Mitral valve surgery: current status and future prospects of the minimally invasive approach

ABSTRACT

Introduction: During the past five years the approach to procedural planning, operative techniques and perfusion strategies for minimally invasive mitral valve surgery (MIMVS) has evolved. With the goal to provide a maximum of patient safety the procedure has been modified according to individual patient characteristics and is largely based on preoperative imaging.

Areas covered: In this review article we describe the important factors in image based therapy planning and simulation, different access strategies, the operative key-steps, a rationale use of devices, and highlight a few future developments in the field of MIMVS. Published studies were identified through pearl growing, citation chasing, a search of PubMed using the systematic review methods filter, and the authors’ topic knowledge.

Expert opinion: With the help of expert teams including surgeons specialized in mitral repair, anesthesiologists and perfusionists a broad spectrum of mitral valve pathologies and related pathologies can be treated with excellent functional outcomes. Avoiding procedure related complications is the key for success for any MIMVS program.

KEYWORDS:

• Cardiac surgery
• mitral valve
• minimally invasive mitral valve surgery
• endoscopic surgery

Article highlights

• It is crucial that imaging tools (CT, MRI, TEE) are available for preoperative planning because they add valuable information, especially for minimally invasive procedures.

• Pre-bypass TEE guiding valvular surgery has a positive impact, particular on MV repair.

• When performing fully endoscopic surgery on the MV, 3D images provide valuable in-depth information regarding the LA and LV, as well as providing structural details regarding the papillary muscles, MV leaflets, and chordae tendineae.

• High and durable MV repair rates are reported with minimal mortality, in hight-volume programmes.

• Surgical repair will remain the standard for many years for patients with low-risk degenerative MR. For high risk or inoperable patients who are not amenable for surgical repair, transcatheter approaches will play an important role.

• A principal role in the future of MV surgery, TMVI or transcatheter MV repair is the careful selection of patients and the identification of those who would profit the most from these procedures.

Declaration of interest

V. Falk declares that he has relevant financial activities outside the submitted work with the following commercial entities: Medtronic GmbH (Meerbusch, Germany), Biotronik SE & Co. (Berlin, Germany), Abbott GmbH & Co. KG (Wiesbaden, Germany), Boston Scientific (Ratingen, Germany), Edwards Lifesciences (Unterschleissheim, Germany), Berlin Heart (Berlin, Germany), Novartis Pharma GmbH (Nuremburg, Germany), JOTEC GmbH (Hechingen, Germany) and Zurich Heart (Zurich, Switzerland) in relation to educational grants (including travel support), fees for lectures and speeches, fees for professional consultation and research and study funds. J Kempfert reports personal fees from Edwards, personal fees from LSI, outside the submitted work.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.