Minimally invasive mitral and tricuspid valve surgery

Prof. Parwis Massoudy

Klinikum Passau, Germany

Clinic for Cardiac Surgery

Head of Department

What does ‚minimally invasive‘ mean in

the context of mitral and tricuspid valve

surgery?

Standard Sternotomy

Right Anterolateral Incision

positioning of the patient (right side up)

Incision (5-8 cm)

Set up for minimally invasive

Access for Cardiopulmonary Bypass

small incision in the groin but safe access to both vessels Seldinger technique

Intraoperative setup

open pericardium

Protect phrenic nerve

use CO2 to prevent air embolism

Why small and lateral incisions ?

Reduction of surgical trauma

Stability of chest is not compromised

Better cosmetic result

Direct view on the mitral valve

Where is the mitral valve?

MV-anatomy

Functional unit

Annulus Leaflets Chordae Papillary Muscle Myocardium

MV-disease

Prolaps syndrom

Degeneration

(chordal rupture)

MV-disease

Elongation after infarction

PMI

AI

MV-disease

Ischemic MR / DCM

„Functional MR“

Secondary alteration caused by surrounding structures

Aims of Surgery

Correction of annular dilatation Restoration of annular geometry Elevation of anterior / posterior annulus Improvement of leaflet coaptation Verification of normal valve physiology

• Annuloplasty (Ring support)

(Physio, Cosgrove, Rigid Saddle, 3D-Profile)

• Resection of prolaps

• Chordal replacement (Loop-technique)

• „Edge to edge repair“ (Alfieri)

• Patchplastic (leaflet defects)

• Decalcification of leaflet / annulus

Techniques of MV repair

Figure 7. The edge-to-edge approximation (Alfieri repair) consists of suturing the anterior and posterior leaflets together to create a “double orifice” mitral valve.

Fedak P W et al. Circulation 2008;117:963-974

Copyright © American Heart Association

Annuloplasty in functional regurgitation

Cardinal System (Valtech) Encor SQ (Micardia)

In secondary or functional mitral valve regurgitation, the problem of the disease is the dilatation of the mitral valve annulus. Even after correction

with a ring, there is a certain recurrence rate.

A new generation of mitral rings was created that allows for readjustment of the ring at the time of clinical follow up.

Operation videos / photographs

• Prolapse of anterior leaflet of the mitral valve

• Prolapse of posterior leaflet of the mitral valve

• Bileaflet prolapse of the mitral valve

• Bicommissural prolapse of the mitral valve

• Regurgitation of the tricuspid valve

• Calcification of the tricuspid valve

• Left atrial myxoma

• Endocarditis of the mitral valve

Techniques of MV repair

AML prolaps

Techniques of MV repair

PML prolaps

Techniques of MV repair

Bileaflet prolaps

Techniques of MV repair

bicommissural prolaps

Tricuspid valve repair

Tricuspid valve replacement

Other atrium pathology

LA myxoma

Other leaflet pathology

Endocarditis

Conclusion

The minimally invasive access to the Mitral and Tricuspid valves (including any pathology in both atria) is an elegant

technique wich offers fast recovery from surgery because of remained stability of the

chest.

Compared to conventional surgery with median sternotomy patients like the

cosmetic result.