Highlights on Minimally Invasive Mitral Valve Surgery

Abstract

Over 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 level on 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 minithoracotomy incision. This 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. Cardiopulmonary bypass is established via femoral venous cannulation and 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 more better than 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: (1) Visualization of the mitral valve. (2) Cosmetic results, minimally invasive mitral valve surgery gave strikingly better cosmetic result than sternotomy, and this was of a particularly importance in females. (3) Stability of the thorax and post operative ambulation of the patient. (4) Infection, minimally invasive mitral valve surgery had a reduced risk of wound infection and so mediastinitis, this is due to the smaller size of the incision, limited manipulations and continuous CO2 insufflation during the procedure. (5) Blood loss and need for transfusions, minimally invasive mitral valve surgery had fewer blood losses in all patients due to decreased muscle skeletal trauma that was prominent especially in patients with a previous sternotomy, due to limited dissection of adhesions and preservation of the cardiac structures from injury. (6) Post operative pain, minimally invasive mitral valve surgery has significantly decreased post operative pain compared to sternotomy. (7) Post operative intensive care unit and hospital stay, minimally invasive mitral valve surgery had a much faster recovery compared to sternotomy. (8) Costs, minimally invasive mitral valve surgery had more intra-operative costs than with a sternotomy due to longer cardio pulmonary bypass and cross clamp time, need for videoscopy, echocardiography, and specific instruments, but when compared to the reduced intensive care unit and hospital stay, improved outcome, decreased need for transfusion, less post operative morbidity and faster return to normal activity than with sternotomy, the procedure is considered more cost effective than sternotomy. Moreover, minimally invasive mitral valve surgery have less community cost as it allows patients to return to their work more rapidly than with a sternotomy.