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Minimally invasive aortic and mitral valve surgery

Minimally invasive aortic and mitral valve surgery
Literature review current through: Jan 2024.
This topic last updated: May 05, 2022.

INTRODUCTION — 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]. These improved outcomes and durability for both surgical and catheter-based valve interventions and durability have led to lower thresholds for intervention in the American College of Cardiology/American Heart Association guidelines for the management of patients with valvular heart disease [3]. Despite this, because of concerns related to the real and perceived invasiveness of surgical intervention, there is persistent hesitation and apprehension by patients, families, caregivers, 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, nonsternotomy, thoracoscopic, 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 intervention for severe calcific aortic stenosis" and "Transcatheter edge-to-edge mitral repair" and "Transcatheter pulmonary valve implantation".)

Minimally invasive coronary artery bypass graft surgery is discussed separately. (See "Minimally invasive coronary artery bypass graft surgery: Definitions and technical issues".)

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 [4,5]. 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 and less than 11 per institution [6]. Equally notable is that only 53 percent of all cardiac centers in the United States performed more than 25 mitral valve repairs per year [7]. Finally, only 70 percent of low-risk potentially eligible patients undergo repair rather than replacement based upon data from 2007 to 2010 from the STS database [8]. Performing these procedures through minimally invasive valve surgery (MIVS) is even more challenging and may require single lung ventilation for portions of the procedure. Maze atrial fibrillation ablation procedures (with left atrial appendage amputation) are commonly indicated in patients with mitral valve pathology and are more challenging through nonsternotomy approaches. (See "Atrial fibrillation: Surgical ablation".)

Patient selection and evaluation — A detailed patient assessment is required prior to aortic or mitral valve surgery to assess potential anatomical and physiological risks and benefits of alternative available approaches in order to choose the optimum surgical approach. Although minimally invasive aortic valve surgery procedures are becoming more standardized and common, patients are still highly screened and selected. In contemporary series by leading centers, nearly 30 percent of patients undergoing aortic valve surgery undergo this procedure [9], and in large national registries, only 20 percent of patients are approached by these techniques [10], although the incidence is rising.

Routine imaging (contrast enhanced computed tomography (CT) angiography or magnetic resonance angiography) is critical in the selection of incisions for potential MIVS to better assess precise location of the aorta, degree of calcification, distance from the planned incision to the valve and annulus, degree of aortic valve and subvalvular calcification, and to assess peripheral arteries to help plan precise aortic cannulation and cross clamping sites. Widespread adoption of transcatheter aortic valve implantation led to more routine use of CT angiography to assess specific anatomical features in all patients with aortic valve pathology (such as annular diameter, valve and aortic calcification, coronary artery heights, sinotubular junction measurements, and assessment of diameter and tortuosity of peripheral vessels).

The following are typical exclusions (although some experienced surgical teams will perform MIVS in selected patients with one or more of these characteristics):

Need for concomitant coronary revascularization (although isolated non-left main/left anterior descending coronary artery disease can be treated with percutaneous coronary intervention as a "hybrid" open and percutaneous approach).

Presence of complex ascending aortic pathology.

Complex aortic or mitral valve pathology (acute bacterial endocarditis, bicuspid valve, heavy calcification extending onto the mitral valve, and/or left ventricular outflow track).

Obesity or funnel chest limiting access or visibility.

Prior right thoracotomy, radiation, pulmonary hypertension, or severe chronic obstructive pulmonary disease if a limited anterior thoracotomy approach is contemplated, as these conditions may preclude single lung ventilation and safe robotic or port access thoracoscopic approaches.

POSSIBLE ADVANTAGES — A potential advantage of minimally invasive valve surgery (MIVS) is that a smaller incision may result in the following potential benefits:

Decreased risk of sternal infection.

Reduced ventilator support time and postoperative pulmonary complications.

Reduced transfusion and perioperative atrial fibrillation rates.

Shorter intensive care unit and hospital stays.

