FrederickGrover 2016 PARTIVMITRALVALVEPROC MasterTechniquesInSur

Part IV
Mitral Valve Procedures

All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Copyright 2016. Wolters Kluwer Health.
EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 9/12/2023 2:23 AM via RAJAVITHI HOSPITAL (LIBRARY)
AN: 1565714 ; Frederick Grover, Michael J. Mack.; Master Techniques in Surgery: Cardiac Surgery
Account: ns195392.main.ebooks 215
16
Mitral Valve Repair
Javier G. Castillo and David H. Adams
INDICATIONS/CONTRAINDICATIONS
The mitral valve (MV) is a dynamic assembly of independent anatomical components including
annulus, leaflets and commissures, chordae tendinae, papillary muscles, and left ventricle. During
systole, a coordinated interaction of all these anatomic structures seals the valve against left ventricular
pressure and allows one-way forward blood flow through the left ventricular outflow tract in practically
frictionless fashion. Minimal anatomical alterations of the MV components may result in reduction of
leaflet coaptation or opening and, consequently, mitral regurgitation (MR) or mitral stenosis (MS)
respectively. While even a normal competent valve may allow a trivial amount of reversed flow, more
than a trace of MR is considered pathologic. Mild to moderate MR might be tolerated indefinitely as
long as it doesn’t worsen. However, more severe degrees of MR cause left ventricular remodeling,
reduced forward cardiac output, neurohumoral activation, left ventricular damage, heart failure, and
ultimately death.
The natural history of MR depends intimately on its etiology, the severity of left ventricular volume
overload as well as its contractile performance, and the appearance of overlapping clinical conditions
secondary to reversal flow such as atrial fibrillation or pulmonary hypertension. Degenerative disease is
the most prevalent cause of surgical MR in the United States (representing 60% to 70% of cases). Other
major causes of surgical MR are ischemic cardiomyopathy (20%), endocarditis (3% to 5%), and
rheumatic disease (2% to 5%). Currently, MV repair is recommended in most circumstances as a
primary surgical therapy versus valve replacement, particularly in asymptomatic patients and specific
etiologies such as degenerative disease.
Currently, there is no strong surgical indication for patients with a severity of less than severe MR,
except in symptomatic patients where there is a high suspicion of underestimation. In such patients,
exercise testing is critical to clarify the decision-making. While there is the concern that moderate MR
will likely worsen over time, the majority of patients should be treated with close observation until the
MR has progressed in severity.
The standard class I indications for MV surgery are the onset of symptoms and/or left ventricular
dysfunction. However, there is a significant trend toward offering early surgical intervention for
asymptomatic patients who have preserved left ventricular function based on two tenets: (a) Equal or
above 95% repair rate based on preoperative evaluation of the valve anatomy and lesions and (b)
according to the literature patients with severe MR will develop a significant adverse event (symptom
onset, atrial fibrillation, left ventricular dysfunction) within 5 years of diagnosis. In addition, recent
reports have suggested survival benefit with early surgery, providing additional support to the argument
for earlier elective intervention. High-volume centers have shown a near 100% repair rate for
degenerative MV disease, with an operative risk of less than 1%. Matching surgical expertise and
experience to the complexity of a specific valve morphology and patient is important in the modern era
to assure high repair rates.
The presence of severe preoperative symptoms (New York Heart Association [NYHA] functional
class III or IV) has been observed to confer a poor prognosis for patients postoperatively, even if left
ventricular function is preserved. The onset of symptoms translates as a variation in the normal cardiac
physiology as MR has begun to compromise cardiac output. In addition, there may be a small risk of
EBSCOhost - printed on 9/12/2023 2:23 AM via RAJAVITHI HOSPITAL (LIBRARY). All use subject to https://www.ebsco.com/terms-of-use 216
sudden death in patients who have developed symptoms. It is extremely important to correct MR at the
onset of even mild symptoms since watchful waiting for the progression of symptoms seems dangerous.
Left ventricular dysfunction secondary to MR may or may not induce symptoms. However, if not
corrected, dysfunction may become permanent leading to a poor surgical outcome and eventually to
death. In the absence of symptoms, two indicators of left ventricular dysfunction have been accepted: (a)
An ejection fraction below 60% and (b) left ventricular end systolic dimension equal or greater than 40
mm. Classic mitral literature have demonstrated superior survival and ventricular remodeling in those
patients who do not meet these criteria.
Decision-making in patients with severe secondary or functional MR (not requiring concomitant
coronary artery bypass grafting [CABG] surgery) is more complex and challenging. In this setting,
several factors need to be taken into account including the negative impact of ischemic MR on mid-term
survival, the impact of a potential concomitant CABG on surgical outcomes, and, of course, the choice
of valve repair versus replacement. In this regard, the clinical literature remains contradictory, making it
difficult to synthesize and distill the information into concrete and practical clinical recommendations.
In patients with NYHA functional class I or II, surgery is only indicated in the presence of pulmonary
hypertension and an acceptable ventricular function (left ventricular ejection fraction [LVEF] >30% and
left ventricular end-diastolic dimension [LVEDD] 41 to 64 mm); otherwise, the initial therapy is
medical management. This may often result in reduction of severity of regurgitation, with a varying
degree of symptom improvement. Cardiac resynchronization therapy with biventricular pacing should
be employed in patients with severe secondary MR who show evidence of dyssynchrony. Alternatively,
in patients with NYHA functional class III or IV, the initial therapy is MV surgery unless there is severe
LV dysfunction (LVEF 30% and LVEDD 65 mm) or no viable myocardium. In this case, advanced
heart failure therapies are indicated.
