Minimally Invasive Valve Surgery

by Lawrence H. Cohn, MD

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Representative Case Echocardiograms

Preoperative

The findings are similar to previous echocardiograms. Severe mitral regurgitation with reversal of flow in the pulmonary veins is readily apparent. Both anterior and posterior leaflets appear myxomatous and prolapse above the plane of the annulus. However, no ruptured chordae were identified.

Intraoperative

Repeat transesophageal echocardiography was then performed after separation from cardiopulmonary bypass. It shows significant improvement in the mitral regurgitation with only mild residual regurgitation. In addition, no mitral stenosis was observed. There was mild septal hypokinesis, but the overall left ventricular function remained unchanged.

Operative Technique for Mitral Valve Replacement

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The incision here in the groin is a very small incision, and there is a very small incision in the parasternal area as well. The groin incision is transverse above the inguinal crease.

The small areas of the costal cartilages of ribs 3 and 4 are removed. This allows access into the pericardium, much as with a mediastinotomy for thoracic oncologic disease.

The pericardium is now opened and marsupialized to the skin.

Cannulation in this case was done in the groin with a small incision in the femoral artery after checking that the descending aorta was ok. The femoral vein is used through a purse string. A wire is placed through the purse string and then a Biomedicus cannula, in this case a 25 French, is placed.

Here is the right atrium, and in this particular case the approach will be trans-septal. There is some accumulation of blood from cardioplegia and coronary circulation. The right atrium is incised generously, and the septum is visualized.

After the septum is opened, the valve is exposed. Traction sutures on each layer for exposure are important. Once these are in place, a single arm of the Cosgrove retractor is utilized.

The intracardiac camera now shows the valve in this particular patient. Additional exposure is gained by placing the annuloplasty sutures in order to retract the valve annulus toward the operator so the pathology is exposed. The posterior leaflet of this patient is pathologic, with ruptured chordae. Placement of additional annular sutures will straighten out the annulus and bring it toward the surgeon.

We found a good bit of calcium below the valve which had to be removed in order to do the rolling leaflet advancement. Careful removal of annular calcification can be done in myxomatous disease.

Further annuloplasty stitches are placed, and the P3 segment is incised. This will be brought down to reduce the height of the residual valve and reduce the circumference of the posterior annulus. This technique was popularized by Dr. Carpentier.

We only use running suture on these repairs, as this provides better remodeling and a much smoother valve annulus surface, resulting in a very low incidence of thromboemboli.

Operative Technique for Aortic valve Replacement

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As you can see in this incision, we perform a partial median sternotomy. Here the previous wire are removed, although we often leave the wires in place, and we have obtained access for femoral bypass should it be needed. If the femoral arteries are unsatisfactory, the right or left axillary arteries can be used. The sternotomy is then "T"'d off to provide exposure.

Four prior bypass grafts had been done, including an intact mammary. The ascending aorta is cannulated with the no-clamp technique used at the Brigham.

Using a purse string in the innominate vein, a 25 French Biomedicus cannula is slid into the right atrium to provide full access for cannulation. the advantage of this technique is that both cannulae will be behind the aortic cross clamp.

In this case, the exposure was so excellent we used retrograde cardioplegia as well as antegrade cardioplegia.

The aortic valve is exposed through the aortic incision and traction sutures are placed both anterior and superior. The old bioprosthesis is seen.

Sizing of the aortic annulus is performed, and a pericardial valve is inserted using mattress suture technique.

Publication Date: 7-Feb-2005
Last Modified: 7-Feb-2005