Strategy-specific durability of mitral valve repair through the video-assisted right minithoracotomy approach

Abstract

Aims We sought to analyze the early and follow-up results of minimally invasive video-assisted mitral valve repair. With particular focus on degenerative disease, results were stratified according to type of lesion, strategy of repair and surgical technique. Methods We retrospectively built a database over 241 patients who received mitral repair for severe regurgitation through right minithoracotomy in the 2009–17 period. Cause was degenerative in 92.1%, restrictive in 5.8% and mixed in the remainders. Clinical and echocardiographic follow-up (98.7% complete, average duration 2.9 years ± 1.4) was obtained through contact of in-house and territorial cardiologists. Recurrent mitral regurgitation at follow-up was defined as being at least mild-to-moderate (2+). Results Operative mortality was 1.7%, and related to the technique in one case. Five-year actuarial survival was 95% ± 2; there was no valve-related death and one reoperation. At follow-up, we observed eight cases of 2+ regurgitation and one instance of 4+ regurgitation (4-year actuarial freedom: 92% ± 4). Freedom from recurrent regurgitation was significantly lower in the ‘restrictive’ subgroup vs. the ‘degenerative’ subgroup (P = 0.02); no statistically significant difference in freedom from recurrence was observed among patients who received mitral repair using a ‘resect’ vs. ‘nonresection’ strategy (P = 0.46), and in those who received the Totally Endoscopic technique (endoaortic balloon occlusion, no costal spreading) vs. controls (external aortic clamp, costal spreading) (P = 0.98). Conclusion Durability of minimally invasive mitral repair is optimal. Nonresection repair techniques are at least noninferior to previous approaches based on leaflet resection.

Versatility of endoaortic balloon occlusion device for less invasive management of complex and reoperative cardiac cases

“…Some reports have alerted about a possible increase in perioperative neurological risk after use of endoaortic occlusion device vs external aortic clamp in minimally invasive surgery, both subgroups receiving retrograde arterial perfusion. Such finding is not confirmed in other series . To this respect, we emphasize features of intraoperative monitoring (such as right radial artery cannulation for systemic pressure and continuous cerebral oximetry through near‐infrared spectroscopy for prompt detection of right brain hypoperfusion), and of preoperative evaluation (CT scan for detection of aortic plaques) in cases where use of the Intraclude device is planned.…”

“…Such finding is not confirmed in other series. 7,8 To this respect, we emphasize features of intraoperative monitoring (such as right radial artery cannulation for systemic pressure and continuous cerebral oximetry through near-infrared spectroscopy for prompt detection of right brain hypoperfusion), and of preoperative evaluation (CT scan for detection of aortic plaques) in cases where use of the Intraclude device is planned.…”

Comparative myocardial protection of endoaortic balloon versus external clamp in minimally invasive mitral valve surgery

“…19 An additional port was utilized for cardiotomy suction and carbon dioxide insufflation. 19 Peripheral cardiopulmonary bypass (CPB) was established by the cannulation of the femoral artery and vein and conducted under hypothermia. 19 In patients operated with the employment of the EAC, the Chitwood or Cygnet clamp was used with the application of a costal retractor at the working port.…”

“…19 Peripheral cardiopulmonary bypass (CPB) was established by the cannulation of the femoral artery and vein and conducted under hypothermia. 19 In patients operated with the employment of the EAC, the Chitwood or Cygnet clamp was used with the application of a costal retractor at the working port. Cardioplegia was administered through an aortic root needle.…”

“…19 In patients treated with EABC, the endoaortic balloon (Intraclude; Edwards Lifesciences Inc., Irvine, CA, USA) was adopted for ascending aortic endo-clamping, administration of cardioplegia and root venting; it was advanced retrogradely from the right femoral artery under transesophageal echocardiography guidance. 19 Myocardial protection was obtained by cold crystalloid cardioplegia (HTK solution, Custodiol, Franz Ko ¨hler Chemie GmbH, Bensheim, Germany) in all cases. 19 The choice of using EAC or EABC was the surgeons' decision and based on preoperative evaluation of the patient through CT-scan: the presence of ascending aortic diameter >35 mm was considered a relative contraindication to the EABC, whereas >40 mm was an absolute contraindication; a right common femoral artery diameter <8 mm was a contraindication to EABC; a scrupulous assessment of the presence and extension of arterial and mitral calcification was also performed.…”