International Society For Minimally Invasive Cardiothoracic Surgery

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Initial Experience With The Minithoracotomy Approach For Multiple Valve Disease
Antonio Lio, Federico Ranocchi, Andrea Montalto, Marcello Bergonzini, Antonio Giovanni Cammardella, Francesca Nicoḷ, Francesco Musumeci.
Azienda Ospedaliera San Camillo Forlanini, Rome, Italy.

Background.Benefits of minimally invasive cardiac surgery have been well recognized; however, few experiences exist in minimally invasive treatment of multiple valve disease. We describe our experience with right minithoracotomy treatment of multiple valve disease. Methods.From April 2017 to September 2018, 20 patients with mitro-aortic and triple valve disease were operated by this method. A 3-4 cm skin incision is performed at the level of anterior axillary line entering into the 3rd intercostal space (ICS). Cardiopulmonary bypass (CPB) is estabilished with a femoro-femoral platform. Aorta is opened transversely, native valve is removed and decalcification of the annulus performed. Following that, the mitral valve is approached: annuloplasty or prosthetic sutures are passed without implanting the selected ring/prosthesis. Then, aortic valve is again approached: surgical stitches are passed through the annulus and the prosthesis implanted. Thereafter, the selected mitral ring/prosthesis is implanted. Finally, the tricuspid valve disease is treated. Results.There were 14 women (70%) with a mean age of 67 ± 5 years. Mean EuroScore II was 7.8 ± 10. Aortic and mitral valve replacements were performed in 15 patients (75%), whereas 5 (25%) underwent aortic valve replacement and mitral valve repair. Concomitant tricuspid annuloplasty was performed in 5 patients (25%). Aortic cross-clamp and CPB times were 130 ± 22 and 172 ± 33 minutes, respectively. No conversion to full sternotomy was recorded intraoperatively. Postoperatively, only 1 patient (5%) died, due to multiorgan failure and sepsis. Re-exploration for bleeding occurred in 1 patient (5%), which led to conversion to sternotomy. No significant morbidity was recorded. Conclusion.Our results show the feasibility of minimally invasive treatment of multiple valve disease. Our approach, obtained via a lateral minithoracotomy in the 3rd ICS, guarantees an optimalexposure of the mitral valvein an effort to perform more complex mitral valve repairs. Moreover, the proposed modification, that includes implantation of the mitral ring/prosthesis after completion of the aortic valve treatment, allows an easier passage of surgical sutures through the aortic annulus, expexially through the non-coronary sinus, and implantation of aortic prostheses with larger sizes, avoiding the distortion of the annulus due to the presence of a mitral ring/prosthesis.

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