Beating Heart Mitral Valve Surgery Research Articles

Beating Heart Mitral Valve Replacement in Secondary Mitral Regurgitation with Poor Left Ventricular Function Literature Review

The poor early and mid-term prognosis of secondary mitral regurgitation (MR) with impaired left ventricular function after restrictive annuloplasty with cardioplegic arrest has opened the way for transcatheter repair. The indication for surgery is only incontestable when concomitant coronary revascularization is required. Beating heart mitral valve surgery without aortic clamping has been promoted as an alternative to the technique of cardioplegic arrest. Its potential advantage is the elimination of ischemic reperfusion injury and its impact on myocardial function. On the other hand a randomized study confirmed that for ischemic MR, mitral valve replacement (MVR) reduces the rate of MR recurrence and re-hospitalization compared to restrictive annuloplasty. We performed a review of the literature to assess the strength of the evidence supporting the efficacy of beating heart MVR without aortic clamping compared to the conventional technique for secondary MR with poor left ventricular function. In a randomized study of patients with chronic severe mitral regurgitation and left ventricular dysfunction, beating heart MVR was associated with better LV function, reduction of cardiac enzymes early postoperatively, reduced duration of mechanical ventilation, and ICU than MVR using warm blood cardioplegic arrest. This together with the absence of related perioperative mortality and the major complications suggests that this technique is safe and beneficial to LV function. This finding has been verified by a multitude of other observational studies which have shown that the benefit of this technique is more palpable in cases of redo mitral surgery or in cases of MR with poor left ventricular function.

Robotic-assisted beating heart mitral valve surgery: Preliminary report.

Robotic mitral valve surgery is a challenging issue, particularly in patients who are not suitable for aortic cross-clamping. In this study, we aimed to determine the feasibility and benefits of robotic, beating heart mitral valve surgery. From February 2019 to February 2022, 17 patients underwent robotic beating heart mitral valve surgery. Fourteen of the patients had previous cardiac surgery. The mean age was 58.1 ± 10.3. Dense periaortic adhesions, heavily calcified aorta, and low ejection fraction were retained as indications for beating heart surgery. Mitral valve replacement was performed in 14 patients. Mitral ring annuloplasty was performed in two patients with low ejection fraction (EF). A severe paravalvular leak was repaired in one patient. Additional tricuspid annuloplasties were performed in three patients. Cardiopulmonary bypass time were 185.6 ± 55 min. There were no cases of conversion to sternotomy or thoracotomy. No cerebrovascular event occurred in the follow-up. One patient died as a result of secondary hepatorenal syndrome and multiorgan failure. Robotic beating heart mitral valve surgery is a feasible and effective technique with favorable early and mid-term results, especially in patients who are not suitable for aortic cross-clamping, secondary to periaortic adhesions, severe aortic calcifications, and low ejection fraction.

BEATING HEART MITRAL VALVE REPLACEMENT. EXPERIENCE AT A TERTIARY CARE HOSPITAL

Objective: To study the early outcomes of mitral valve surgery performed with a beating heart and cardiopulmonary bypass.
 Study Design: Prospective descriptive study.
 Place and Duration of Study: Cardiac Surgery department, Rawalpindi Institute of Cardiology, Rawalpindi, from Aug 2017 to Aug 2019.
 Methodology: Consecutive patients requiring mitral valve surgery were included in the study. Those requiring multiple procedures, redo procedures and emergency procedures were excluded from the study. Data was collected on preformed proformas and perioperative variables were recorded. Patients were followed till discharge or 30 days after the surgery. Statistical Package for Social Sciences version 23.0 was used to analyse the data.
 Results: A total of 27 patients were included in the study, 21 (77.78%) female and 6 (22.2%) male patients. The mean age of the patients was 30.89 ± 10.8 years. Of the cohort, 4 (14.8%) had mitral stenosis, 16 (59.3%) had mitral regurgitation and mixed disease (both mitral stenosis and mitral regurgitation) was present in 7 (25.9%). The median pulmonary artery pressure (mPAP) was 34 mmHg. All the patients received mechanical mitral valve prosthesis, 27 (100%). A modified Devaga’s procedure for tricuspid valve repair was done in 4 (14.8%) patients. Most of the patients required only mild inotropic support, 22 (81.4%). Median intensive care unit stay was 24 hours with a mean of 33 ± 16 hours. All the patients were alive at the end of the early follow up.
 Conclusion: Beating heart mitral valve surgery on cardiopulmonary bypass is a feasible technique. It has acceptable early outcome in terms of mortality and major morbidity indicators.

