Single Incision Mitral Valve Repair and LIMA-to-LAD Bypass via a Left Anterior Minithoracotomy

Minimally invasive cardiac surgery is increasingly becoming a standard approach for the treatment of various cardiac pathologies. Minimally invasive techniques are well established for isolated procedures such as mitral and/or tricuspid valve repair, aortic valve replacement (1), and coronary artery bypass grafting (CABG) (2), particularly when involving the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) (3). It is commonly accepted that valvular pathologies and CABG are typically approached through right and left minithoracotomies, respectively. In cases requiring concomitant procedures (valvular surgery plus CABG), the surgical strategy must be tailored to the individual patient (4). 

While the most straightforward minimally invasive approach in such cases would be to combine both right and left minithoracotomies, it is possible in selected patients to perform the entire operation through a single minithoracotomy to further minimize surgical trauma and reduce the number of incisions. 

In this video, the authors present their technique for performing both mitral valve repair and LIMA-to-LAD CABG through a single left anterior minithoracotomy. The patient was positioned supine with a lateral support pad under the left hemithorax. Intubation was performed with a single-lumen endotracheal tube. A 7–8 cm anterior minithoracotomy was made in the fourth intercostal space. For LIMA harvesting, the surgeons used a specially designed rib retractor, which significantly enhanced surgical exposure. During this phase, the lung was ventilated without positive end-expiratory pressure (PEEP) and with a low tidal volume and then displaced using a large surgical gauze introduced into the thoracic cavity. 

Following LIMA harvesting, cardiopulmonary bypass (CPB) was established percutaneously and under echocardiographic guidance via the femoral vessels. The LIMA was divided, and its flow was verified. The pericardium was then opened, allowing progressive exposure of the mediastinum. Vascular tapes were passed around the aorta and subsequently around both the superior and inferior vena cava. These tapes were brought out through the thorax to optimize exposure. 

The mitral valve was addressed first via a transseptal Guiraudon incision. Mitral valve repair was performed using Gore-Tex loops, as per the authors’institutional standard. The second stage of the operation involved the LIMA-to-LAD anastomosis. With the heart arrested, the LAD was readily identified, and the anastomosis was performed using standard surgical instruments. 

Closure and drainage of the pleural and pericardial spaces were carried out in the conventional manner. 

The authors believe that this technique, performed through a single left anterior minithoracotomy, is a feasible and efficient approach for selected patients requiring combined CABG and mitral or tricuspid valve surgery. This approach expands the range of options available to the minimally invasive cardiac surgeon. 

References

1. Babliak O, Demianenko V, Melnyk Y, Revenko K, Babliak D, Stohov O, et al. Multivessel Arterial Revascularization via Left Anterior Thoracotomy. Semin Thorac Cardiovasc Surg. 2020;32:65562.
2. Davierwala PM, Verevkin A, Bergien L, von Aspern K, Deo SV, Misfeld M, et al. Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience. J Thorac Cardiovasc Surg. 2021;S0022-5223:00343-3.
3. Babliak O, Lazoryshynets V, Demianenko V, Babliak D, Marchenko A, Revenko K, et al. New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures. JTCVS Tech. 2024;24:5763.

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