Minimally invasive aortic and mitral valve surgery
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
Mortality and morbidity for coronary artery bypass and valve surgical procedures continue to improve in the United States despite increased patient acuity, complexity, and risk profiles [1,2]. Despite this, because of concerns related to the real and perceived invasiveness of surgical intervention, there is hesitation and apprehension by patients, families, and physicians that may delay referral for definitive surgical therapy. In this review, the term "minimally invasive" valve surgery (MIVS) refers specifically to a set of techniques using direct, thorascopic, or robotic approaches developed specifically for cardiac surgical interventions with a smaller incision than with the traditional median sternotomy approach. These techniques, introduced in the 1990s, aim to reduce morbidity and enhance patient recovery and satisfaction by replacing the traditional median sternotomy with smaller alternative nonsternotomy incisions.
This topic will discuss minimally invasive aortic and mitral valve surgery. Although MIVS procedures share common rationale and approaches, their specific uses in aortic and mitral valve surgery are discussed separately.
Transcatheter approaches for aortic, pulmonic, and mitral valve disease are not included in the category of minimally invasive surgery. These transcatheter approaches obviate the need for both open incision and cardiopulmonary bypass and are reviewed elsewhere. (See "Choice of therapy for symptomatic severe aortic stenosis" and "Transcatheter mitral valve repair" and "Percutaneous pulmonic valve implantation".)
WHEN TO CONSIDER A MINIMALLY INVASIVE APPROACH
The choice of a conventional or minimally invasive approach for a patient undergoing aortic or mitral valve surgery depends on patient factors as well as surgeon and institutional factors.
Surgeon and institutional factors — Expert and experienced surgical, anesthesia, nursing, and perfusion teams are required to optimize the benefits and minimize the risks of surgery through limited incisions. This is even more critical for mitral valve repair since the likelihood of successful repair (versus replacement) varies significantly with both individual surgeon and institutional volumes . Performing these procedures through minimally invasive valve surgery (MIVS) is even more challenging. Many cardiac surgeons perform low numbers of valve operations as reflected by a report based on the Society of Thoracic Surgeons (STS) database that documented a median of five mitral valve surgical interventions performed per year per surgeon. It is also notable that only 70 percent of low-risk patients undergo repair even in the current era (2007 to 2010) based upon data from the STS database .
- ElBardissi AW, Aranki SF, Sheng S, et al. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg 2012; 143:273.
- Lee R, Li S, Rankin JS, et al. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg 2011; 91:677.
- Bolling SF, Li S, O'Brien SM, et al. Predictors of mitral valve repair: clinical and surgeon factors. Ann Thorac Surg 2010; 90:1904.
- Chatterjee S, Rankin JS, Gammie JS, et al. Isolated mitral valve surgery risk in 77,836 patients from the Society of Thoracic Surgeons database. Ann Thorac Surg 2013; 96:1587.
- Johnston DR, Roselli EE. Minimally invasive aortic valve surgery: Cleveland Clinic experience. Ann Cardiothorac Surg 2015; 4:140.
- Salenger R, Gammie JS, Collins JA. Minimally Invasive Aortic Valve Replacement. J Card Surg 2016; 31:38.
- Holzhey DM, Seeburger J, Misfeld M, et al. Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation 2013; 128:483.
- Malaisrie SC, Barnhart GR, Farivar RS, et al. Current era minimally invasive aortic valve replacement: techniques and practice. J Thorac Cardiovasc Surg 2014; 147:6.
- Ng PC, Chua AN, Swanson MS, et al. Anterior thoracotomy wound complications in minimally invasive direct coronary artery bypass. Ann Thorac Surg 2000; 69:1338.
- Castillo JG, Milla F, Anyanwu AC, Adams DH. Video-atlas on minimally invasive mitral valve surgery-The David Adams technique. Ann Cardiothorac Surg 2013; 2:828.
- Cosgrove DM 3rd, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg 1998; 65:1535.
- Grossi EA, Galloway AC, Ribakove GH, et al. Impact of minimally invasive valvular heart surgery: a case-control study. Ann Thorac Surg 2001; 71:807.
- Cosgrove DM 3rd, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62:596.
- Navia JL, Cosgrove DM 3rd. Minimally invasive mitral valve operations. Ann Thorac Surg 1996; 62:1542.