PREOPERATIVE PLANNING
Preoperative workup for patients undergoing MV repair should include the acquisition of a
comprehensive medical history with an emphasis on cardiovascular details, physical examination with
additional dental clearance (a letter from a dental specialist is requested), routine laboratory tests
(complete blood count, basic metabolic panel, coagulation profile, liver function tests, spirometry in
patients with airway disease or chronic obstructive pulmonary disease [COPD], type and screen,
methicillin-resistant staphylococcus aureus [MRSA] swabs, urine dipstick and hemoglobin A1C in
diabetic patients), ECG (atrial fibrillation can be corrected with a concomitant maze procedure) and
chest x-ray. In addition, all patients should have a timely preoperative consultation with anesthesia,
particularly those undergoing surgery on the day of admission.
Coronary catheterization is indicated for most patients over 50 years of age or in younger patients
with congenital malformations (right and left), ventricular dysfunction (right and left), or risk factors for
coronary artery disease. A computed tomography angiogram is indicated in younger patients without
any of the aforementioned conditions. In addition, a computed tomography of the chest without contrast
will be obtained in the setting of reoperative sternotomy (assessment of the proximity of the cardiac
structures to the sternum) or in patients over 70 years old for assessment of aortic calcifications. A head
and abdominal computed tomography are indicated in patients with endocarditis not undergoing
emergent surgery in order to rule out the presence of embolic foci.
In general, beta-blockers, diuretics, and other medications for noncardiovascular conditions should be
stopped the night before surgery. However, angiotensin-converting-enzyme (ACE) inhibitors should be
discontinued at least 48 hours before the procedure to avoid intraoperative vasoplegia. Regarding
anticoagulation, clopidogrel will be ideally discontinued at least 5 to 7 days before surgery, if possible
(individualize patients with drug-eluting stents), aspirin 3 days before surgery, and coumadin 3 to 5 days
before surgery (patients at a significant risk of thromboembolic complications are started on intravenous
heparin or subcutaneous low molecular weight heparin). Patients with right ventricular dysfunction or
elevated pulmonary hypertension (>60 mm Hg) may benefit from hemodynamic optimization with
supplemental oxygen and intravenous nesiritide the day before surgery.
SURGERY
Positioning and Valve Exposure
An excellent exposure of the MV is critical to the success of the surgical procedure. Multiple approaches
have been classically described including median sternotomy (most common and standard approach in
patients with complex lesions or in need of concomitant procedures), right anterolateral thoracotomy
(almost abandoned in favor of minimally invasive approaches), and minimally invasive techniques. In
turn, the latter can be subdivided into three different categories: Limited skin incision (with full or
partial sternotomy), video assisted (through a right thoracotomy), or robot assisted ( Fig. 16.1).
Minimally invasive techniques other than median sternotomy through a limited skin incision will be
reviewed and discussed in subsequent chapters.
Our routine institutional surgical access to the MV is median sternotomy through a limited small skin
incision. The patient is placed in a supine position and all surgical landmarks are marked before skin
prep (straight line from the sternal notch to the xyphoid and lower border of the ribs and breasts in
female patients). A 7- to 8-cm incision is made in the lower portion of the chest and the incision is
carried down to the sternum with cautery. The fascia overlying the pectoralis muscle must be freed to
provide more laxity to the skin and the subcutaneous tissue for better retraction and exposure. Once the
midline has been identified and marked from the xyphoid to the sternal notch, a reciprocating saw is
used to divide the sternum from the xyphoid upwards as far as the skin incision allows. An Army-Navy
retractor is subsequently placed in the divided portion of the sternum and turned 90 degrees to spread the
two edges of bone and facilitate the division of the remaining sternum and manubrium with an
oscillating saw. After hemostasis, a customized or a pediatric Cosgrove retractor (Kapp Surgical
Instruments) is used to separate the sternum and allow access to the mediastinum.
After complete division of the pericardial sac in a standard fashion, the pericardial edge on the right
side is sandwiched between the retractor blade and the right sternal edge to lift the right atrium and cava
toward the skin edge, improving exposure. Subsequently, a clamp can be used to retract the aorta
inferiorly into the field for cannulation. If the distance is suboptimal or the angle of exposure is too
difficult, a Fem-Flex (Edwards Lifesciences LLC) cannula can be placed in the ascending aorta using a
Seldinger technique. Cannulation of both cavas is then facilitated with the use of 24-Fr cannulas, and we
typically use vacuum assistance. Finally, retrograde cardioplegia is used routinely on all mitral
procedures via standard coronary sinus cannulation. The interatrial approach to the MV through
Sondergaard’s groove remains the most efficient since it provides an excellent view and causes less
tissue damage. The groove is usually developed by carefully dissecting the interatrial space up to the
fossa ovalis. After complete dissection, the roof of the left atrium should be fully exposed and
cardiopulmonary bypass is instituted. The left atrium is then opened at the midpoint between the right
superior pulmonary vein insertion and the groove. Exposure of the MV is achieved via a curvilinear
incision extended longitudinally both superiorly to 1 cm from the superior vena cava and inferiorly to
the midpoint between the right inferior pulmonary vein and the inferior vena cava. If further exposure of
the left atrium is required, the pericardial reflection on both vena cavas is released and blunt dissection
is used to free the lateral aspects of both veins for about 2 to 3 cm (Fig. 16.1).
Figure 16.1 TOP PANEL. A: Surgical approaches to the left atrium and the mitral valve include median sternotomy (
central dashed line), right anterolateral thoracotomy (lateral dashed line), and minimally invasive techniques (video-
or robot-assisted dots). B: Current standard skin incision is about 8 cm. C: Full sternotomy can be performed
through a limited skin incision. BOTTOM PANEL. A: The interatrial groove is dissected and both atriums are divided
up to the fossa ovalis. B: The right atrium can be retracted medially and anteriorly. The right superior pulmonary vein
at its junction to the left atrium is exposed. The dissection exposes the roof of the left atrium which is opened at the
midpoint between the right superior pulmonary vein insertion and the groove. C: The curvilinear incision is extended
longitudinally both superiorly to 1 cm from the superior vena cava and inferiorly to the midpoint between the right
inferior pulmonary vein and the inferior vena cava.
