Abstract
Minimally invasive mitral valve surgery (MIMVS) was introduced in the mid-1990s to refer to a variety of surgical techniques that avoid full sternotomy through smaller or alternative chest wall incisions, as an attempt to reduce complications, but at the same time preserve outcomes of the full sternotomy approach. In this review, different aspects of MIMVS are discussed in relation to its approaches (right parasternal incision, lower ministernotomy, right anterolateral minithoracotomy and left posterior minithoracotomy) as well as strategies (mini-incisions, video-assistance, video direction with robotic assistance and telemanipulation) passing through more than 2 decades of continuous evolution. In the current practice MIMVS shows similar outcome to conventional surgery with even more superior results regarding blood loss, ICU and hospital stay, as well as functional recovery. The accumulating experience with MIMVS encouraged surgeons to extend the application of these techniques to high-risk patients, redo surgeries, concomitant double or triple valve procedures as well as combined coronary artery and mitral valve diseases in a hybrid approach, reducing the need for full median sternotomy. In addition there is an emerging trend of transcatheter valve implantation in the mitral position with small reports of valve-in valve or valve-in- ring implantation as well as valve replacement in case of severe MAC. This new trend may establish itself in the future as a modality in treating native mitral valve diseases in high risk patients. Therefore it is recommended for cardiac centers to build up a program for MIMVS in order to fulfill the recent requirements of cardiac surgery.
Highlights
Mitral valve surgery (MVS) has passed through major advances over the past 2 decades regarding its indications, repair techniques, prosthetic valves and surgical approaches. [1] Median sternotomy has been the standard approach with the best outcome in heart surgery for more than 30 years
[2] owing to the major advancements achieved in percutaneous procedures including transcatheter aortic valve implantation (TAVI) and MitraClip, surgeons were forced to adopt new less aggressive techniques to cope with patient demands and maintain their role in treating heart diseases
The term ‘minimally invasive mitral valve surgery’ (MIMVS) was introduced in the mid-1990s to refer to a variety of surgical techniques that avoid full sternotomy through smaller or alternative chest wall incisions, as an attempt to reduce complications, but at the same time preserve outcomes, of the full sternotomy approach. [3]
Summary
Mitral valve surgery (MVS) has passed through major advances over the past 2 decades regarding its indications, repair techniques, prosthetic valves and surgical approaches. [1] Median sternotomy has been the standard approach with the best outcome in heart surgery for more than 30 years. It allows more exposure to the heart and great vessels, easier arterial and venous cannulation for cardiopulmonary bypass and better myocardial protection This approach is associated with some drawbacks in the form of postoperative bleeding, postoperative pain, sternal dehiscence, long functional recovery and long (sometimes non-cosmetic) scars. These techniques are minimally invasive for the patients but are maximally stressful to the surgeons They are in general more complex and require a learning curve due to the use of special instruments;the non-traditional exposure of the mitral valve and in many cases the non-familial cannulation of peripheral vessels. These techniques were first applied to highly selected patients with low risk profile to ensure the best outcome. The past experiences, the current status and the future trends of these techniques are thoroughly discussed in order to emphasize their importance for cardiac surgeons to fulfill the recent requirements of the cardiac surgery specialty
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