Towards robot-assisted anchor deployment in beating-heart mitral valve surgery.

Beating-heart intracardiac surgery promises significant benefits for patients compared with cardiopulmonary bypass based procedures. However, the fast motions of the heart introduce serious challenges for surgeons. In this work, a new impedance-controlled master-slave telerobotic system is developed to help perform anchor deployment for mitral valve annuloplasty under the guidance of live ultrasound images of the heart. The proposed bilateral teleoperation system can both reflect the non-oscillatory portion of slave-heart tissue interaction force on the surgeon's hand as haptic feedback and implement rapid compensation for the beating heart's motion. The surgical task involves performing anchor deployment on a simulated moving heart tissue to evaluate the effectiveness of the proposed strategy for safely interacting with a moving organ. The results obtained show that the telerobotic system increases the success rate of anchor deployment by 100% and reduces the excess force application rate by 70% compared with manual attempts.

Beating heart mitral valve surgery: results in 120 consecutive patients considered unsuitable for conventional mitral valve surgery.

The purpose of the study was to test whether a beating heart mitral valve operation was a valuable option in a heterogeneous group of patients considered very high risk for conventional mitral valve surgery. We conducted a retrospective, single-centre, observational cohort study of 120 patients (mean age 63.7 ± 12.1 years, range 25.3-88.8 years; mean logistic EuroSCORE 26.1 ± 20.6%, range 1.5-84.3%) undergoing beating heart mitral valve operations using normothermic cardiopulmonary bypass without aortic cross-clamping and without cardioplegia between September 2002 and April 2014. Preoperatively, 14 (11.7%) patients were in cardiogenic shock, 16 (13%) on a ventilator, 33 (27.5%) receiving inotropic support, 12 (10%) on dialysis and 1 on extracorporeal membrane oxygenation. Sixty-five (54%) patients had had at least 1 (range 1-6) previous heart operation. The mean follow-up period was 920 ± 973 days. A mitral valve procedure was performed alone in 75 (62.5%) patients and combined with additional cardiac procedures in 45 (37.5%). Fifty-eight (49%) patients had emergency or urgent procedures and 62 (51%), elective procedures. The mean cardiopulmonary bypass time was 103 ± 39 min (median 94 min, range 45-252, interquartile range 75-121.5 min). There were no conversions to conventional procedures and no intraoperative deaths. The 30-day mortality rate for patients without cardiogenic shock was 7.5% (8 deaths among 106 patients). Among 14 (11.7%) patients who underwent an operation in cardiogenic shock, 4 died during the first 30 days (30-day mortality rate = 28.6%, Fisher's exact test P = 0.338 versus patients without shock). The lowest 30-day mortality rate was in patients operated on with the beating heart because of a porcelain aorta (n = 8 patients, 30-day mortality rate = 0%). Patients considered unsuitable for a conventional mitral valve operation had favourable postoperative outcomes if the operation was performed on the beating heart.

Beating Heart Mitral Valve Surgery: Results in 120 Consecutive Patients Considered Non-suitable Candidates for Conventional Mitral Valve Surgery

Objectives: To assess whether beating heart mitral valve surgery is a valuable option in patients considered very high-risk candidates or inoperable for conventional mitral valve surgery.

