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Christoph Krapf, Bastian Schneider, Cenk Özpeker, Juliane Kilo, Michael Grimm, Ludwig Müller.
Medical University of Innsbruck, Innsbruck, Austria.

OBJECTIVE: Minimally invasive mitral valve surgery (MIMVS) through mini-thoracotomy is facilitated by video assistance. Due to difficult depth perception with 2D video systems most steps of the procedure by most surgeons are done under direct vision. We report our results of an 18 months period using 3D video-endoscopy.
METHODS: A continuous series of 65 patients operated totally endoscopic with 3D imaging is included. Perioperative and short-term results are analyzed retrospectively. Crossclamping and CPB times for isolated MIMVS in 45 patients were compared with those from 275 MIMVS patients operated from 2001 to 2014 with 2D and direct vision. A total of 8 surgeons either operated self-responsible or were assisted by the MIMVS program director.
RESULTS: From 06/2014 to 12/2015, 65 patients (median age 63 years), 37 (56.9%) male underwent totally endoscopic MIMVS with 3D imaging. In 63 patients (96.9%) transthoracic aortic clamping with cardioplegic arrest median ischemic and CPB times were 123 min (sd 32.2) and 222 min (sd 65.1); in 2 patients (3.1%) a redo procedure was done under ventricular fibrillation. In 59 patients (90.8%) MV repair was possible, 5 received planned MV replacement. Additional tricuspid valve repair, ASD/PFO closure and left atrial ablation were done in 8 (12.3%), 13 (20%) and 6(9.2%) cases. In 2 patients (3.1%) conversion to median sternotomy was necessary: one due to bleeding and one due to unsucsessful reconstruction with final MV replacement. 30 days mortality was 0.
In 45 patients with isolated MIMVS CPB times were longer with 3D (221.0 min. sd 63.9) compared to 275 patients with 2D imaging (194.5 min. sd 64.6) p=0.011. Crossclamp times were comparable (121.9 sd 28.9 min. vs 110.4 sd 41.9 min., p=0.082).
CONCLUSIONS: Totally endoscopic MIMVS with 3D imaging is safe. Standard Carpentier techniques for repair or replacement can be performed without direct vision even in a training institution. Crossclamping times using 3D imaging are not different, however, total CPB times are longer, since preparative and final steps from pericardiotomy to crossclamping and vice versa were performed mostly by surgeons less experienced with the MICS approach.

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