Enhanced patient satisfaction and sense of recovery along with:

Decreased postoperative pain.

Enhanced early sternal stability (more limited sternal precautions) with earlier return to full unrestricted activity and improve quality of life.

While some observational studies have found modest improvements in the above metrics (see 'Outcomes for minimally invasive aortic valve surgery' below and 'Outcomes for minimally invasive mitral valve surgery' below), these gains are meaningful only if MIVS procedures meet expectations for not compromising the safety, scope (extent), success, or durability of more established surgical approaches. The following expectations have been largely met by highly expert and experienced surgical teams, but these results cannot be generalized to non-experts:

Be performed with comparable morbidity and mortality to the conventional median sternotomy approach (including no added neurologic or vascular complications) while not compromising scope and outcomes of planned surgery.

Be performed with comparable cross clamp and cardiopulmonary bypass times (not prolong procedures).

Not compromise intraoperative myocardial protection (most critical in patients with depressed ventricular function and longer cross clamp times).

Be reproducible and could be safely performed by most cardiothoracic surgeons and teams.

Have durable intermediate- and long-term outcomes.

Be applied broadly to many patients undergoing open valve surgery.

POSSIBLE DISADVANTAGES

Limitations — While minimally invasive valve surgery (MIVS) offers some potential benefits, there are some limitations to this approach and the evidence comparing MIVS and median sternotomy is limited. Limitations of MIVS approaches compared with traditional median sternotomy include:

More restricted operative field.

Limited ability to perform adjunctive procedures to deal with varied, complex, or unexpected valve and aortic pathologies, such as coronary artery bypass graft surgery or atrial fibrillation ablation (eg, Maze procedure, etc).

Limited exposure increases complexity of dealing with unanticipated complications (such as aortic cannulation site, cardioplegia cannulation site, aortotomy incision, or coronary sinus injuries and bleeding).

Requires more extensive and careful preoperative imaging, evaluation, planning, and patient selection.

Requires greater experience and expertise of the surgeon, surgical assistant, anesthesiologist, and nursing teams [4,11,12].

Limited information is available on cost-benefit (nonrandomized comparisons).

In addition, the following are limitations specific to right anterior thoracotomy approaches for aortic and mitral valve surgery:

Frequently require peripheral arterial cannulation with need for retrograde perfusion for cardiopulmonary bypass (which is associated with twice the risk of stroke compared to antegrade perfusion). (See 'Complications' below.)

May be associated with incisional complications (groin: seroma, infection; thoracotomy: seroma, hernia, and infection [13]).

May be associated with phrenic nerve injuries (from traction or direct trauma during pericardial exposure).

As noted above, MIVS entails limited exposure for arterial, venous, and coronary sinus cannulae insertion for cardiopulmonary bypass (CPB). For traditional median sternotomy, arterial cannulation is generally performed in the ascending aorta and venous cannulation is generally performed through the appendage of the right atrium with the distal tip in the inferior vena cava (or through separate superior vena cava and inferior vena cava cannulation) (figure 1). Specific considerations and modifications for minimally invasive aortic valve surgery and minimally invasive mitral valve surgery are discussed below. (See 'Access for cardiopulmonary bypass and cardioplegia' below.)

Factors limiting generalizability of results — Although outcomes have been promising for many study populations as described below, generalizing study conclusions to most or all patients undergoing surgical aortic and mitral valve surgery is problematic given the following issues:

Individual patient risks (including comorbidities, clinical status prior to valve surgery, and body habitus) and valve pathologies are highly varied.

Constant evolution of techniques and technologies for both standard median sternotomy and MIVS make comparisons challenging and less relevant over time. It is important to note that because of strong patient preferences, median sternotomy approaches have also evolved to smaller (7 to 10 cm) incisions to provide similar cosmetic and recovery goals of nonsternotomy minimally invasive mitral valve surgery and minimally invasive aortic valve replacement incisions with standard central cardiopulmonary bypass techniques with very high mitral valve repair rates (>90 percent) [14].

