Minimally invasive treatment of multiple valve disease: A modified approach through a right lateral minithoracotomy

Abstract

Background and aim of the study: Today there is little experience with minimally invasive treatment of multiple valve disease and no standard techniques have been provided yet. We report our early experience with combined aortic and mitral valve surgery with or without tricuspid surgery through a right lateral minithoracotomy (RmT), describing the technical aspects of our approach. Methods: From April 2017 to April 2019 thirty patients with mitro-aortic valve disease or with triple valve pathology underwent surgery through a 3 to 4 cm lateral RmT into the third intercostal space. Cardiopulmonary bypass was established through femoral vessels cannulation. Surgery on the mitral valve (MV) was performed first and sutures put into the mitral annulus. Aortic valve replacement (AVR) was performed next. Then, the selected ring or prosthetic valve was implanted in a mitral position throughout previously placed sutures. Finally, if required, tricuspid valve surgery was performed. Results: In combined with AVR, MV replacement was performed in 20 patients (66%), and MV repair in 10 patients (34%). Concomitant tricuspid annuloplasty was performed in five patients (17%). There was no conversion to full sternotomy. Postoperatively, one patient died. Postoperative echocardiography showed no perivalvular leakage in aortic or in the mitral position. No residual mitral regurgitation was observed in patients who underwent MV repair.Conclusions: Minimally invasive surgery of double and triple valve disease is feasible.Our approach through a lateral RmT allows optimal visualization of the aortic, mitral, and tricuspid valves, simplifies the surgical procedure and allows excellent results also in complex MV repair procedures.

Minimally invasive triple valve surgery: A single center experience

“…In this series, cardiopulmonary bypass times (median 166 minutes) are similar to those observed within our institution in patients who underwent TVS utilizing an open approach without other concomitant cardiac procedures, such as CABG (median 168 minutes in seven patients, data not shown). Moreover, cross‐clamp times were similar, and actually slightly lower, in this cohort compared with our previous open patients with TVS (median 137 minutes), and is also lower than similar reports in the literature, which range from 131 to 181 minutes 6,8,11,12 . A study of double valve procedures by Atik et al 25 which used propensity scoring to match patients undergoing open and minimally invasive approaches showed that utilizing the minimally invasive approach did not prolong cross clamp time or total time on cardiopulmonary bypass.…”

Outcomes in minimally invasive double valve surgery

“…Non‐comparative studies reported low mortality rates using the MIS approach. One study reported 30‐day mortality as 1.78% and reported four more deaths during the follow up period (7%), 34 with other studies also reporting similar rates (in‐hospital mortality: 1.7%, 31 3.5%, 28 4% 29 ; 30‐day mortality: 3%, 30 4%, 29 4.3% 14 ). Four studies reported 0 mortalities using MIS, 17,32,33,38 two of which used an endoscopic approach 17,38 …”

“…18 Other studies have found the 5-year survival rate following double valve MIS to be 88% 29 . 18,30,31,34 The techniques and centers used in the studies vary significantly, and so it is difficult to compare the data to the MIS versus MS data obtained in comparative studies. Total endoscopic double valve surgery resulted in a significant decreased length of stay compared with a right transaxillary incision with direct vision.…”

“…18 The three comparative studies which reported this outcome found no significant difference between the groups (MIS vs. MS: 0% vs. 0.04%, 26 1.2% vs. 0% 24 24,26 Other studies using the MIS technique reported varying numbers of patients experiencing new onset AF following double valve surgery (9%, 12.8%, and 30%). [29][30][31] Again, more research is needed to fully evaluate this outcome.…”

“…As surgical experience grows, Lio et al 37 state these patients may be managed more easily. This was indeed the case as Musumeci et al 30 in 2020 no longer listed the 10 cm aorta‐sternal distance cut off when stating their exclusion criteria for the same technical approach. Also, using a totally endoscopic approach, patients whose ascending aorta to sternum distance was greater than 10 cm could be included, 38 however this was a study on single value surgery, but another study in 2020 used the same endoscopic technique to carry out both single and double valve surgeries 17 .…”