Totally Endoscopic Bileaflet Mitral Valve Repair With Preformed Chordae Loops

The patient was a 38-year-old man with dyspnea on exertion class II and severe mitral regurgitation seen on transthoracic echocardiography. Intraoperative transesophageal echocardiography (TEE) revealed a flail A2/A3 segment and posteromedial commissure and a P3 segment prolapse. The chest was entered in the fourth intercostal space through a 3 cm right periareolar working incision. A three-dimensional endoscope was placed in the same intercostal space in the right anterior axillary line, through a port that was also used for CO₂ infusion.

On cardiopulmonary bypass (CPB) through the femoral vessels, the pericardium was opened and retracted with pericardial sutures. The superior vena cava was dissected for the first 3 cm. Also, the ascending aorta was dissected away from the right pulmonary artery. A Chitwood clamp was introduced in the third intercostal space anterior to the right anterior axillary line. The aorta was cross-clamped, and the heart was arrested with Custodiol® cardioplegic solution. A left atriotomy incision was performed, and a left atrial retractor was used to expose the mitral valve after placing a sump sucker in the left lower pulmonary vein.

The valve was examined, and the TEE diagnosis was confirmed. A separate leaflet-opening device was used to allow work in the subvalvular apparatus. The optimal length for the anterior leaflet chordae was measured as 24 mm; it was measured as 18 mm for the posterior leaflet. Two sets of four preformed polytetrafluoroethylene loops of 24 and 18 mm were anchored in the posteromedial papillary muscle, and three (24 mm) synthetic chordae were inserted in the A2/A3 segments, one (18 mm) in the posteromedial commissure, and one (18 mm) in the P3 scallop.

Then, a posterior annulus annuloplasty was performed with the use of a custom-made band and the annuloplasty sutures were secured over the band with the Cor-Knot® device. The left atrium was closed with a double suture line, the heart was deaired, and the aortic clamp was removed. After coming off CPB, TEE confirmed an excellent valve function with no regurgitation, systolic anterior motion, or stenosis.

Suggested Reading

1. Van Praet KM, Stamm C, Sündermann SH, et al. Minimally invasive surgical mitral valve repair: state of the art review [published correction appears in Interv Cardiol. 2018;13(2):99.]. Interv Cardiol. 2018;13(1):14-19.
2. Melnitchouk SI, Seeburger J, Kaeding AF, Misfeld M, Mohr FW, Borger MA. Barlow’s mitral valve disease: results of conventional and minimally invasive repair approaches. Ann Cardiothorac Surg. 2013;2(6):768-773.
3. Davierwala PM, Seeburger J, Pfannmueller B, et al. Minimally invasive mitral valve surgery: “the Leipzig experience”. Ann Cardiothorac Surg. 2013;2(6):744-750.