Democratizing Minimally Invasive Mitral Repair​

This video submission is from the 2025 CTSNet Innovation Video Competition. Watch all entries from the competition, including the winning videos.   

Minimally invasive mitral valve repair offers clear advantages over conventional sternotomy, including reduced postoperative pain, shorter recovery time, and improved cosmetic results. However, its broader adoption has been limited by variability in patient selection, incision planning, and intraoperative technique. This video presents a comprehensive, standardized method that addresses both the preoperative and operative phases of minimally invasive mitral valve repair. 
 
The process began with preoperative contrast-enhanced computed tomography (CT) of the chest. Using 3D reconstruction, a patient-specific model of the heart, great vessels, ribs, and thoracic structures was generated. A key component of this analysis was measuring the acuity of the angle between a line drawn across the mitral valve annular plane and a transverse line through the interventricular septum. This measurement helps determine the optimal intercostal space and trajectory for valve exposure while anticipating anatomic challenges such as cardiac rotation, rib spacing, or aortic position. Patients with unfavorable anatomy, such as severe chest wall deformities, a calcified aorta, or inadequate working space, can be identified early and directed toward alternative approaches. 
 
Once the incision and exposure were established, the mitral valve was approached in a reproducible, stepwise fashion. Annular stitches were placed immediately to secure exposure. Valve analysis was performed using standard assessment techniques. Visualization was enhanced with a metallic flexible intracardiac retractor, which allowed for improved access to all segments of the valve. 
 
For repair, the Memo 4D mitral ring was used, which reduced the technical difficulty of chordal measurements and facilitated neochordal implantation. This device also helps maintain consistent annular geometry. Suture placement strategies that minimized the need for subsequent chordal adjustments were discussed, thereby reducing operative time and improving repair durability. 
 
By integrating a structured imaging-based selection process with a standardized intraoperative sequence, this method addressed two of the main barriers to reproducibility in minimally invasive mitral valve surgery—patient variability and procedural inconsistency. The combination of precise preoperative planning, reliable exposure, optimized visualization, and technically streamlined repair steps has the potential to improve efficiency, safety, and outcomes across surgical teams and institutions. 

This video demonstrates the complete workflow, from imaging acquisition and 3D reconstruction through operative execution, with the goal of making minimally invasive mitral valve repair more consistent, accessible, and successful. 

References

1. Heuts S, Maessen JG, Sardari Nia P. Preoperative planning of left-sided valve surgery with 3D computed tomography reconstruction models. Interact Cardiovasc Thorac Surg. 2016;22(5):633-638. doi:10.1093/icvts/ivv380
2. LivaNova PLC. Memo 4D Mitral Repair Device: Product Brochure. London, UK: LivaNova PLC; 2020. Available at: https://usacampuslivanova.com/wp-content/uploads/2020/01/03-Memo4D-Brochure-IM-01782-C.pdf. Accessed August 8, 2025.
3. Heuts S, Maessen JG, Sardari Nia P. Planning minimally invasive mitral valve surgery. J Vis Surg. 2018;4:33. doi:10.21037/jovs.2018.01.10
4. Okamoto K, Yozu R. Designing innovative retractors and devices to facilitate mitral valve repair surgery. Ann Cardiothorac Surg. 2015;4(4):364-369. doi:10.3978/j.issn.2225-319X.2015.01.06

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