Beating Heart Minimally Invasive Mitral Valve Surgery in Patients With Patent Coronary Bypass Grafts

BackgroundRedo mitral valve surgery in patients with patent coronary bypass grafts carries a risk of graft injury and postoperative bleeding. We compare early results of reoperative minimally invasive on-pump beating heart mitral valve surgery (OPBMS) via mini thoracotomy vs the results of standard sternotomy mitral valve surgery (SSMS) in the presence of patent coronary bypass grafts. MethodsBetween 2009 and 2015, 12 patients underwent OPBMS through a right mini thoracotomy and 6 patients underwent SSMS. All patients had at least 1 patent bypass graft. ResultsMedian age and EuroSCORE II were not statistically different between the 2 groups. There was no early death in the OPBMS group vs 1 death (17%) in the SSMS group. There was a statistically significant lower median perioperative blood loss in the OPBMS group compared with the SSMS group (200 vs 650 mL; P = 0.005). Four patients (33%) in the OPBMS group required blood transfusion compared with 4 in the SSMS group (67%; P = 0.32). There was 1 perioperative stroke (17%) and 1 acute myocardial infarction (17%) in the SSMS group. Four patients developed acute renal failure in the OPBMS group compared with 3 in the SSMS group (50%; P = 0.62). The predischarge transthoracic echocardiogram showed ≤ 1 mitral regurgitation in all patients. ConclusionsRedo mitral surgery in patients with patent bypass grafts can safely be performed via minimally invasive mini thoracotomy on a beating heart. The main benefits of this approach are to avoid the sternotomy and decrease the amount of postoperative blood loss.

Comparison of Neurocognitive Functions after Beating-Heart Mitral Valve Replacement without Aorta Cross-Clamping and after Standard Mitral Valve Replacement with Cardioplegic Arrest

The aim of this study was to compare the postoperative long-term neurocognitive functions of patients who under-went beating-heart mitral valve replacement on cardiopulmonary bypass (CPB) without aorta cross-clamping with those of patients who underwent mitral valve replacement via the classic method. The study group included 25 randomly selected patients who underwent beating-heart mitral valve surgery. During the same period, 25 patients were randomly selected as controls to undergo mitral valve replacement procedures via the standard ascending aorta-cannulation technique. The clinical and postoperative (2 months) neurocognitive functional data of both groups were compared. Neurologic deficit was observed in neither group during the postoperative period. There were no statistically significant differences between the control and the study groups with respect to Hospital Anxiety and Depression Scale (HADS) results (HADS: anxiety, P = .653; HADS: depression, P = .225), in the right hemispheric cognitive function test results (Raven's Standard Progressive Matrices [RSPM] and Line Orientation Test [LOT] tests: RSPM, P = .189), and in the left hemispheric cognitive function test results (the Ray Auditory Verbal Learning [RAVL] and Stroop Color-Word Test [SCWT] tests: SCWT 1 time, P = .300; SCWT 2 time, P = .679; SCWT 3 time, P = .336; SCWT 4 time, P = .852; SCWT 5 time, P = .416; RAVL total verbal learning, P = .167; RAVL immediate recall, P = .791; RAVL distraction trial, P = .199; RAVL retention, P = .174; RAVL delayed recall, P = .111; RAVL recognition, P = .282; SCWT 4 mistake, P = .306; SCWT 4 reform, P = .066; SCWT 5 mistake, P = .236; SCWT 5 reform, P = .301). The technique of mitral valve replacement with normothermic CPB without cross-clamping of the aorta may be safely used for the majority of patients requiring mitral valve replacement without causing deterioration in neurocognitive functions.

