Multimodal Imaging In Patient Selection For Minimal Invasive Mitral Valve Surgery
Sara Abou Sherif, Victoria Parish, Joon Lee, Uday Trivedi, Ishtiaq Ahmed.
Royal Sussex County Hospital, Brighton, United Kingdom.
BACKGROUND- Minimal Invasive Mitral Valve Surgery (MIMVS) is established practice in many high-volume centres globally. However, this remains an area of developing practice in the UK. Reasons for this include learning curves, governance and the financial implications of setting up such a service. Nonetheless, the parallel evolution of imaging modalities has permitted the appropriate patient selection for this procedure and pre-emptive surgical planning. We aimed to set up this service and demonstrate the steps taken, including the utilisation of pre- and intra-operative imaging, so that this can be safely reproduced in other units to help facilitate the widespread implementation of this procedure. METHODS- Patients selected for MIMVS included those with a BMI< 30 with isolated non-complex non calcified mitral valve dysfunction of which the latter was assessed with pre-operative 3D TOE. To further assess their eligibility, patients underwent pre-operative CT with 3D reconstruction for better visualisation of any aberrant thoraco-abdominal anatomy and vasculature (i.e. severe vessel tortuosity or calcification) that may result in intraoperative complications such as difficulties with exposure or optimal cardiopulmonary bypass and cannulation. 3D reconstruction allowed precise planning of surgical incisions, rib space entry as well as caval drainage strategies. All patient's 3D echo and CT imaging were pre-operatively discussed in a dedicated multidisciplinary team meeting consisting of Cardiac Surgeons, Cardiac Radiologists and Echocardiographers, to allow for individualised procedural planning. Furthermore, intra-operative ultrasound was used to aid safe superior vena caval cannula placement by the anaesthetist. RESULTS- The programme has now been successfully set up, with an initial repair rate of 100%. Careful pre-operative planning using multimodal imaging techniques has allowed us to exclude patient's ineligible for MIMVS due to various aberrant findings on imaging (Figure 1). There has been no sternotomy conversions. CONCLUSIONS- We demonstrate the importance of pre-operative multimodal imaging and multidisciplinary input for appropriate patient selection and operative strategy planning in MIMVS. This has ensured a safe and efficient adoption of this procedure. 
LEGEND- FIGURE 1. Significant features identified which altered the operative strategy of MIMVS, counting from top left to bottom right, horizontally. Pre-operative CT revealing Incidental Left sided SVC, Mural Thrombus and Calcium in Descending Aorta, Liver Haemangioma. Incidental aneurysm, Bifid 4th Rib on 3D volume rendered images obtained from a CT scan. Calcified mitral annulus on coronary angiography.
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