Outcomes vary with individual surgeon and institutional experience. Results from high-volume institutions may not be generalizable.

Randomized trials comparing these approaches with more traditional median sternotomy approaches are limited and frequently underpowered [15,16]. Thus, most of the available evidence comes from observational studies subject to the following limitations that may not be adequately adjusted for by analysis tools such as propensity matching:

Patients undergoing current MIVS are carefully screened and selected, and have different clinical profiles (lower risk), as well as scope of therapies (more limited procedures or pathologies) from those undergoing median sternotomy valve surgery.

Surgeons and teams performing MIVS procedures are typically more experienced (operator and institutional biases).

Complications — Complications with MIVS are similar to those for conventional surgery but there are some specific site-related complication risks [2,17-22].

Current open cardiac surgical therapies, whether performed through a median sternotomy or alternative smaller incisions, continue to rely on cardiopulmonary bypass, a still operative cardiac field (myocardial cardioplegic arrest and protection), and, when needed, intracardiac venting [2,17-22]. This facilitates complete and safe exposure that enables full correction of all underlying valve pathologies. Much of the morbidity of open cardiac surgical interventions are related to the proinflammatory and anticoagulant effects of cardiopulmonary bypass, to aortic manipulation (cannulation, clamping, and de-clamping), and to myocardial protection during cardioplegic arrest. Thus, minimally invasive techniques do not avoid most of the complications related to open cardiac surgery.

Various surgical approaches are associated with some specific site-related complications. Partial or hemi-sternotomy is associated with an increased risk of injury to the right internal mammary artery and vein. These have to be carefully inspected and controlled to avert postoperative bleeding and re-exploration. Anterior thoracotomy and parasternal incisions may be associated with an increased wound complication rate, including incisional (and lung) hernias, dehiscence, seroma formation, phrenic injury, and infection [13]. Single lung ventilation performed with cardiopulmonary bypass has been associated with rare lung re-expansion reperfusion injuries [23,24].

Conversion from minimally invasive incisions to full sternotomy occur in 2 to 3 percent of patients [10,25]. These can occur pre-cardiopulmonary bypass for poor visualization. When conversions occur after initiation of cardiopulmonary bypass for bleeding complications or ventricular dysfunction, conversions are associated with a much higher in-hospital mortality (33 percent) [26]. Patients and their families and caregivers should be informed of this potential risk along with the risk of other complications before informed consent is obtained.

As discussed above, peripheral vascular atheromatous disease should be excluded preoperatively (via computed tomography or magnetic resonance). Even in the absence of overt peripheral vascular pathology, retrograde arterial perfusion for cardiopulmonary bypass through the femoral artery is associated with a risk of vascular complications including the following:

A 2 to 4 percent incidence of access site complications such as seroma formation, infection, femoral artery dissection, stenosis, pseudoaneurysm formation, and lymphatic leaks [25,27]. These complications can significantly delay recovery.

Femoral venous thrombosis from instrumentation for cardiopulmonary bypass is rare (0.6 percent).

Increased (twofold) incidence of stroke (attributed to cerebral emboli) [18,25].

The pericardium and multiple port access incisions are less effectively inspected and drained during MIVS than with a conventional median sternotomy. Drainage may be impaired in the postoperative period, resulting in subacute tamponade or residual pericardial effusion in the presence of excess postoperative mediastinal drainage.

Complete evacuation and removal of air trapped in the left ventricle is more difficult and incomplete, thus posing a potential risk of air emboli. This should be monitored with transesophageal echocardiography and can be ameliorated with carbon dioxide (CO2) field insufflation (since CO2 is heavier and more soluble than air) [12,28].

MINIMALLY INVASIVE AORTIC VALVE SURGERY (MI-AVR)

Approaches — For MI-AVR, the following alternatives to median sternotomy involve a 5 to 10 cm incision:

Partial upper (hemi or mini) sternotomy, most commonly referred to as a "J" incision into the right third or fourth intercostal space.