Direct Endoscopy-Guided Mitral Valve Repair in the Beating Heart An Acute Animal Study

: The purpose of this study was to develop a new method for minimally invasive mitral valve repair under direct endoscopic visualization in the beating heart. : Fiberoptic cardioscopy of the left heart was conducted in 12 calves. Systemic perfusion was maintained by cardiopulmonary bypass through a median sternotomy. A clear solution (Ringer's lactate) was temporarily administered via the pulmonary artery to flush out the pulmonary vasculature, and additional perfusion of the left heart chambers enhanced visualization of the intracardiac anatomy. The endoscope, with an open-ended transparent flexible outer sheath, was inserted through the left ventricular apex, and an endoscopic clip was used for edge-to-edge mitral valve repair. Hemodilution was avoided by the drainage of irrigation fluid via a left ventricular cannula. : Direct endoscopic visualization of the mitral valve in an in vivo beating heart was obtained clearly, avoiding systemic hemodilution. In the last experiment, edge-to-edge repair using an endoscopic clip was successfully performed. Use of an effective intracardiac irrigation method was important for successful image acquisition and achievement of repair procedures. : This acute animal study showed the technical feasibility of beating-heart mitral valve surgery under direct endoscopic imaging. Although this study was performed under open-chest conditions, our successful experiment is a first step toward closed-chest intracardiac surgery with direct endoscopic visualization.

Robotic tissue tracking for beating heart mitral valve surgery

The rapid motion of the heart presents a significant challenge to the surgeon during intracardiac beating heart procedures. We present a 3D ultrasound-guided motion compensation system that assists the surgeon by synchronizing instrument motion with the heart. The system utilizes the fact that certain intracardiac structures, like the mitral valve annulus, have trajectories that are largely constrained to translation along one axis. This allows the development of a real-time 3D ultrasound tissue tracker that we integrate with a 1 degree-of-freedom (DOF) actuated surgical instrument and predictive filter to devise a motion tracking system adapted to mitral valve annuloplasty. In vivo experiments demonstrate that the system provides highly accurate tracking (1.0 mm error) with 70% less error than manual tracking attempts.

Beating Heart Mitral Valve Surgery: Innovation or Back to the Past?

Beating Heart Mitral Valve Surgery: Innovation or Back to the Past?

Efficacy, Feasibility, and Pitfalls of Transseptal Approach in Beating-Heart Mitral Valve Surgery

Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls. Between 2000 and 2007, 214 patients underwent mitral valve procedures using the beating-heart surgical approach. One hundred and forty-three patients (66.8%) had mitral valve replacement, 68 patients (31.7%) mitral valve repair, and 82 patients (38.3%) concomitant valve procedures. Coronary artery bypass grafting was simultaneously performed in 30 (14%) patients. Thirty-day mortality was 7.4%, reoperation for bleeding 7%, stroke 0.4%, and myocardial infarction 0.4%, and failed mitral valve repair 0.9%. Our experience suggests that beating-heart mitral valve surgery is facilitated by using the trans-septal approach.

Resultados da abordagem transeptal para a valva mitral com coração batendo

Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls.Between 2000 and 2007, 214 consecutive patients were operated upon utilizing beating heart technique for mitral valve surgery. The operation was performed via transseptal approach with the aorta unclamped, the heart beating, with normal electrocardiogram and in sinus rhythm.Mean age was 56.03 +/- 13.93 years (range: 19-86 years; median: 56 years). There were 131 (61.2%) males and 83 (38.8%) females. Of the prostheses used, 108 (50.5%) were biological, and 39 (18.2%) were mechanical. Mitral repairs were performed in 67 (31.3%) patients. Mean hospital stay was 17.4 +/- 20.0 days (range: 3-135 days; median: 11 days). Intra-aortic balloon pump (IABP) utilization was required in 12 (5.6%) of 214 patients. One-month mortality was 7.4%, and re-operation for bleeding was needed in 15 (7%) patients.Beating-heart mitral valve surgery is an option for myocardial protection in patients undergoing mitral valve surgery. This technique is facilitated by the trans-septal approach due to reduced aortic insufficiency and improved visualization of the mitral apparatus.

