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Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
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Posts tagged as mitral valve surgery

There are many ways to repair a mitral valve and I have always liked the “tool box” concept.  In other words, I think that you have to be prepared to use different techniques, for similar pathologies, in different patients.  I think that you cannot resort to only one technique to repair all valves. Not all valves are created equally.

I have been using the loop technique now for all anterior leaflet repairs and occasionally for posterior leaflet repairs. I know that everyone has there own concepts and tricks on using loops. I think that for the anterior leaflet the loops should be in front of the papillary muscles and for the posterior leaflet the loops should be behind them.  The trick here is that the loops need to be positioned between the chords when they are being attached to the posterior leaflet. I think that this concept is more anatomical from a chordal standpoint. The mitral collar provides unimpeded visualization of the entire infra-valvular apparatus. Furthermore, a mini-thoracotomy approach provides direct in-line, truly anatomical visualization of the mitral valve.

I would be interested in what others think.

1. The first picture shows the loops to the anterior leaflet positioned to the anterior aspect of the papillary muscle. The posterior loops are behind the papillary muscle and are tied anterior to the papillary muscle. The tied knot to the posterior loops is visualized anteriorly.

2. The second picture shows the posterior loops behind the papillary muscle and positioned between the individual chords. In other words, all the loops are not brought around the entire set of chords.
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I have performed a total of 35 minimally invasive MVRepairs with an anterior leaflet augmentation for multiple different pathologies including rheumatic disease. severe MAC, radiation valvulopathy, and severe SAM with IHHS.

33 have been with bovine pericardium, 1 with untreated autologous pericardium and 1 with CardioCel.  I have not used CorMatrix because of the multiple reports claiming that on the left side of the heart, there can be a disruption of the patch.  I cannot personally attest to this since I have only used it once on a tricuspid valve reconstruction.

The last of the 35 cases that I performed an anterior leaflet augmentation was with CardioCel.  I found it very comfortable to work with.  It is very flexible and soft and it is easy to pass a 5-0 needle through it. A  saline test of the valve can be performed with this material as opposed to bovine pericardium which is very stiff and competency of the repair can only be assessed once the heart is beating.

I think this will be my go to patch for now and would like to eventually compare its results with the bovine pericardial cases. Of note, I have been told that all of the bovine pericardial patches will eventually calcify but I have not seen that yet since my follow up is not long enough.

I have enclosed pictures.  All of my cases have been performed via a right lateral mini thoracotomy. I truly believe that the visualization is superior to a sternotomy in addition to the fact that a more extensive and complete myectomy can be performed via the mitral valve.

 

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When performing a minimally invasive AVR or MVR via a right mini-thoracotomy approach, assessing whether you are in the right interspace is sometimes questionable.  Even after performing thousands of cases, I question this at times. I have come to the conclusion that there is one landmark that I need to see in order to confirm that I have entered the correct interspace.  That structure is the Right Superior Pulmonary Vein.

During a mini AVR, after instituting CPB and opening the pericardium, if I see the RSPV directly in line with interspace that I entered, I know that I should be able to perform the operation, even if the aorta is displaced. It is key to then take your time and place as many pericardial stay sutures as needed to develop the exposure. This is crucial to optimizing the exposure. (TOP picture)

During a mini MVR, after instituting CPB and opeing the pericardium, if I see the RSPV directly in line with the interspace that I entered, or one interspace above the site that I entered, I know that I am in the correct interspace. I don’t what to be in line with the IVC. This will be very low and if this were the case, I would move to the next higher interspace. Again, use the pericardial stay sutures to optimize exposure. (BOTTOM picture)

Mini AVR

Mini AVR

Mini MVR

Mini MVR

 

I truly believe that the easiest way to perform a septal myectomy is through the mitral valve. The majority of cases that have severe MR secondary to SAM and septal hypertrophy will have a small anterior leaflet. There have been reports describing the detachment of the anterior leaflet chords and elongating them with artificial gortex neochordae to eliminate the SAM. I am sure this can be done but there is a more consistent solution. With SAM, MR and septal hypertrophy, I believe that detaching the anterior leaflet and extending the leaflet incision past the commisures, performing a septal myectomy and then suturing a pericardial patch to the defect in the anterior leaflet will resolve the problem. When performing the septal myectomy, I usually take a 3-0 silk needle and drive it into the thickened septum pull it down. Thereafter and 11 blade is used to incise the septum 3-4 mm from the aortic annulus. I will then use the long shafted metsenbaum scissor to complete an extensive myectomy. You can usually take more that you think. This approach will allow you to go deep into the septum towards the apex.
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