- Fann JI, Pompili MF, Stevens JH, et al. Port-access cardiac operations with cardioplegic arrest. Ann Thorac Surg 1997; 63:S35.
- Murzi M, Cerillo AG, Miceli A, et al. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg 2013; 43:e167.
- Falk V, Cheng DC, Martin J, et al. Minimally invasive versus open mitral valve surgery: a consensus statement of the international society of minimally invasive coronary surgery (ISMICS) 2010. Innovations (Phila) 2011; 6:66.
- Tabata M, Umakanthan R, Khalpey Z, et al. Conversion to full sternotomy during minimal-access cardiac surgery: reasons and results during a 9.5-year experience. J Thorac Cardiovasc Surg 2007; 134:165.
- Sagbas E, Caynak B, Duran C, et al. Mid-term results of peripheric cannulation after port-access surgery. Interact Cardiovasc Thorac Surg 2007; 6:744.
- Johnston WF, Ailawadi G. Surgical management of minimally invasive aortic valve operations. Semin Cardiothorac Vasc Anesth 2012; 16:41.
- Glauber M, Ferrarini M, Miceli A. Rapid deployment aortic valves and minimally invasive aortic valve replacement: a perfect marriage of technology and technique? J Thorac Cardiovasc Surg 2015; 149:441.
- Murzi M, Glauber M. Central versus femoral cannulation during minimally invasive aortic valve replacement. Ann Cardiothorac Surg 2015; 4:59.
- Krapf C, Wohlrab P, Häußinger S, et al. Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate? Eur J Cardiothorac Surg 2013; 44:898.
- Loforte A, Luzi G, Montalto A, et al. Video-assisted minimally invasive mitral valve surgery: external aortic clamp versus endoclamp techniques. Innovations (Phila) 2010; 5:413.
- Mazine A, Pellerin M, Lebon JS, et al. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes. Ann Thorac Surg 2013; 96:2116.
- Lim JY, Deo SV, Altarabsheh SE, et al. Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data. J Card Surg 2015; 30:125.
- Phan K, Xie A, Tsai YC, et al. Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis. Ann Cardiothorac Surg 2015; 4:3.
- Phan K, Xie A, Di Eusanio M, Yan TD. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann Thorac Surg 2014; 98:1499.
- Glower DD, Landolfo KP, Clements F, et al. Mitral valve operation via Port Access versus median sternotomy. Eur J Cardiothorac Surg 1998; 14 Suppl 1:S143.
- Walther T, Falk V, Metz S, et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999; 67:1643.
- Phan K, Zhou JJ, Niranjan N, et al. Minimally invasive reoperative aortic valve replacement: a systematic review and meta-analysis. Ann Cardiothorac Surg 2015; 4:15.
- Byrne JG, Aranki SF, Couper GS, et al. Reoperative aortic valve replacement: partial upper hemisternotomy versus conventional full sternotomy. J Thorac Cardiovasc Surg 1999; 118:991.
- Tabata M, Khalpey Z, Shekar PS, Cohn LH. Reoperative minimal access aortic valve surgery: minimal mediastinal dissection and minimal injury risk. J Thorac Cardiovasc Surg 2008; 136:1564.
- Kaneko T, Loberman D, Gosev I, et al. Reoperative aortic valve replacement in the octogenarians-minimally invasive technique in the era of transcatheter valve replacement. J Thorac Cardiovasc Surg 2014; 147:155.
- Lindman BR, Pibarot P, Arnold SV, et al. Transcatheter versus surgical aortic valve replacement in patients with diabetes and severe aortic stenosis at high risk for surgery: an analysis of the PARTNER Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol 2014; 63:1090.
- Makkar RR, Jilaihawi H, Mack M, et al. Stratification of outcomes after transcatheter aortic valve replacement according to surgical inoperability for technical versus clinical reasons. J Am Coll Cardiol 2014; 63:901.
- Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012; 366:1686.
- Makkar RR, Fontana GP, Jilaihawi H, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012; 366:1696.
- Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2010; 90:1401.
- McClure RS, Cohn LH, Wiegerinck E, et al. Early and late outcomes in minimally invasive mitral valve repair: an eleven-year experience in 707 patients. J Thorac Cardiovasc Surg 2009; 137:70.