A superior sternal split approach (T incision into both right and left third or fourth intercostal spaces). Improved exposure with this incision has to be weighed against a greater potential for postoperative sternal instability.

Limited anterior right thoracotomy (second or third intercostal space) with or without transection of an adjacent rib or cartilage.

Intraoperative two- and three-dimensional transesophageal echocardiography (TEE) is used to better assess valve pathology to make sure it can be safely and fully treated through a more restricted operative field.

Access for cardiopulmonary bypass and cardioplegia — Since patients with aortic valve stenosis are typically older and have concomitant atherosclerotic carotid and peripheral vascular disease (26 percent) [2], central ascending/arch aortic or alternatively right axillary artery cannulation for cardiopulmonary bypass (CPB) is strongly preferred to avoid the vascular and embolic risks of peripheral access and retrograde arterial perfusion [18-22]. If femoral arterial access is contemplated, peripheral vascular atheromatous disease needs to be routinely and carefully assessed and excluded preoperatively (by contrast enhanced computed tomography angiography or magnetic resonance angiography). Whereas central aortic cannulation, clamping, and subsequent repair are straightforward with partial (mini) sternotomy, these are more complex with limited anterolateral thoracotomy incisions so that more experience is needed for optimal outcomes with this approach [29,30]. (See "Management of cardiopulmonary bypass".)

Venous cannulation (for drainage and in-flow into the CPB circuit) is usually accomplished directly through the operative field into the right atrium, although femoral venous cannulation (percutaneous or open) is possible to unclutter the restricted operative field. Adjunctive dynamic or vacuum drainage of the venous cannula is important to avoid incomplete venous drainage and right atrial distention through a smaller cannula that further limits view of the root and aortic valve.

Aortic cross clamping for cardioplegic arrest (to allow myocardial protection and a still operative field) is accomplished by direct external aortic cross clamping. It is more complex in reoperations performed through a limited anterior thoracotomy because of presence of adhesions, and endoaortic cross clamping (with a transcatheter balloon) can be considered as an alternative [12,31-33]. Cardioplegia for myocardial protection is administered antegrade via the root supplemented by retrograde delivery via the coronary sinus. Coronary sinus cardioplegia cannula placement is more complex, especially through a limited anterolateral thoracotomy approach but can be accomplished via a jugular approach with TEE or fluoroscopic guidance.

Outcomes for minimally invasive aortic valve surgery

Primary aortic valve surgery — Mortality and most major morbidities are comparable for conventional sternotomy and MI-AVR. The limitations of the available evidence were illustrated by a meta-analysis that included seven trials in which a total of 511 patients undergoing aortic valve replacement were randomly assigned to either limited upper hemi-sternotomy or full median sternotomy [15]. Given the small study samples and heterogeneity among studies, the evidence in this review was assessed as low to moderate quality. Moderate-quality evidence showed no significant difference in mortality rates with upper hemi-sternotomy or full median sternotomy. Postoperative blood loss was lower (mean difference [MD] -158.00 mL, 95% CI -303.24 to -12.76), intensive care unit stay was shorter (MD -0.57 days, 95% CI 0.93 to -0.20), and postoperative pulmonary function test was very slightly higher (MD 1.98 percent predicted FEV1, 95% CI 0.62-3.33) in the minimally invasive group. Similar cardiopulmonary bypass times and aortic cross-clamp times were seen in the upper hemi-sternotomy and full sternotomy groups, though evidence was low quality. Rates of postoperative atrial fibrillation, deep sternal wound infection, and re-exploration, as well as pain scores, postoperative ventilation times, and lengths of hospital stay were similar in the two treatment groups.

Meta-analyses including observational studies and randomized trials using propensity matching demonstrated modest improvements with MI-AVR in lengths of time on ventilator times (-2.1 hours), of intensive care unit stay (-0.46 days), of hospital stay (-0.9 days), and chest tube drainage in the first 24 hours [10,34,35].

