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Totally Endoscopic Redo Mitral Valve Surgery With Different Myocardial Protection Strategies
Castillo-Sang M, Penaranda J. Totally Endoscopic Redo Mitral Valve Surgery With Different Myocardial Protection Strategies. May 2025. doi:10.25373/ctsnet.29103377
In this CTSNet series, Dr. Mario Castillo-Sang presents innovative, totally endoscopic cardiac procedures for a variety of conditions. Stay tuned for more series videos in the coming weeks.
Redo endoscopic mitral valve surgery can be performed safely and successfully with good preoperative planning (1). Cannulation and myocardial protection strategies are paramount to safe reoperation. In this video, the authors present four cases of redo surgery to illustrate different myocardial protection strategies and various cannulation modes.
First Case
The first case involved a 55-year-old male who had previously undergone coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) with a bioprosthetic bovine valve. Thepatient had vein grafts and a left internal mammary artery (LIMA) to the left anterior descending artery (LAD) from the prior MVR. The patient’s valve showed severe mitral stenosis gradients, and transesophageal echocardiogram (TEE) suggested that the mode of implantation contributed to this condition, which was endorsed by his New York Heart Association (NYHA) Class III symptoms and near systemic pulmonary artery pressures of 79/50 mmHg. His left ventricular ejection fraction (LVEF) was 30 percent and had been as low as 15 percent in the past. The valve was implanted in situ without any mobilization or resection of the central anterior leaflet. Echocardiography showed tenting of the anterior leaflet over the posts of the valve.
The patient underwent endoscopic mitral valve replacement with a mechanical valve. The endoscopic approach consisted of a 2.5 cm working incision in the fourth intercostal space and a 10 mm port in the third intercostal space for a 30-degree angled endoscope. The pericardiotomy was made 3 cm above the phrenic nerve, extending along the center portion of the aorta superiorly and all the way to the diaphragm inferiorly, where it was directed anteriorly toward the left side. In reoperative cases, the surgeons incise the pericardium to create a small window and then use the endoscopic “peanut” to bluntly dissect the tissue planes. The authors focused on the ascending aorta to find spaces for a root vent and cross-clamp before turning to the pulmonary veins for interatrial entry. Finally, the surgeons looked for a right ventricular site for the ventricular pacing wire. In this case, given the patency of the left internal mammary graft and the depressed LVEF of 30 percent with a history of ischemic cardiomyopathy that had been as low as 15 percent LVEF, the surgeons elected to perform fibrillatory arrest.
The mitral valve was found to be covered in panus, with a heavy burden originating from the anterior posts that were fused to the body of the anterior leaflet of the mitral valve, which had progressed to covering the base of the leaflets. The valve was successfully explanted, and a mechanical mitral valve with a deep cage was used. The patient did well and was extubated three hours postoperatively after the inhaled nitric oxide was weaned. He made a full recovery and was discharged home on postoperative day five. At the one-year follow-up, he was found to be doing well, with a LVEF of 30-35 percent on guideline-directed medical therapy (GDMT) and was classified as NYHA Class I.
This case highlights that reoperative cardiac surgery for the mitral valve can be performed safely with effective brain and myocardial protection using fibrillatory arrest and modest hypothermia of 32 degrees Celsius. Performing reoperative mitral valve surgery in patients with pulmonary hypertension has been shown to be safe when taking the appropriate steps for right ventricular offloading (2).
Second Case
The second case involved a 62-year-old female patient with rheumatic severe mitral valve regurgitation and a prior history of right video-assisted thoracoscopic (VATS) lobectomy for early-stage lung cancer. She had also required hematoma evacuation postoperatively at that time. Her mediastinum had not been violated before. The patient had preserved ejection fraction, but severe aorto-iliac vascular disease that required axillary cannulation. Although this case does not represent reoperative mitral valve surgery or reoperative mediastinal surgery, it does highlight that re-entry through the right chest under adverse conditions can be performed endoscopically. The patient underwent an endoscopic approach as described herein. In cases like this, a double lumen ventilation strategy was used to take down the adhesions of the right lung, and once the pericardium could be seen, both lungs were ventilated for at least two minutes. Heparinization was then initiated, and cannulation was performed to institute cardiopulmonary bypass. Given the patient’s pulmonary hypertension of 68/40 mmHg, the surgeons supported her after induction with inhaled nitric oxide. Supported on bypass, the rest of the operation was carried on conventionally.
The patient underwent successful lysis of adhesions and was cannulated through a cutdown on the right axillary artery (due to severe aorto-iliac calcific disease) with direct insertion of the arterial cannula (without graft anastomosis, and with bilateral brachial arterial monitoring lines). The venous cannula was inserted in the right femoral vein percutaneously. The patient underwent a successful mitral valve replacement with a bovine tissue valve using antegrade cardioplegic arrest with del Nido solution, along with a tricuspid valve repair on a beating heart. After separation from bypass, the pulmonary pressures decreased to 40 mmHg systolic, and the inhaled nitric was not resumed. The patient was extubated in the operating room and made a full recovery, being discharged home on postoperative day three. At her three-month echocardiogram and follow-up, she was found to be doing well, classified as NYHA Class I.
