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Ann Thorac Surg 1997;63:1150-1152
© 1997 The Society of Thoracic Surgeons

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Case Report

Mitral Valve Replacement Under Video Assistance Through a Minithoracotomy

Department of Cardiovascular Surgery, Benetti Foundation, Rosario, Argentina

Accepted for publication October 31, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Minimally invasive techniques for mitral valve replacement offer an alternative for selected patients. In this report we present a woman with recurrent mitral valve stenosis, after mitral valve repair 10 years ago, who underwent mitral valve replacement through a minithoracotomy using stereo video assistance in combination with direct vision.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Recently there has been a proliferation of reports detailing less invasive techniques for cardiothoracic surgical procedures. Designed to limit surgical trauma while decreasing costs, less invasive heart surgery has caught the attention of patients, the press, and industry. Lytle [1] recently recommended cautious optimism, especially regarding percutaneous cardiopulmonary bypass and performance of intracardiac procedures. Because of our extensive experience with minimally invasive coronary bypass grafting [2–5], and encouraged by Carpentier and associates' recent report of video-assisted mitral valve repair [6], we decided to attempt redo mitral valve repair in an obese young woman. Lin and associates [7] recently published their report on mitral valve operations performed using video assistance. Our case report further supports these experiences because, due to anatomic findings, mitral valve replacement rather than mitral valve repair was necessary and this was further facilitated by the ergonomic approach offered by the head-mounted video display. We believe this minimally invasive approach offers an alternative for selected patients in whom valve replacement is indicated.

A 44-year-old woman with a history of mitral valve repair 10 years ago presented in class IV heart failure. Diagnostic evaluation demonstrated recurrent mitral stenosis, with heavy calcification of the anterior leaflet. There was no evidence of tricuspid regurgitation. The patient weighed 100 kg and had typical findings of mitral stenosis. We recommended repeat repair of the mitral valve via a minithoracotomy. The patient consented and was aware that sternotomy might be required and that the valve may not be repairable.

The procedure was performed with the patient reclined 30 degrees to the left with her arm over her head to facilitate access (Fig 1). The patient was intubated with a single-lumen endotracheal tube. The right and left femoral vessels were exposed. A 9-cm incision was made in the right anterior fifth intercostal space. The pericardium was opened and the right side of the heart was dissected until the pericardium could be suspended to the chest wall, thus bringing the interatrial groove into view (Fig 2). With video assistance, the interatrial groove was dissected. The patient was then heparinized and placed on cardiopulmonary bypass using routinely available cannulas: an 80-mm, 20F percutaneous cannula placed in the right atrium, a short left femoral venous cannula, and a right femoral artery cannula. During systemic cooling to 26°Celsius, a stereo videoscope was passed into the chest through a port created more laterally in the same right anterior fifth intercostal space. The ascending aorta was exposed, the heart was electrically fibrillated, and a 6-cm incision was made in the interatrial groove. The incision was kept open with a small retractor and the videoscope was then passed into the left atrial cavity. The structures of the mitral valve were well visualized with the assistance of the stereo videoscope through a head-mounted display; the visualization would have been extremely difficult without the assistance of the videoscope because the valve was deep in the chest, the plane of the valve was inclined, and the heart was immobile due to the adhesions. Finding severe calcification of the anterior leaflet, we elected to replace the mitral valve. Under stereo video assistance, the anterior leaflet was resected, the posterior leaflet was left intact, and the annulus was sized. The posterior annular sutures were placed under direct vision, but video assistance was necessary for those in the commissure and anterior portions of the annulus. A 26-mm prosthetic mitral valve was selected and sutured in place using 12 interrupted mattress sutures. The atriotomy was then closed and just before the suture line was completed, the left atrium was deaired. Air was also evacuated from the ascending aorta using suction through a 14-gauge needle and the heart was defibrillated. The patient was then easily separated from bypass without inotropic support. The perfusion time was 150 minutes. A chest tube was placed through the videoscope port site and the thoracotomy was closed in a standard fashion so, at the end of the procedure, the patient had only one incision.

View larger version (23K): [in this window] [in a new window]   Fig 1. . Patient reclined 30 degrees for optimal access.

View larger version (38K): [in this window] [in a new window]   Fig 2. . Exposure of interatrial groove through the right anterior fifth intercostal space.

	Comment

Top Footnotes Abstract Introduction Comment References

 
We planned mitral valve repair but were discouraged by the anterior leaflet calcification. We thus elected to perform mitral valve replacement, which was easily accomplished through the small anterior thoracotomy incision. The dense adhesions around the left side of the heart prevented complete mobilization and therefore the stereo video assistance was essential in visualization of the valve structures, leaflet excision, and placement of sutures for prosthetic valve implantation. Based on the excellent results achieved with this patient and similar success with mitral valve operations, thrombectomy, and repair recently published by Lin and associates [7], we plan to perform additional minimally invasive intracardiac cases. The technical challenges will undoubtedly be lessened as new instruments are developed and made available. Specifically, we believe innovations that facilitate intraaortic cannulation and enable central cannulation for cardiopulmonary bypass and development of better retractors for improved access may further enhance the results of these procedures.

	Footnotes

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Address reprint requests to Dr Benetti, Entre Rios 134, P.6, (2000) Rosario, Argentina.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Lytle B. Minimally invasive cardiac surgery [Editorial]. J Thorac Cardiovasc Surg 1996;111:554–5.
2. Benetti FJ, Ballester C, Barnia A. Uso de la torascopia en cirurgia coronaria para diseccion de la mamaria interna. Prensa Med Argent 1994;81:877–9.
3. Benetti FJ, Ballester C. Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. J Cardiovasc Surg 1995;36:159–61.[Medline]
4. Benetti FJ, Ballester C, Sani G, Boonstra P, Grandjean J. Video assisted coronary bypass surgery. J Cardiac Surg 1995;10:620–5.[Medline]
5. Benetti FJ, Ballester C. Coronary revascularization with the arterial conduits via a small thoracotomy and assisted by thoracoscopy, although without cardiopulmonary bypass. Coronary Revasc 1995;4:22–4.
6. Carpentier A, Loulmet D, Carpentier A, et al. Open heart operation under videosurgery and minithoracotomy. First case (mitral valvuloplasty) operated with success. CR Acad Sci III 1996;319:219–23.
7. Lin PJ, Chang CH, Chu JJ, et al. Video-assisted mitral valve operations. Ann Thorac Surg 1996;61:1781–7.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Federico J. Benetti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Benetti, F. J. Articles by Polanco, A. Search for Related Content PubMed PubMed Citation Articles by Benetti, F. J. Articles by Polanco, A.