Valve Analysis
Meticulous echocardiographic and intraoperative interrogation (identification, localization, and
assessment of magnitude) of the mitral lesions as well as determination of the mechanism of
regurgitation (dysfunction) are essential to evaluate reparability. The differentiation of MV dysfunction
(I, II, and III) as described by Carpentier is based on the position of the leaflet margins with respect to
the normal mitral coaptation plane. Type I dysfunction implies normal leaflet motion, and the most
common cause of significant MR is the perforation of one of the leaflets (e.g., endocarditis) or severe
annular dilatation with a central regurgitant jet (e.g., long-standing atrial fibrillation). Type II
dysfunction denotes excess leaflet motion generally secondary to chordal elongation or rupture or
myxomatous degeneration of the leaflets. Type III dysfunction involves restricted leaflet motion and
typically results from retraction of the subvalvular apparatus (IIIA) or papillary muscle displacement
secondary to leaflet tethering from LV remodeling or dilatation (IIIB) (Fig. 16.2).
Figure 16.2 Carpentier’s pathophysiologic triad of mitral valve regurgitation composed of leaflet dysfunction, lesions,
and etiology. Common lesions in type I dysfunction are annular dilatation and leaflet perforation. Patients with type II
dysfunction mostly present with prolapsing valves due to degenerative mitral valve disease. Frequent lesions in type
IIIA dysfunction are leaflet thickening and restriction as well as chordal fusion and retraction. The most frequent
lesion in patients with secondary MR is leaflet tethering.
Intraoperative valve inspection should be performed in a very systematic fashion (annulus, leaflets,
chordae, and papillary muscles). The left atrial endocardial surface should be carefully examined for jet
lesions, thrombi, and areas of calcification beforehand. The mitral annulus is then evaluated to assess
shape, symmetry, any degree of dilation, as well as areas of severe calcification (potential impediments
to place annular sutures). The leaflets are subsequently examined with a nerve hook to identify
pathologic segments (A1 to 3; P1 to 3, anterior and posterior commissures). After structural evaluation,
the saline test helps to analyze “functional” leaflet lesions. Chordae tendinae are commonly interrogated
for elongation, rupture, or more complex lesions such as chordal thickening, fibrosis, or fusion. Finally,
the papillary muscles are examined for calcification, fusion, and/or abnormal ventricular insertion.
Figure 16.3 Algorithm of mitral valve repair strategies and techniques in patients with type I dysfunction.
Surgical Technique in Type I Dysfunction

The most common lesions in patients with type I dysfunction are symmetric annular dilation (most
frequent scenario especially in patients with long-standing atrial fibrillation) or leaflet perforation (also
known as windsock leaflet deformity) secondary to acute bacterial endocarditis (Fig. 16.3).
Every patient undergoing MV repair requires a remodeling annuloplasty in order to restore the native
annular size and shape allowing full leaflet motion at the same time. This prevents any risk of recurrence
by stabilizing the annulus (particularly the posterior aspect) with a prosthetic device (complete ring,
open ring, or posterior band). Although remodeling annuloplasty is considered a very routine part of the
repair, several anatomical structures are susceptible to injury during placement of annuloplasty sutures.
Among them, in decreasing order of importance, the left circumflex coronary artery, the aortomitral
curtain (including the left and the noncoronary aortic sinus with their corresponding aortic leaflets), and
the coronary sinus (Fig. 16.4).
Patients with type I dysfunction and isolated annular dilation can be successfully repaired with only a
remodeling annuloplasty. Placement of the annular sutures mandates complete visualization and
identification of the mitral annulus first, located approximately 2 mm away from the leaflet hinge.
Grasping the leaflets transversally (as close to the annulus as possible) while applying traction toward
the ventricle provides exposure and facilitates positioning of the sutures. Placing sutures along the
anterior leaflet should be done using a backhand position with the needle tip oriented toward the
ventricle (avoiding the aortic cusps). Sutures within the posterior annulus follow the same premises but
require slightly deeper bites to reach the fibrous skeleton. For sutures along the posterior commissure,
sutures are placed using a forehand position and oriented downwards. Finally, placing sutures within the
anterior commissure requires a forehand position and the needle tip must be oriented toward the
ventricle in order to avoid the circumflex artery. Approximately 12 to 15 2-0 braided polyester mattress
sutures are placed. Selection of the ring size (some centers exclusively use standard-sized posterior
bands) is based on the assessment of the base (intercommissural distance) and height of the anterior
leaflet. After annuloplasty, saline testing should show a competent valve, with a symmetric and
posteriorly displaced line of coaptation.
Figure 16.4 A: Anatomical relationships of the mitral valve. B: Nomenclature of the different segments of the mitral
valve and appropriate placement of annular sutures (arrows). Ring annuloplasty (the needle is angled 2 mm away
from the hinge point).
Another common lesion leading to type I dysfunction is leaflet perforation, generally due to bacterial
endocarditis. The aggressive infection process usually results in the formation of a vegetation abscess on
the body (atrial side) of the anterior leaflet (perforation of the posterior leaflet is unusual) that eventually
becomes aneurysmatic and perforates or even fistulates. Early surgical intervention should be performed
after isolation and identification of the organism and initiation of the appropriate antibiotic therapy. The
infected tissue needs to be debrided with a minimum of 2-mm margins of healthy tissue. Subsequently, a
piece of glutaraldehyde-fixed autologous pericardium (previously immersed in a 0.625% buffered
glutaraldehyde solution—Poly Scientific, Bay Shore, NY—for 15 minutes) may be used to proceed with
leaflet patch replacement. It is important to highlight that the patch should match the shape of the leaflet
defect accounting for 2 to 3 mm of margin for the continuous suturing with 5-0 polypropylene.
Surgical Technique in Type II Dysfunction

The most recent mitral literature has demonstrated that all prolapsing valves are repairable in
high-volume centers with very low mortality rates (around 1%). However, a systematic “all comers”
strategy of MV repair by blending a wide variety of surgical techniques is necessary to achieve high
repair rates. In this regard, we tend to grossly classify repair techniques into chordal or nonresectional
and resectional techniques (Fig. 16.5).