In the only contemporary randomized control trial comparing MI-AVR to full sternotomy AVR, operating theater, cardiopulmonary, and cross clamp times were longer for the MI-AVR with no impact on hospital stays and at a higher cost that persisted for 12 months following discharge [36]. Variations in reported outcomes comparing MI and full sternotomy approaches suggest the possible impact of patient selection/biases as well as variation in perioperative care processes in higher volume centers performing these procedures.

Reoperative aortic valve surgery — The overall incidence of open surgical reintervention for degenerated aortic valve prosthesis has fallen significantly with the introduction and evolution of valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) [37]. Open surgical interventions are currently performed in younger patients or in those with complex anatomy (such as low coronary artery heights, small left ventricular outflow tract or annulus, and narrow sinotubular junction) that represent an increased risk of patient prosthesis mismatch or coronary artery obstruction for ViV TAVI. Minimally invasive and full sternotomy approaches present differing benefits and risks in patients undergoing reoperation with prior aortic valve replacement and/or coronary artery bypass graft surgery (CABG). A full sternotomy approach is commonly performed for reoperative aortic valve surgery, particularly if concomitant surgical revascularization is required since it provides maximal exposure and control that facilitate performance of concomitant CABG, as well as surgical Maze procedure. Full sternotomy also facilitates control of surgical grafts in patients with prior CABG (particularly a patent left internal mammary artery graft) and enhanced cardioplegic arrest.

Advantages of a minimally invasive approach in patients undergoing reoperation include reduction in surgical trauma and blood loss due to avoidance of lower mediastinal surgical dissection and potential injury to anterior cardiac structures during sternal reentry, especially patent CABG conduits [38-40] and the right ventricle. Large, prospective, nonrandomized databases have reported equivalent results compared with conventional full sternotomy aortic valve replacement in appropriately selected patients [38]. One observational study of octogenarians undergoing reoperative isolated aortic valve replacement found that those undergoing a minimally invasive approach had improved survival at one and five years compared with those undergoing full sternotomy [41]. Many of these patients are also potential candidates for percutaneous transcatheter aortic valve replacement procedures if their associated anatomical or patient-specific comorbidities are appropriate [42-45]. (See "Choice of intervention for severe calcific aortic stenosis".)

MINIMALLY INVASIVE MITRAL VALVE SURGERY (MI-MVR) — Although there is an increasing acceptance of MI-MVR procedures, particularly in high volume centers, broad adoption is still limited to selected patients with MI-MVR performed in approximately 20 percent of the United States population [46].

Approaches — The mitral valve can be approached through the following incisions:

Partial sternal split (lower J shaped or less commonly upper hemisternotomy)

Limited right thoracotomy incision

Multiple smaller thoracotomy incisions for a robotic approach

The mitral valve is visualized most commonly directly through the left atrium or occasionally through the right atrium via the interatrial septum if concomitant right-sided procedures (tricuspid valve repair, atrial septal defect closure) are needed. The latter technique requires repair of the iatrogenic atrial septal defect at the conclusion of the procedure and may be associated with transient atrial conduction abnormalities (commonly junctional rhythm) that typically resolve in days unless patients have underlying sinus node pathology.

MI-MVR techniques allow treatment of concomitant atrial fibrillation with either "cut-and-sew" or less invasive Maze procedure (cryo or radiofrequency ablation) with excellent outcomes and restoration of sinus rhythm. In addition, amputation or clipping of the left atrial appendage can further decrease thromboembolic risk but again is more technically challenging. (See "Atrial fibrillation: Surgical ablation" and "Atrial fibrillation: Left atrial appendage occlusion".)

Because of the limited access, the ability to perform concomitant coronary artery bypass graft surgery, if required, is more difficult. When clinically appropriate, coronary artery disease may be addressed with staged percutaneous coronary intervention. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)

Access for cardiopulmonary bypass and cardioplegia — MI-MVR is performed with specially designed cardiopulmonary bypass techniques (vacuum assist, smaller cannulas, transthoracic aortic cross clamps). A partial sternal split approach allows central aortic cannulation (rather than peripheral femoral cannulation) for cardiopulmonary bypass. A limited right thoracotomy incision or multiple smaller incisions for a robotic approach requires femoral arterial and venous cannulation. (See "Management of cardiopulmonary bypass".)

