I have enclosed a link for a comprehensive video on a Minimally Invasive approach to treat both ischemic and non-ischemic mitral regurgitation.These patients usually have poor EF’s. dilated LV with an inter papillary muscle distance greater than 2.5cm.
Femoral cannulation is preferred unless there is significant PVD and therefore axillary cannulation would be performed. This technique is performed via a 5-6cm right mini-thoracotomy incision. Aortic cross clamping is performed directly through the incision. I have been using Del Nido cardioplegia on a more frequent basis and delivering repeat doses every 45-55 minutes.
After the heart is arrested and an the atriotomy is performed, I place an atrial lift device and a Visor to provide additional visibility. Once I have decided to place the papillary muscle SLING, I will use a mitral collar to provide further visibility of the the infra valvular structures. I then utilize a long curved clamp or a specialized curved instrument (developed by Raul Martinez, Nurse in charge of our Cardiac Team) to encircle the papillary muscles. (It is very rare not to be able to encircle the papillary muscles. I have recently encountered one case that had the papillary muscles completed fused to the ventricular wall.) It is important to use a 4mm Gortex graft and to place the graft around the trabecula to avoid it from slipping and choking the chordae. Once the graft is completely around the papillary muscles, I utilize a 4-0 proline to approximate the ends of the graft together. The graft needs to be relatively tight. A reference that I use is to place a yankour suction between the approximated papillary muscles. You should not be able to softly push the suction between the papillary muscles. If so, it needs to be tightened further. Once the SLING is in place, I then place the annular sutures. I never down size the annuloplasty ring in these cases. I will size the ring to the exact size of the anterior leaflet.
I truly believe that this is a very good solution to a very difficult problem. Our short and mid term results have been very good.
Stay blogged and I will soon post our data on over 35 cases.