Posterior Leaflet Prolapse

Posterior leaflet prolapse (particularly, isolated P2 prolapse) is the most common cause of MV
regurgitation. Generally speaking, nonressectional and ressectional techniques can be effectively
performed in patients with posterior leaflet prolapse with very satisfactory outcomes. However, there is
a tendency to apply nonressectional techniques in cases of minimal leaflet tissue, while resection
techniques are reserved to those patients with advanced disease and excess leaflet tissue (usually
combined with a posterior band or a large-sized ring annuloplasty to avoid systolic anterior motion
[SAM]). Valves with minimal leaflet tissue and lesions secondary to fibroelastic deficiency do not allow
aggressive resections; therefore, nonressectional techniques are mainly chosen. These techniques mainly
comprise chordal transfer and polytetrafluoroethylene (PTFE) neochordoplasty (including the loop
technique and its variants).
Figure 16.5 Algorithm of mitral valve repair strategies and techniques in patients with type II dysfunction. Preferred
techniques in patients with minimal leaflet tissue are chordal techniques (loop-in-loop) and triangular resection. In the
setting of excess leaflet tissue, indentation closure (to treat all segments as one), quadrangular resection, and
asymmetric sliding plasty are a valuable option. Patients with bacterial endocarditis benefit form commissuroplasty
“magic suture” and commissural resuspension with PTFE neochordoplasty.
Chordal transfer implies the mobilization of one or several strong secondary chordae to the free
margin of the prolapsing area. The chordae is detached 2 mm from its origin (if the chordae is cut at the
leaflet base we may cause leaflet perforation) and reattached to the leaflet margin using a 5-0
polypropylene suture. Although using native chordae avoids height discrepancies and facilitates
adequate leaflet resuspension, one must be cautious if no additional reinforcement (artificial
neochordoplasty) is planned. Native chordae are subject to fibroelastic changes difficult to notice
macroscopically and, of course, to disease progression.
PTFE neochordoplasty and its variants have been increasingly used in MV repair since they are
thought to not demand as many skills as ressectional techniques (Fig. 16.6). However, one of the main
difficulties associated with PTFE neochordoplasty is to determine the exact height in order to correct
prolapse without inducing leaflet restriction. First, a CV-5 double-armed PTFE suture is passed and
looped (no pledgets are required) through the fibrous tip of the papillary muscle. After reconstruction
and annuloplasty, the two ends of the artificial chord are passed through the leaflet margin
(approximately with a 3-mm distance between them) and two slip knots are tied. Subsequently, optimal
chordal height is achieved by intermittent ventricular injections of saline (functional adjustment). The
use of PTFE has been expanded and modified into different variants such as the loop technique or the
loop-in-loop technique. The loop technique was chiefly introduced to avoid problems of functional
adjustment of the neochordae. Three premeasured 20-mm CV-5 PTFE loops are attached to the body of
the papillary muscle (mandatory use of pledgets) and the free margin of the prolapsing leaflet using 5-0
polypropylene sutures in both maneuvers (functional adjustment not allowed). Alternatively, the
loop-in-loop technique consists of a premeasured 13-mm set of pledget-supported CV-5 PTFE loops
which are attached to the anterior papillary muscle head. Secondary CV-3 PTFE loops are then created
and looped around the premeasured loops and attached to the anterior leaflet margin (functional
adjustment allowed) (Fig. 16.5).
Figure 16.6 Repair of posterior (P2) leaflet prolapse with 5-0 PTFE (polytetrafluoroethylene) neochords can be done
as a primary repair procedure (top row), or in combination with a resection strategy to add free margin support or to
adjust leaflet height (bottom row). The final neochordal height adjustment is usually done after implantation of a ring
or band under saline testing (a functional adjustment strategy). Alternatively a geometric strategy involves matching
the neochordal length to the distance from the papillary muscle tip to the reference leaflet margin, or by targeting the
knots at a reference point (usually the annular plane).
In cases of concentrated myxomatous degeneration (isolated one-segment disease in an otherwise

normal valve) several approaches have been suggested such as posterior leaflet displacement with
artificial chords (see previous section), leaflet plication, and triangular resection. McGoon’s plication
technique is used to repair very limited prolapses and involves the placement of two imbricated “magic”
5-0 polypropylene sutures to plicate the prolapsing leaflet segment. Triangular resection is a very useful
technique in patients with isolated posterior leaflet prolapse. Normally, the resection is limited to within
a few millimeters of good marginal chords and must not extend to the annulus (this is key to avoid
excessive leaflet tension and funnel effect after repair). Leaflet continuity is then restored using either
interrupted or continuous 5-0 polypropylene sutures, depending on the pliability of the tissue. A
continuous suture technique is best avoided in the setting of leaflet calcification or retraction. After
completion of the sutures, a nerve hook is utilized to asses leaflet continuity and to detect residual
defects. It is important to mention that the repair may require reinforcement by a neochordoplasty if the
adjacent native chords do not look totally healthy or in light of severe disease progression.
When excessive leaflet tissue is present (advanced myxomatous degeneration i.e., Barlow disease) it
is important to reduce the height of the posterior leaflet to avoid postoperative SAM. In this setting,
more aggressive resection techniques are needed including quadrangular resection, annular plication,
and sliding leaflet plasty. However, with the growing adoption of chordal techniques, many surgeons
have decided to respect as much tissue as possible and abandon more complex techniques often required
in large resections. After valve analysis, a quadrangular resection of the prolapsing area is carried out to
the annulus. The tallest portion of the leaflet is frequently excised well within the margin of normal
chordae (typically about 1 cm wide). Clefts or indentations are often targeted as one margin of the
resection. It is important not to remove “all abnormal tissues.” In the setting of additional deep
indentations, we close these first with a figure-of-eight suture in order to “treat all the segments as one.”