- Galloway AC, Schwartz CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg 2009; 88:1180.
- Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001; 121:842.
- Suri RM, Taggarse A, Burkhart HM, et al. Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Midterm Clinical and Echocardiographic Quality Outcomes. Circulation 2015; 132:1961.
- Moscarelli M, Fattouch K, Casula R, et al. What Is the Role of Minimally Invasive Mitral Valve Surgery in High-Risk Patients? A Meta-Analysis of Observational Studies. Ann Thorac Surg 2016; 101:981.
- Cao C, Gupta S, Chandrakumar D, et al. A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease. Ann Cardiothorac Surg 2013; 2:693.
- Speziale G, Nasso G, Esposito G, et al. Results of mitral valve repair for Barlow disease (bileaflet prolapse) via right minithoracotomy versus conventional median sternotomy: a randomized trial. J Thorac Cardiovasc Surg 2011; 142:77.
- Iribarne A, Easterwood R, Russo MJ, et al. Comparative effectiveness of minimally invasive versus traditional sternotomy mitral valve surgery in elderly patients. J Thorac Cardiovasc Surg 2012; 143:S86.
- Miceli A, Murzi M, Canarutto D, et al. Minimally invasive mitral valve repair through right minithoracotomy in the setting of degenerative mitral regurgitation: early outcomes and long-term follow-up. Ann Cardiothorac Surg 2015; 4:422.
- Lee CY, Sauer JS, Gorea HR, et al. Comparison of strength, consistency, and speed of COR-KNOT versus manually hand-tied knots in an ex vivo minimally invasive model. Innovations (Phila) 2014; 9:111.
- Grapow MT, Mytsyk M, Fassl J, et al. Automated fastener versus manually tied knots in minimally invasive mitral valve repair: impact on operation time and short- term results. J Cardiothorac Surg 2015; 10:146.
- Martens S, Sadowski J, Eckstein FS, et al. Clinical experience with the ATS 3f Enable® Sutureless Bioprosthesis. Eur J Cardiothorac Surg 2011; 40:749.
- Flameng W, Herregods MC, Hermans H, et al. Effect of sutureless implantation of the Perceval S aortic valve bioprosthesis on intraoperative and early postoperative outcomes. J Thorac Cardiovasc Surg 2011; 142:1453.
- Santarpino G, Pfeiffer S, Schmidt J, et al. Sutureless aortic valve replacement: first-year single-center experience. Ann Thorac Surg 2012; 94:504.
- Miceli A, Santarpino G, Pfeiffer S, et al. Minimally invasive aortic valve replacement with Perceval S sutureless valve: early outcomes and one-year survival from two European centers. J Thorac Cardiovasc Surg 2014; 148:2838.
- Laborde F, Fischlein T, Hakim-Meibodi K, et al. Clinical and haemodynamic outcomes in 658 patients receiving the Perceval sutureless aortic valve: early results from a prospective European multicentre study (the Cavalier Trial)†. Eur J Cardiothorac Surg 2016; 49:978.
- Takagi H, Umemoto T. A Meta-Analysis of Sutureless or Rapid-Deployment Aortic Valve Replacement. Thorac Cardiovasc Surg 2016; 64:400.
- WHEN TO CONSIDER A MINIMALLY INVASIVE APPROACH
- Surgeon and institutional factors
- Patient selection and evaluation
- POSSIBLE ADVANTAGES
- POSSIBLE DISADVANTAGES
- MINIMALLY INVASIVE AORTIC VALVE SURGERY (MI-AVR)
- Access for cardiopulmonary bypass and cardioplegia
- Outcomes for minimally invasive aortic valve surgery
- - Primary aortic valve surgery
- - Reoperative aortic valve surgery
- MINIMALLY INVASIVE MITRAL VALVE SURGERY (MI-MVR)
- Access for cardiopulmonary bypass and cardioplegia
- Outcomes for minimally invasive mitral valve surgery
- - Primary mitral valve surgery
- - Reoperative mitral valve surgery
- ENABLING TECHNOLOGIES
- Automated knot tying
- Thorascopic and robotic technologies
- Sutureless rapid deployment aortic valves
- SUMMARY AND RECOMMENDATIONS