in patients with a previous sternotomy operation, minimizing the risk of injury to the cardiac structures and dissection of adhesions which may lead to mortalities from bleeding. For the future, minimally invasive mitral valve surgery via right anterolateral mini thoracotomy and port access is likely to become the standard approach for patients with an isolated mitral valve disease