After quadrangular resection, two scenarios might be common: excessive leaflet defect after vast
removal of abnormal tissue and excessive leaflet height. The former is easy to avoid unless there is very
abnormal leaflet tissue that mandates resection (calcification or vegetation). If the remaining leaflet
defect is >2 cm, plication techniques (horizontal or vertical) might be necessary to avoid excess leaflet
tension. In the setting of excess leaflet height (>1.5 cm), a sliding leaflet plasty (symmetric or
asymmetric) needs to be performed. For this purpose, a specially angled scissors is used to detach the
leaflet remnant starting from the remaining left position of P2 and going to the anterior commissure. At
this point, the leaflet is suspended by their primary and secondary chordae with the basal chordae
remaining on the annular side. Secondary chordae are detached to maintain free mobility of segments
after advancement. This prevents secondary chords from restricting the leaflet after leaflet advancement.
In addition, at this stage, further resection of the base of P1-P2 may be considered in order to
re-establish a uniform leaflet height. A double layer of 4-0 polypropylene running suture is used to
reattach the leaflet to the annulus assuring no excess tension on either segment. Excess height is
compensated for by taking sutures up to 5 mm deep into the leaflet, whereas in areas of adequate height,
sutures are taken just 1 to 2 mm from the leaflet edge. The two leaflet margins are then joined using a
running 5-0 polypropylene suture. The margins of the reconstructed posterior leaflet are then examined
to ensure that all segments are adequately supported. Any gaps in support, or areas supported by thinned
out chordate (even in the absence of prolapse), are reinforced by transferring previously detached
secondary chordae, or implantation of artificial neochordae (Fig. 16.7).
Figure 16.7 TOP PANEL. Quadrangular resection and symmetric sliding plasty. BOTTOM PANEL. Quadrangular
resection and asymmetric sliding plasty.
Anterior Leaflet Prolapse
The anterior leaflet is not amenable to aggressive margin resections, and currently, every surgical
strategy is mostly based on non-resectional techniques (limited triangular resection is feasible bur rarely
done). However, when there is true leaflet prolapse (as opposed to billowing or tendency to prolapse due
to posterior leaflet lesions) we have found that a small triangular resection offers a more robust and
symmetric line of coaptation. In addition to the previously mentioned nonressectional techniques (see
section on posterior leaflet prolapse) and always in the setting diffuse degenerative disease and bileaflet
prolapse requiring resection of the posterior leaflet, a chordal transposition (also known as posterior
leaflet flip technique) can be used in the absence of healthy anterior chordae. This technique involves
the mobilization of an isolated chord (unusual) or a segment (strip) of the posterior leaflet (usually the
one opposed to the prolapsing area of the anterior leaflet) with its marginal chordae to the free margin of
the anterior leaflet using 5-0 polypropylene sutures.
Commissural Prolapse
The mitral commissures are mostly affected in two relatively common scenarios: Diffuse myxomatous
degeneration (severe prolapse and the presence of commissural leaflets) and bacterial endocarditis
(active infection with commissural destruction and vegetations; or prolapsing segment after healing).
The optimal technique to address commissural prolapse is the “magic suture” or commisuroplasty.
Using 5-0 polypropylene sutures, both commissural edges are approximated using imbricated sutures to
invaginate the prolapsing tissue below the coaptation plane (Fig. 16.8). This is often reinforced by a
PTFE neochordoplasty that anchors to both edges (commissural resuspension). Resection is only
required in very complex scenarios where concomitant extensive debridement of bacterial vegetations
and destroyed tissue is necessary. In this case, a sliding plasty of the paracommissural area is performed
and the new commissure is recreated with additional commisuroplasty sutures.
Figure 16.8 Commisuroplasty “Magic Suture” and commissure resuspension with a 5-0 PTFE
(polytetrafluoroethylene) neochord.
Surgical Technique in Type IIIA Dysfunction

The most common lesions in patients with type IIIA dysfunction are commissural fusion, leaflet
thickening and retraction, and chordal restriction (often combined with diffuse areas of inflammatory
fibrosis and calcification) (Fig. 16.9).
The technique of choice for commissural fusion should be commissurotomy and additional
commisuroplasty “magic suture” when required. In addition, leaflet mobilization and resuspension can
be achieved with chordal techniques (cutting, fenestration, or replacement). When the mobilization of
the subvalvular apparatus is not possible or there is a severe degree of leaflet retraction, a
gluteraldehyde-fixed pericardial patch enlargement might be useful to augment the body of the leaflet
either in anterior or posterior position. Traction sutures (5-0 polypropylene) are placed in order to unfold
the leaflet as much as possible and proceed with the incision about 5 mm from and parallel to the
annulus. The extent of the incision depends on the degree of leaflet retraction. A semilunar autologous
pericardial patch is then tailored to the leaflet defect adding a 2-mm margin for suturing. The patch is
finally sutured using continuous 4-0 polypropylene sutures. Interlocked bites are used on the leaflet side
to prevent a potential pursestring effect.
Figure 16.9 Algorithm of mitral valve repair strategies and techniques in patients with type IIIA dysfunction. Valuable
techniques include commissurotomy, leaflet extension with a glutaraldehyde-fixed pericardial patch, and subvalvular
or chordal techniques (cutting and fenestration).
Figure 16.10 Algorithm of mitral valve repair strategies and techniques in patients with type IIIB dysfunction.
Surgical Technique in Type IIIB Dysfunction

Patients with secondary or functional MR have a lack of available posterior leaflet tissue for coaptation (
Fig. 16.10). This particular circumstance mandates to perform a remodeling annuloplasty with a
complete downsized ring by one or two sizes or to use a true-sized rigid asymmetric “ischemic mitral
regurgitation (IMR)” ring specifically designed to ensure an adequate surface of coaptation in the setting
of leaflet tethering. The potential increased tension associated to functional annular dilation requires
placing the sutures very close together along the annulus, and suture crossover may be encouraged
especially in the P3 area. In valves with severe tethering, the battery of adjunct techniques include
cutting of the secondary strut chord to the anterior leaflet in the setting of a “hockey stick” deformity of
the closure line, closure of all clefts and indentations in the posterior leaflet, or cutting restricted
marginal chords if a residual leak is still present (replace with chordal transfer or artificial neochordae, if
necessary).
