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Right-sided minimally invasive mitral valve surgery on the fibrillating heart - a safe and effectice strategy
Jens Garbade, Piroze Davierwala, Joerg Seeburger, Bettina Pfannmueller, Martin Misfeld, Friedrich-Wilhelm Mohr, Michael A. Borger.
Herzzentrum Leipzig, Leipzig, Germany.

OBJECTIVE: Minimally invasive mitral valve surgery (MiniMV) after previous cardiac procedures or in patients with porcelain aorta is a challenging clinical scenario. We reviewed our experience in patients operated on with a non-aortic clamping, fibrillating heart technique during MiniMV.
METHODS: Between 1999 and 2011, a total of 3500 patients underwent MiniMV at our institution. Of these, 190 (5.4%) were operated without clamping of the aorta and on the fibrillating heart. The majority of patients had a history of previous cardiac surgery: aortocoronary bypass grafting, n=85; isolated valve procedure, n=60; or combined interventions, n=30. Some patients had a severely calcified aorta or severe adhesions because of previous irradiation therapy (n=15). The indication for surgery was severe symptomatic MV regurgitation in all patients. Mean age of patients was 65.8±10.8 years and 125 were male. The mean ejection fraction was 48±14% and the mean EuroSCORE predicted risk of mortality was 18.9±14.6%.
RESULTS: MV repair, including repeat repair, was accomplished in 57% of patients (n=108) and MV replacement was required in 43% (n=82). Duration of CPB was 144±59 min and fibrillating time was 67±26 min. Primary MV repair included the implantation of an annuloplasty ring in all patients (complete and partial rings were implanted in 85 patients). Concomitant procedures consisted of tricuspid valve repair in 17, atrial fibrillation ablation in 41, and ASD closure in 2 patients. Thirty-day mortality was 6.8% (n=13). The over-all rate of stroke or TIA was 3.7 % (n=7). Conversion to full sternotomy was necessary in 4 patients (2.1%), while 17 patients (9%) required reexploration for bleeding. Early echocardiographic follow-up revealed adequate MV function in the vast majority patients. MV-related re-intervention was required in 12 patients, while one additional patient underwent heart transplantation. Ten-year freedom from MV reintervention rate was 93 %.
CONCLUSIONS: MiniMV without aortic clamping and on the fibrillating heart is technically demanding but can be performed successfully, with low rates of peri-procedural complications and good early and long-term results.

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