Beating Heart Mitral Valve Surgery: How to Test Mitral Valve Competence After Repair?

Beating Heart Mitral Valve Surgery: How to Test Mitral Valve Competence After Repair?

On-Pump Beating Heart Mitral Valve Surgery without Cross-Clamping the Aorta

Cardiac reperfusion injury is a well-described complication occurring after ischemia or following cardioplegic arrest. Various strategies have been developed to prevent ischemic reperfusion injury. The aim of this study was to assess the efficacy and applicability of the on-pump beating heart mitral valve surgery without cross-clamping the aorta in order to prevent reperfusion injury. The prospective study (between April 2005 and December 2006) included 88 consecutive patients who underwent mitral valve surgery. The operations were carried out on a beating heart using normothermic cardiopulmonary bypass without cross-clamping the aorta, therefore perfusing the heart antegradely through the aortic root. Venting the heart from the aorta and the pulmonary vein provided adequate visualization of the operative field. Seventy-eight patients (88.6%) underwent mitral valve replacement and 10 patients (11.3%) underwent mitral valve repair with this technique. Concomitant surgery was required in 29 patients (32.9%). Twenty-five patients (28.4%) had also undergone previous open heart surgery. Mean cardiopulmonary bypass time was 57.4 +/- 18.4 minutes. Mean duration of ventilation was 12.2 +/- 3.5 hours, mean intensive care unit stay was 1.3 +/- 1.6 days, and mean hospital stay was 6.9 +/- 4.5 days. One-year survival was 96.6% for all causes of mortality. In this study, we showed that on-pump beating heart operations without cross-clamping is an acceptable surgical choice for mitral valve disease. Complication rates are low and perioperative mortality is lower than that generally reported with conventional technique.

Surgery for Cardiac Valves and Aortic Root Without Cardioplegic Arrest ("Beating Heart"): Experience with a New Method of Myocardial Perfusion

Simultaneous antegrade/retrograde warm blood perfusion with a beating heart has not been previously reported as a mean of protecting hypertrophied hearts in cardiac valve and aortic root surgeries. Similarly, beating heart mitral valve surgery via the trans-septal approach with the aorta unclamped, is a novel technique. We, herein, report a series of 346 patients with a variety of cardiac pathologies who were operated upon utilizing a new modality of myocardial perfusion. Among this group of patients, there were 55 patients who were diagnosed with endocarditis of one or more valves. These patients were excluded from this series of patients. Mean age was 59 +/- 12, and there were 196 (67.3%) males and 95 (32.7%) females. There were six aortic root procedures, 90 mitral valve replacements (MVR), 46 mitral valve repairs, 20 MVR+ coronary artery bypass grafting (CABG), 28 tricuspid valve repairs, 106 aortic valve replacements (AVR), 17 AVR+CABG, and 8 AVR/MVR. Crude mortality for the group was 20 of 291 (6.8%). Intra-aortic balloon pump utilization at time of weaning from cardiopulmonary bypass was 6/291 (2.06%), and re-operation for bleeding was needed in 12 of 291 (4.1%) patients. Postoperative stroke occurred in 4 of 291 (1.3%) patients. In these patients, the clinical diagnosis of stroke was made prior to surgery. This initial experience with this new method of myocardial perfusion indicates that results are at least comparable, if not superior, to conventional techniques utilizing intermittent cold blood cardioplegia.