Aortic cross clamping for the purpose of cardioplegic diastolic arrest is performed directly through the incision (transthoracic aortic clamping) with specially designed clamps or with endoaortic balloon occlusion. The endoaortic clamp has to be carefully monitored by transesophageal echocardiography (TEE) to prevent over-inflation (risk of rupture) or migration (distally, it can lead to cerebral malperfusion or proximally into the left ventricle). Direct aortic clamping is preferred whenever possible.

Myocardial protection and cardioplegia delivery are of increased importance, as cross clamp and pump times are longer (particularly earlier in the learning curve). Control of live grafts (such as left internal mammary artery graft) is much more challenging. In those circumstances, there is increased reliance on myocardial cooling and retrograde cardioplegia. Placement of cardioplegia catheters requires expertise with jugular vein access using TEE or fluoroscopy guidance, particularly in robotic MI-MVR surgery. Ventricular distention from aortic regurgitation is more challenging to deal with and may impair mitral valve visualization.

All minimally invasive nonsternotomy mitral valve surgical approaches require femoral arterial and venous cannulation. Careful evaluation and exclusion of atheromatous peripheral vascular disease are required and patients with severe peripheral vascular disease are excluded.

Outcomes for minimally invasive mitral valve surgery

Primary mitral valve surgery — Outcomes and cost effectiveness of various types of MI-MVR approaches remain to be determined. Although the results demonstrate safety, there are scant under-powered randomized comparisons of conventional and alternative approaches to valve surgery with regard to clinical outcomes, postoperative complications, and cost. As with MI-AVR, growing clinical experience and large prospective nonrandomized registries have demonstrated that less invasive surgical approaches to the mitral valve can be performed with very low perioperative morbidity similar to conventional surgery with equivalent intermediate-term outcomes in appropriately selected patients when performed by experienced teams and surgeons [28,47-51].

A meta-analysis included seven studies (one randomized controlled trial and six retrospective studies with a total of 953 patients undergoing minimally invasive procedures and 1011 patients undergoing conventional sternotomy) comparing minimally invasive and conventional median sternotomy mitral valve repair for patients with degenerative valve disease [52]. There were no differences in mortality, stroke, renal failure, wound infection, re-exploration for bleeding, aortic dissection, myocardial infarction, atrial fibrillation, or 30-day readmission rates. A minimally invasive approach was associated with longer pump and cross clamp times (relative risk 1.47, 95% CI, p<0.001) and shorter intensive care unit stay (by relative risk 0.77, 95% CI, p = 0.01), but overall hospital stay was similar. Echocardiographic improvement (freedom from >+2 mitral regurgitation) was also comparable (<0.3 percent in both groups).

A meta-analysis of seven observational studies with a total of 523 patients undergoing MI-MVR and 731 undergoing conventional sternotomy mitral valve surgery also found no difference in early mortality or mitral valve repair rate [51]. Cardiopulmonary bypass time was longer but the transfusion requirements were lower with minimally invasive surgery. The risk of stroke was lower (odds ratio 0.35; 95% CI, 0.15 to 0.82) in the minimally invasive group.

Although some studies have reported improvement in early pain scores with minimally invasive surgery compared with conventional sternotomy [53], other meta-analyses demonstrated no differences in pain, ventilation times, transfusion, or hospital stays. In an observational study, older patients (age greater than or equal to 75 years) undergoing MI-MVR had shorter hospital stays and were more likely to be discharged to home [54].

Intermediate-term (five-year) outcomes and freedom from reintervention were also comparable with MI-MVR and median sternotomy [50,55].

