Minimally invasive mitral valve surgery was introduced in Europe and the United States in the late 1990's. There has been a low, but increasing adoption rate in the United States. The low adoption rate is likely secondary to the lack of formalized training during cardiothoracic surgery residency and a culture that has failed to accept the procedure. In this manuscript, we provide a detailed, step-by-step guide to minimally invasive mitral valve surgery via a limited right thoracotomy.
Surgical mitral valve repair has been the gold standard treatment for severe degenerative mitral regurgitation. However, a segment of patient population is considered too high risk for surgery because of their age and/or comorbidities.Catheter-based interventions have been developed during the last decade to address mitral regurgitation in high surgical risk patients. MitraClip System (Abbott Vascular, Santa Clara, CA, USA) is FDA approved in high risk patients with primary or secondary mitral regurgitation who meet certain criteria. This article touches briefly on indications for transcatheter edge to edge mitral valve repair (TEER) and focuses on describing procedural steps to perform TEER usig MitraClip device. These steps include preoperative assessment and planning using TEE images, transseptal access to mitral valve, introducing transseptal sheath, steerable guide catheter (SGC), and clip delivery system (CDS), crossing the mitral valve, grasping the leaflets in desired location, and deployment. Procedural steps are also demonstrated in a brief video.
Median sternotomy provides standard access in cardiac surgery. Sternal closure traditionally involves use of stainless steel wires with satisfactory results. Fixation of sternum using titanium plates with screws has been used in some institutions over the last two decades. This technique uses sternal wires in combination with a rigid plate fixation system. The wires are passed at the manubrium and xiphoid to help with approximation, while plates are used to fix the body of the sternum. The screws are passed through the outer table and penetrate the inner table of the sternum. There is increasing evidence to suggest that rigid plate fixation provides better mechanical stability of sternum; which seems to translate to less post-operative pain; better healing of sternum; lower incidence of deep sternal wound infection and sternal non-union. This approach is particularly useful in patients who have multiple risk factors predisposing them to post-operative sternal complications.
Aortic valve disease in children presents a considerable surgical challenge. When repair is not feasible, the Ross procedure represents the best option for replacement as it allows growth and does not require anticoagulation. However, there is a risk of progressive autograft dilatation, and eventual failure of the autograft with severe regurgitation. Autograft stabilization has proven beneficial in adults but has not been widely adopted in children undergoing the Ross procedure. We present a series of techniques for autograft stabilization which can be used at different stages of development, from infants to fully grown adolescents.
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