On-pump beating-heart mitral valve plasty without aortic cross-clamping

Patients with ischemic cardiomyopathy often have mitral regurgitation, which should be corrected for better long-term survival. Mitral valve surgery is usually performed during cardiopulmonary bypass under the arrested heart condition. The ascending aorta is cross-clamped and the heart is arrested using a cardioplegic solution. However, because ischemic cardiomyopathy patients often have a severely atherosclerotic ascending aorta and low cardiac function, aortic cross-clamping and cardiac arrest increase the risk of postoperative thromboemboli and low cardiac output syndrome. Under the on-pump beating-heart condition, we performed mitral valve plasty concomitant with coronary artery bypass grafting, tricuspid annuloplasty, left ventricular aneurysmectomy, and the maze procedure without aortic cross-clamping for a patient with ischemic dilated cardiomyopathy and bradycardial atrial fibrillation. The patient had no postoperative complications and re covered rapidly. Thus, to prevent serious postoperative complications, on-pump beating-heart mitral valve surgery without aortic cross-clamping may be a suitable surgical option for patients with ischemic cardiomyopathy.

Concomitant Beating-Heart Mitral Valve Surgery and Coronary Artery Bypass in Patients with Compromised Ventricular Function

Concomitant Beating-Heart Mitral Valve Surgery and Coronary Artery Bypass in Patients with Compromised Ventricular Function

Concomitant Beating-Heart Mitral Valve Surgery and Coronary Artery Bypass in Patients with Compromised Ventricular Function

: Surgical repair of mitral valve disease and concomitant coronary artery occlusive disease has high operative risk. Myocardial protection for protracted, complicated procedures is seminal to the overall operative outcome; specifically, preservation of left ventricular function. The authors conducted a retrospective review of 25 patients undergoing combined mitral valve repair/replacement (MVR) and coronary artery bypass surgery (CABG) using the beating-heart technique at the Miller/University of Miami School of Medicine. The CABG was performed without cardiopulmonary bypass support. During the mitral valve surgery the perfusion pressure was maintained at 80-90 mm Hg and the systemic temperature at 35-36ºC. The aorta was not cross-clamped. : Twenty-five patients underwent MVR/CABG, including 7 patients with acute myocardial infarction. Preoperative echocardiograms revealed a mean ejection fraction (EF) of 41 ± 4.5%. One patient required a preoperative intraarterial balloon pump. An average of 2.12 ± 0.9 grafts and a total of 10 mitral valve repairs were performed. The average length of stay in the intensive care unit was 14 ± 1.8 days, and average hospitalization time was 23 ± 3. The mean postoperative EF was 41 ± 4.5%. The mortality in this patient group was 12 % (3/25) with a morbidity rate of 52% (13/25). : The data suggest that the technique is safe and reproducible, and that it potentially has a short-term benefit on left ventricular function. Therefore, this particular technique may be efficacious in patients with compromised left ventricular function requiring a combined MVR/CABG.

Beating-heart mitral valve surgery: preliminary model and methodology.

It is our hypothesis that image-guided mitral valve repair can be performed on the beating heart without cardiopulmonary bypass. As a first phase, we tested the feasibility of suturing the anterior and posterior mitral valve leaflets under image guidance. In a water bath model, imaging approaches and suturing techniques were developed. Then, in 6 pigs, the left atrium was cannulated with a custom-made 15-mm valved port through a left thoracotomy. Atrial pressure was elevated by shunting of arterial blood to minimize air induction. A multiplane transesophageal echocardiographic probe was evaluated in the intraesophageal and epicardial positions. With a commercial endoscopic suturing device, sutures were placed through the anterior and posterior mitral leaflets under echocardiographic guidance. The animals were killed, and suture accuracy was evaluated by measuring the distance from the intended target areas on the anterior and posterior mitral leaflets. Air induction was monitored by echocardiography and graded as minimal to severe. There were no cases of hemodynamic instability or significant arrhythmia. The most effective imaging plane was a short-axis view that used the transesophageal echocardiographic probe epicardially at the heart base. Air induction was minimal in 2 animals, mild in 3, and moderate in 1. Sutures were successfully placed 9 of 12 times (mean error 0.8 +/- 0.5 cm). With these methods, off-pump, image-guided suturing of the beating-heart mitral valve was possible. This model may be a useful starting point for developing off-pump mitral valve repair procedures.