Three-dimensional Totally Endoscopic Reoperative Mitral Valve Surgery With Fibrillatory Arrest
Jae Suk Yoo1, Jihoon Kim2.
1Sejong General Hospital, Bucheon-si, Korea, Republic of, 2Kangnam Sacred Heart Hospital Hallym University Medical Center, Seoul, Korea, Republic of.
Objectives : In mitral valve (MV) surgery after previous sternotomy, right minithoracotomy and fibrillatory arrest (FA) offers the simplest approach with no need for mediastinal adhesiolysis. Despite this advantage, limited dissection and fibrillating heart sometimes yields limited exposure. A three-dimensional (3D) endoscope might facilitate to visualize and manipulate the MV, which enables totally endoscopic surgery. We present the earliest Korean experience of applying 3D endoscopic system in redo MV surgery with FA. Methods : Between May 2018 and November 2018, we performed aortic no-touch totally endoscopic redo mitral valve surgery on 16 patients; second-time in 12 patients, third-time in three patients, fourth-time in one patient. All patients had undergone previous valve surgeries involving mitral valves only through sternotomy approach (EuroScore II 11.09 ± 7.91%). Previously implanted prosthetic aortic valves existed in six patients. All procedures were performed through 5 to 6 cm right minithoracotomy incision with two extra ports; a left atrial sump drain and a 10 mm-scope trocar (Figure). Temporary pacing wires were implanted on the right ventricular anterior wall or right ventricular endocardium after right atriotomy, and left atrium was opened after inducing FA with a fibrillator. Results : Mean cardiopulmonary bypass time was 175.1 ± 33.4 minutes. No intraoperative events such as great vessel injury or lung laceration occurred. There were no perioperative mortality, postoperative bleeding reoperation, low cardiac output syndrome, pneumonia, or wound problem. One minor stroke (cerebellar embolic infarction) occurred in a patient with third-time redo mitral valve replacement. Concomitant procedures including tricuspid valvuloplasty in 10 and maze procedure in three were performed.
Conclusions : Our experience illustrates feasibility and safety of the 3D totally endoscopic right minithoracotomy approach under FA to treat mitral pathology without reoperative sternotomy risks. 
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