Reoperative mitral valve surgery — Very little data are available on outcomes of minimally invasive reoperative mitral valve surgery. Patients with prior bioprosthetic mitral valve replacement or rigid complete or C-shape mitral annuloplasty rings can also be considered for transcatheter mitral valve-in-valve or valve-in-ring therapies.

ENABLING TECHNOLOGIES — The following are some of the evolving technologies that enable minimally invasive valve surgery.

Automated knot tying — Newer, automated suturing instruments and enabling techniques have been developed to facilitate anchoring of aortic or mitral prosthetic valves as well as mitral annuloplasty rings. These are particularly useful when surgery is performed through limited (eg, nonsternotomy) incisions at a greater distance from the surgeon’s reach. Sutures secured with these devices were noted to be stronger, more consistent, and faster to perform compared with manually tied knots [56,57]. Although these devices are easy to use and result in decreased cross-clamp and cardiopulmonary bypass times, no decreases in perioperative morbidity or mortality have been documented [58].

Thoracoscopic and robotic technologies — Visualization of the mitral valve through smaller incisions can be enhanced by advanced thoracoscopic instruments that recreate three-dimensional (depth) stereoscopic visualization. Robotic technologies and specially designed longer surgical instruments facilitate accurate repair of complex mitral valve lesions through smaller incisions.

Sutureless rapid deployment aortic valves — A new generation of bioprosthetic aortic valves has been developed that mount conventional valves on stented scaffolding and allows a more rapid implantation of valves with minimal or no anchoring sutures [59-62]. In contrast to transcatheter aortic valve replacement, this approach entails removal of all pathological leaflet and annular aortic valve calcification, thus facilitating implantation of a larger expandable prosthesis (to maximize effective orifice area and minimize potential of patient-prosthesis mismatch). Since no or minimal (one to three) guiding or anchoring sutures are needed, cross clamp times were dramatically reduced by 40 to 50 percent to less than 30 minutes, as were cardiopulmonary bypass times. The incidence of paravalvular leak and heart block requiring permanent pacemaker placement were similar to those of sutured surgical aortic valve replacement [62]. However, longer-term follow-up on this novel technique is limited [38,63,64]. Sutureless valves are particularly suited to minimally invasive aortic valve surgery, as these facilitate valve deployment through limited incisions [29,30].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cardiac valve disease".)

SUMMARY AND RECOMMENDATIONS

The term minimally invasive valve surgery (MIVS) refers to an evolving set of techniques and technologies to perform open valve surgery through a smaller incision as an alternative to median sternotomy. (See 'Introduction' above and 'Possible advantages' above.)

Current open cardiac surgical therapies, whether performed through a median sternotomy or alternative smaller incisions, continue to rely on cardiopulmonary bypass and a still operative cardiac field (myocardial cardioplegic arrest and protection). Much of the morbidity of open cardiac surgical interventions is related to the proinflammatory and anticoagulant effects of cardiopulmonary bypass, to aortic manipulation (cannulation, clamping, and de-clamping), and to myocardial protection during cardioplegic arrest. Thus, the potential benefit of minimally invasive aortic valve surgery approaches is limited. (See 'Limitations' above.)

Limitations of MIVS approaches compared with traditional median sternotomy include a more restricted operative field; requirement of more preoperative imaging, evaluation, planning, and patient selection; and requirement of greater experience and expertise of the surgical team. (See 'Limitations' above.)

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. (See 'When to consider a minimally invasive approach' above.)

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.

A detailed patient assessment is required prior to aortic or mitral valve surgery to assess potential risks and benefits of available approaches and choose the optimum surgical approach.

Minimally invasive aortic and mitral valve surgery techniques continue to evolve. When performed by experienced surgeons and centers, results are largely similar to those of open conventional surgery. Mortality and most major morbidities are comparable for MIVS and conventional sternotomy surgery with modest improvements in transfusion rates, hospital stay, and markedly enhanced patient satisfaction with MIVS. (See 'Primary aortic valve surgery' above and 'Primary mitral valve surgery' above.)

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Topic 8128 Version 21.0

References

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