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Endoscopic Mitral Valve Surgery Following Basic Setting of Video Assisted Thoracic Surgery
Toshiaki Ito, Masayoshi Tokoro, Jyunji Yanagisawa, Atsuo Maekawa.
Japanese Red Cross Nagoya First Hospital, Nagoya, Japan.

OBJECTIVE: Endoscopic surgery is a common technique in other surgical fields, but endoscopic cardiac surgery is not yet popular. We applied standard techniques of video assisted thoracic surgery to mitral valve surgery, and evaluated its feasibility and safety.
METHODS: Surgical technique: Femoro-femoral cardio-pulmonary bypass was established. Right 4th intercostal thoracotomy was made through 3 to 6 cm of skin incision. An additional 5.5mm trocar was inserted through the 3rd intercostal space, for insertion of forceps controlled by the surgeon’s left hand. Another trocar was inserted through 6th inter costal space for the endoscope. Rib-spreader was not used. The endoscope was manually controlled by an assistant.
Patients: From October 2010 to November 2015, 231 patients underwent endoscopic minimally invasive cardiac surgery(Endo-MICS) for mitral valve. Exclusion criteria were advanced peripheral vascular disease, calcification of the ascending aorta. 50 patients were excluded from Endo-MICS during that period.
Average age was 63.3 years, (range 22 to 88). 104 were male. Etiologies were fibro elastic deficiency in 142, Barlow disease in 13, endocarditis in 14, rheumatic in 24, consolidating degeneration in 7, annular dilatation in 15, and others. 16 were re-do case. As concomitant surgeries, 37 Maze, 46 tricuspid annuloplasty, and 8 aortic valve replacement (AVR)were performed. For concomitant AVR, a rib spreader was applied. Early results were evaluated.
RESULTS: No in-hospital death occurred. As complications, stroke occurred in 2, re-exploration for bleeding in 3, superficial wound infection in 1, renal failure in 1. Eight patients required mechanical ventilation longer than 24 hours. Mitral valve replacement was done in 24, of them, 23 as a scheduled procedure, and one as conversion from attempted repair in active endocarditis. 2 patients needed conversion to sternotomy because of bleeding. 63% of the patients had no blood transfusion. Average operation, bypass, and aortic clamp time were, 258, 176, and 127 minutes, respectively. Average ICU stay was 1.3, and post-operative hospital stay was 9.7 days. In patients who underwent mitral valve plasty, 3 had mild mitral regurgitation at discharge, and others had none or trivial.
CONCLUSIONS: Endoscopic mitral surgery with additional working port and hand-held endoscope was reproducible and safe.

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