POSTOPERATIVE MANAGEMENT
A rigorously protocolized postoperative critical care is crucial to ensure success of MV repair. Major
physiologic and mechanical derangements (LVEF fraction may decrease by one-third after correction of
MR) can occur in patients recovering from a cardiac operation as a consequence of pre-existing
conditions or due to changes secondary to cardiopulmonary bypass. In this regard, a system-based
approach is necessary to deal with problems in an organized fashion. Patients are extubated after
assuring preserved neurologic status, adequate oxygenation (optimal arterial blood gases), and optimal
ventricular function (acceptable urine output). In the presence of ventricular dysfunction, vasodilators
for afterload reduction (ACE inhibitors preferentially) should be initiated in combination with inotropic
agents. If pulmonary hypertension persists after surgery, the administration of nitric oxide while the
patient is intubated has been demonstrated to be very effective.
Chronic or paroxysmal atrial fibrillation is common in patients with chronic MR due to increased left
atrial pressure and progressive atrial stretch and dilation. It is present in 20% to 40% of patients
scheduled for MV repair, and around 20% of the patients develop a new episode of atrial fibrillation
after surgery. In this scenario, the rate control strategy should include the use of beta-blockers or
amiodarone and oral anticoagulation in refractory cases (intravenous coagulation should be used with
caution to potentially avoid mediastinal bleeding). Rhythm should be reassessed at 3 months to
determine who should continue on warfarin therapy. Cardioversion might be indicated if atrial
fibrillation persists (transesophageal echocardiography must demonstrate the absence of atrial thrombus
before any cardioversion attempt).
COMPLICATIONS
Residual Regurgitation
The main objective of MV repair is to recreate a fully competent and durable MV. In this regard, the
procedure should mainly restore the native annular shape meeting the following criteria: (a) Competent
valve on saline and ink testing, (b) a good surface of coaptation at least 8 mm when possible, (c)
symmetric line of closure where the anterior leaflet occupies 80% of the valve area, (d) no residual areas
of billowing, (e) no tendency to SAM (avoid more than 10 mm of anterior leaflet beyond the line of
coaptation).
A common mechanism of residual regurgitation after a successful MV repair is leaflet perforation. In
this regard, leaflet perforation can be subdivided into (a) annular tear (more frequent at the anterior
commissural area) (b) suture line leak after triangular or quadrangular resection (Fig. 16.11). The former
is identified on the transesophageal echocardiogram (TEE) as a high-velocity jet within the annuloplasty
ring. In this case, a piece of autologous pericardium is used as a pledget (we use pledgeted 4-0
polypropylene single suture) to cover the defect. When we have a gap between the two free edges of the
reconstructed leaflet (usually identified as a central leak on the TEE after a successful standard repair) it
is important to consider re-exploration since the problem is very easy to fix (4-0 polypropylene single
suture).
Systolic Anterior Motion (SAM)

SAM of the MV after repair occurs in 3% to 5% of patients (Fig. 16.9). Several factors have been
reported to predispose patients to develop SAM mainly being the presence of a very myxomatous
anterior leaflet (sometimes accentuated by avoiding resectional techniques and placing not large enough
rings), hyperdynamic left ventricles, and an anteriorly displaced line of coaptation (short distance
between the coaptation line and the septum). The problem often can be managed with slow heart rates,
avoiding inotropes, and optimizing preload. If there is trace or no MR and the gradient across the LVOT
is <50 mm Hg, we proceed with medical management unless the patient is young, asymptomatic, and
presents no significant comorbidities (no potential issues with a second run of cardiopulmonary bypass).
If there is mild or more significant MR or left ventricular outflow tract (LVOT) gradients 50 mm Hg, the
decision is always going back on cardiopulmonary bypass and re-explore the MV (exceptions are old
patients with significant comorbidities who are started then on maximized medical therapy and
re-explored later on).
Figure 16.11 Common surgical complications after mitral valve repair include leaflet perforation (A), incomplete
closure of the new suture lines (B) and systolic anterior motion (C) with secondary obstruction of the left ventricular
outflow tract.
If a nonresectional approach was used for the repair, resection of the posterior leaflet and sliding
plasty significantly reduces the leaflet height and therefore brings posteriorly the line of coaptation. If a
leaflet resection was performed, posterior leaflet displacement with neochordoplasty is the technique of
choice to further displace the line of coaptation. In addition, if a complete ring was used, it is important
to ensure proper sizing, particularly in myxomatous valves with large annulus (larger rings facilitate
anterior leaflet extension). Sometimes, a posterior band annuloplasty is indicated in order to not
decrease the anteroposterior diameter and allow complete mobilization of the anterior leaflet in systole.
RESULTS
According to contemporary data, there is a clear trend toward low mortality rates after MV repair
regardless of the etiology. Postoperative mortality rates have been demonstrated to be impacted by age
with an average risk of about 1% for patients younger than 65 years, 2% for those aged 65 to 80 years,
and 4% to 5% for those older than 80 years. In this context, several preoperative factors have been
reported to affect mid- and long-term survival in patients with MR like the presence of left ventricular
dysfunction (left ventricular ejection fraction <60%), functional class III or IV, effective regurgitant
orifice 40 mm2, a left ventricular end systolic dimension >40 mm, a left atrial index 60 mL/m2, a left
atrial dimension >55 mm, pulmonary hypertension or exercise pulmonary hypertension, and the
presence of atrial fibrillation. Patients with preoperative symptoms have increased postoperative
mortality despite symptom relief (especially those with a left ventricular ejection fraction <50%),
whereas in those with no or few symptoms, restoration of life expectancy can be potentially achieved.