This case highlights that prior right chest surgery (VATS or thoracotomy) is not a contraindication to endoscopic cardiac surgery, provided that thorough planning to address these obstacles is carried out. Management of double lumen intubation for single lung ventilation during the lysis of adhesions is nuanced by the experience of the authors and that of others, given the suspicion that instituting bypass while on single lung ventilation may promote congestion of the isolated lung. Therefore, both lungs were ventilated for a period of at least two minutes before instituting bypass. The authors acknowledge that this approach is experiential, however, it has proven to be effective in performing a relatively high volume of reoperative surgery over the years. The etiology of single lung pulmonary edema is elusive at best and is likely multifactorial, involving an inflammatory component, a congestion and pulmonary hypertension component, and a cardiopulmonary bypass drainage component (3).
Third Case
The third case involved a 78-year-old female with mixed severe mitral regurgitation and a prior CABG with patent LIMA to LAD and vein grafts. The patient had systemic pulmonary hypertension (95/68mmHg).
The cannulation strategy for this patient was femoral cutdown for arterial and venous cannulation. The patient was cooled to 32 degrees Celsius on bypass. A root vent was applied, but further dissection of the aorta for a possible cross-clamp proved hazardous, and with the patient’s LIMA to LAD, it was elected to perform the operation on a beating heart.
In these cases, the authors adhere to two concepts: a mean arterial pressure (MAP) of at least 65 mmHg on bypass while always venting the left ventricle using a small cardiotomy sucker or left ventricular (LV) vent. The right chest was flooded with carbon dioxide at 10 LPM to displace natural air. The biggest nuance in these cases is minimizing aortic insufficiency while exposing the left atrium. In this case, the HV Heart Retractor was used, which has a deep blade. Although it provided excellent exposure of the left atrial structures, it could cause or worsen aortic insufficiency. In more recent years, the authors have used the CSV Retractor, which was designed primarily as a tricuspid retractor with a shorter blade. This design avoids pressing on the aortic valve in most instances.
Redo mitral valve surgery via the right chest has been studied before and found to be safe and effective (4). Endoscopic beating heart redo mitral valve surgery is equally effective and offers the benefits of improved visualization of the surgical field.
Fourth Case
The fourth case involved a 70-year-old male with ischemic mitral valve regurgitation and a history of CABG with patent LIMA to LAD and vein grafts to obtuse marginals. The patient presented with NYHA class III symptoms and was optimized medically as an inpatient. He was offered an endoscopic redo mitral valve replacement to a tissue valve, as he was not a candidate for transcatheter edge-to-edge repair (TEER) given the heavy calcification of the anterior leaflet of the mitral valve.
The approach was a typical fourth intercostal 2.5-3 cm incision with 30-degree 10 mm endoscope. Femoral cannulation was performed for both the artery and the vein. The patient was cooled to 32 degrees Celsius. While on bypass, the adhesions of the heart to the pericardium were lysed, and a root vent was applied. There was no safe location to dissect around the ascending aorta or the right ventricle from the pericardium for placement of a cross-clamp or a pacing wire, so the atriotomy was performed on a beating heart. The valve was exposed in the standard fashion, and then the ventricular pacing wire was introduced into the left ventricle to obtain fibrillatory arrest.
This case offers a troubleshooting option for complex situations. Several cases of reoperative mitral surgery with cardioplegic arrest using antegrade del Nido solution have been performed in instances where the mitral valve is native, and the replacement can be achieved within 40 minutes if the LVEF is preserved or only mildly depressed. The authors have found that redosing the cardioplegia at 20-30 minutes is necessary to maintain the arrest. There has been no encountered difference in myocardial function after these cases compared to fibrillatory arrest. Another option in this case would have been to induce systemic hyperkalemia to obtain a fibrillatory arrest (5).
Summary
Preoperative planning is the key to successful reoperative mitral valve surgery. Important techniques to master include alternative cannulation sites, fibrillatory arrest, cardioplegic arrest, beating heart techniques, and, of course, efficient lysis of adhesions.
References
- Casselman FP, La Meir M, Jeanmart H, Mazzarro E, Coddens J, Van Praet F, Wellens F, Vermeulen Y, Vanermen H. Endoscopic mitral and tricuspid valve surgery after previous cardiac surgery. Circulation. 2007 Sep 11;116(11_supplement):I-270.
- Castillo-Sang M, Guthrie TJ, Moon MR, Lawton JS, Maniar HS, Damiano Jr RJ, Silvestry SC. Outcomes of repeat mitral valve surgery in patients with pulmonary hypertension. Innovations. 2015 Mar;10(2):120-4.
- Renner J, Lorenzen U, Borzikowsky C, Schoeneich F, Cremer J, Haneya A, Hensler J, Panholzer B, Huenges K, Broch O. Unilateral pulmonary oedema after minimally invasive mitral valve surgery: a single-centre experience. European Journal of Cardio-Thoracic Surgery. 2018 Apr 1;53(4):764-70.
- Romano MA, Haft JW, Pagani FD, Bolling SF. Beating heart surgery via right thoracotomy for reoperative mitral valve surgery: a safe and effective operative alternative. The Journal of Thoracic and Cardiovascular Surgery. 2012 Aug 1;144(2):334-9.
- Panjwani A, Patel MJ, Youngblood C, Lione A, Schaffer J, Smith R. Inducing systemic hyperkalemia for cardiac arrest during cardiopulmonary bypass with patent cardiac circulation. InBaylor University Medical Center Proceedings 2022 Feb 16 (Vol. 35, No. 2, pp. 217-218). Taylor & Francis.
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