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 and also requires single lung ventilation for portions of the procedure. 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 . Finally, Maze atrial fibrillation ablation procedures (with left atrial appendage amputation) are commonly indicated in patients with MV pathology and are more challenging through nonsternotomy approaches. (See "Surgical ablation to prevent recurrent atrial fibrillation".)
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- WHEN TO CONSIDER A MINIMALLY INVASIVE APPROACH
- Surgeon and institutional factors
- Patient selection and evaluation
- POSSIBLE ADVANTAGES
- POSSIBLE DISADVANTAGES
- Factors limiting generalizability of results
- 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