Degenerative Mitral Valve Disease

According to the Society of Thoracic Surgeons, the average MV repair rate in most centers of the United
States is 70%. However, recent data have shown that all prolapsing valves are repairable in high-volume
centers with a low operative risk (<1% mortality). In terms of repair durability (assessed by follow-up
echocardiography and not by freedom from reoperation), moderate MR has been observed to recur at a
rate of 1% to 2% per year. Freedom from moderate or greater MR at 5, 10, and 20 years has been shown
to be about 95%, 89%, and 69%, respectively. In this regard, failure to use an annuloplasty device, the
use of chordal shortening techniques (currently abandoned), the presence of anterior leaflet pathology,
and, of course, the unavailability of pliable leaflet tissue have been found to be associated to higher
repair failure rates.
Rheumatic Mitral Valve Disease

Without doubt, MV repair is more difficult and less durable in rheumatic patients. The presence of
severe degrees of calcification, leaflet thickening or restriction (no availability of tissue in nonpliable
leaflets), and chordal retraction mostly due to chordal fusion and thickening require advanced repair
techniques and skills. Classic data from very experienced groups have demonstrated repair rates ranging
from 75% up to 95% with freedom from reoperation (as opposed to freedom from moderate MR) rates
of 82% ± 19% at 10 years for all comers (2% per year), and 73% at 10 (3% per year) years for patients
with type IIIA dysfunction. However, nowadays, the average repair rate in high-volume centers is
around 60% with durability being greatly compromised in patients with predominant stenotic lesions,
severe annular calcification and dilatation, opposing dysfunction (concomitant leaflet prolapse), and, of
course, in those patients with nonpliable leaflets (see Chapters 19 and 20).
Secondary Mitral Valve Disease

An increasing life expectancy of the general population, together with improved survival rates after
myocardial infarction, is expected to contribute to a higher incidence of secondary or “functional” MR.
The literature on secondary MR is so controversial that besides recent publications including a
randomized trial of repair versus replacement, the best approach for ischemic MR remains debatable,
especially in patients of advanced age. Although several studies have reported disappointing outcomes
with MV repair, most studies remain limited by critical flaws, thus preventing robust extrapolation.
Common to those studies suggesting ineffectiveness of MV repair is the absence of systematic use of a
restrictive annuloplasty using a complete rigid or semirigid ring, as varying proportions of patients in
these studies received incomplete flexible rings. The Leiden group, notable in their work on systematic
downsized annuloplasty, showed that 85% of patients had zero or mild regurgitation at 4 years, and the
5-year survival rate was 71%. They observed superior outcomes when the preoperative LVEDD was 65
mm or less. Though no good randomized clinical trial has been performed that demonstrates the
superiority of complete rigid ring or semirigid annuloplasty over flexible annuloplasty, there is
mounting evidence showing significantly improved rates of recurrent regurgitation with minimal
incidence of postoperative MS in patients receiving complete rings.
In patients with concomitant coronary artery disease, the general quorum is that the resolution of MR
does not predictably occur after coronary artery bypass surgery alone. Although CABG alone can
sometimes decrease MR severity (particularly in patients with mild MR and poor left ventricular
function), revascularization has an inconsistent and very weak impact on moderate or severe MR (40%
of patients have no improvement). In addition, MR has been identified as an independent risk factor for
late death in patients undergoing CABG.
Recommended References and Readings

Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N
Engl J Med. 2014;370:23–32.
Borger MA, Murphy PM, Alam A, et al. Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J
Thorac Cardiovasc Surg. 2007;133:1483–1492.
Braun J, van de Veire NR, Klautz RJ, et al. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure.
Ann Thorac Surg. 2008;85:430–436; discussion 436–437.
Carpentier A, Chauvaud S, Fabiani JN, et al. Reconstructive surgery of mitral valve incompetence: Ten-year appraisal. J Thorac
Cardiovasc Surg. 1980;79:338–348.
Castillo JG, Anyanwu AC, El-Eshmawi A, et al. All anterior and bileaflet mitral valve prolapses are repairable in the modern era
of reconstructive surgery. Eur J Cardiothorac Surg. 2013;45:139–145.
Castillo JG, Anyanwu AC, Fuster V, et al. A near 100% repair rate for mitral valve prolapse is achievable in a reference center:
Implications for future guidelines. J Thorac Cardiovasc Surg. 2012;144:308–312.
Chauvaud S, Fuzellier JF, Berrebi A, et al. Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve
insufficiency. Circulation. 2001;104:I12–I15.
David TE, Armstrong S, Ivanov J. Chordal replacement with polytetrafluoroethylene sutures for mitral valve repair: A 25-year
experience. J Thorac Cardiovasc Surg. 2013;145(6):1563–1569.
David TE, Armstrong S, McCrindle BW, et al. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative
disease. Circulation. 2013;127:1485–1492.
Flameng W, Meuris B, Herijgers P, et al. Durability of mitral valve repair in Barlow disease versus fibroelastic deficiency. J
Thorac Cardiovasc Surg. 2008;135:274–282.
Gammie JS, O’Brien SM, Griffith BP, et al. Influence of hospital procedural volume on care process and mortality for patients
undergoing elective surgery for mitral regurgitation. Circulation. 2007;115:881–887.
Gillinov AM, Blackstone EH, Alaulaqi A, et al. Outcomes after repair of the anterior mitral leaflet for degenerative disease. Ann
Thorac Surg. 2008;86:708–717; discussion 708–717.
Nishimura RA, Otto CM, Bonow RO. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2014; 63(22):2438–2488.
Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet. 2006;368
:1005–1011.
Russo A, Grigioni F, Avierinos JF, et al. Thromboembolic complications after surgical correction of mitral regurgitation
incidence, predictors, and clinical implications. J Am Coll Cardiol. 2008; 51:1203–1211.
Seeburger J, Borger MA, Doll N, et al. Comparison of outcomes of minimally invasive mitral valve surgery for posterior,
anterior and bileaflet prolapse. Eur J Cardiothorac Surg. 2009;36:532–538.
Suri RM, Schaff HV, Dearani JA, et al. Survival advantage and improved durability of mitral repair for leaflet prolapse subsets
in the current era. Ann Thorac Surg. 2006;82:819–826.
Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs. watchful waiting and
outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA. 2013;310(6):609–616.
Tribouilloy C, Grigioni F, Avierinos JF, et al. Survival implication of left ventricular end-systolic diameter in mitral
regurgitation due to flail leaflets a long-term follow-up multicenter study. J Am Coll Cardiol. 2009;54:1961–1968.
17
Mitral Valve Replacement—Mechanical Versus Tissue
Prosthesis
Julia C. Swanson and Irving L. Kron
INDICATIONS
The surgical approach to mitral valve disease must be tailored to the underlying pathophysiologic
etiology. The mitral valve can be repaired using a number of different strategies to address the
underlying pathophysiology. When repair cannot be done with a reasonable expectation of durability,
replacement is indicated either with a bioprosthetic or a mechanical valve.
Mitral stenosis is associated with rheumatic valve disease and, less frequently, malignant carcinoid
and systemic lupus. Rheumatic mitral valve disease manifests as a progressive fibrotic process that
affects the leaflets and subvalvular apparatus resulting in leaflet thickening, chordal shortening, and
leaflet fusion. The normal mitral valve area is 4 to 6 cm2. When this decreases to less than 2.5 cm2, a
pressure gradient develops across the valve resulting in elevated left atrial pressure. Left atrial pressure
overload translates into left atrial enlargement, elevated pulmonary venous pressure and pulmonary
edema, and in turn pulmonary hypertension as a direct result of pressure transmission and compensatory
vasoconstriction, and ultimately to cor pulmonale. Chronic mitral stenosis ultimately results in
decreased left ventricular function. Symptoms initially are brought on by exertion as flow across the
valve increases, but as the disease progresses, symptoms are present at rest.
Mild mitral stenosis: 1.5 to 2.5 cm2
Moderate stenosis: 1 to 1.4 cm2
Severe stenosis: <1 cm2 or mean transvalvular gradient is >10 mm Hg
Mitral stenosis is a progressive process and when not amenable to repair, replacement is indicated.
Mitral regurgitation is caused by two broad etiologic categories: Structural (degenerative) and
functional regurgitation. The Carpentier classification is a useful framework to evaluate the valve.
After careful review of the transesophageal echocardiogram, the mechanism of regurgitation is
determined. When ischemic (functional) mitral regurgitation is present the valve is normal and
ventricular distortion is the foremost contributor to valve dysfunction and regurgitation. If the left
ventricular cause is not reversible by revascularization, then a valve operation is indicated. Both valve
repair and replacement are viable options depending on the expectation of durability. If a structural
cause is identified, repair should be undertaken to correct the valve and replacement considered if this is
not possible. If a left internal mammary artery is not planned, there is a lateral wall motion abnormality
or a complex mitral regurgitation jet, and mitral valve repair is less likely to be successful.
CONTRAINDICATIONS
Mitral valve replacement is contraindicated in patients who are not surgical candidates based on
evaluation of comorbidities or specific ability to tolerate open heart surgery. These patients may be
candidates for interventional techniques (e.g., MitraClip) to palliate their mitral regurgitation or balloon
valvuloplasty to palliate their mitral stenosis.
Before coming to the operating room, optimal medical management, including occasional in-patient
optimization, is useful. Renal function should be maximized and nephrotoxic medications should be
discontinued.
Coronary angiography is indicated for patients at risk of coronary artery disease or with evidence of
ischemia, decreased systolic function, or with a strong family history of coronary artery disease.
Generally, men older than 40 years of age and postmenopausal women warrant coronary evaluation. In
patients deemed low risk, coronary artery computed tomography (CT) may be elected. The dominance
of the left circumflex artery must be noted as this is important for suture placement.
Right heart catheterization may be performed in select patients preoperatively to assess right heart
function and characterize pulmonary hypertension. Nitroprusside responsiveness can be assessed. In
patients with pulmonary hypertension that is responsive, inhaled nitric oxide may be useful during
weaning from cardiopulmonary bypass postoperatively.
The selection of the valve prosthesis is important. The guidelines set forth by the American Heart
Association and American College of Cardiology follow. In light of advancing transcatheter valve
technology and valve-in-valve replacement, tissue bioprostheses are favored in the seventh decade of
life and beyond and in younger patients with multiple comorbidities. Low-profile prostheses are
indicated in patients with small left ventricles to avoid the struts causing significant left ventricular
outflow tract obstruction.
AHA/ACC Guidelines 2014

Valve choice is a shared decision between cardiologist, cardiac surgeon, and patient
A bioprosthesis is chosen when anticoagulation is contraindicated
A mechanical prosthesis is reasonable for patients <60 years of age who can tolerate
anticoagulation
A bioprosthesis is reasonable for patients >70 years of age
The decision between bioprosthesis and mechanical prosthesis between the ages of 60 and 70
years of age is based on comorbidities, risks of anticoagulation, and concern for bioprosthesis
durability
A chest CT is useful for surgical planning and is imperative if it is a reoperation. This allows for
determination of ascending aortic and mitral annular calcification. Cross-sectional imaging also reveals
the relationship of the heart to the chest wall.
In patients with a history of tobacco abuse or positive respiratory review of systems, pulmonary
function testing is useful to guide intensive care management and expectations postoperatively.
Carotid artery duplex imaging should be performed in patients with atherosclerotic disease, as this
will guide pressure management during cardiopulmonary bypass and in the intensive care unit.
SURGERY
Positioning and Preoperative Considerations
The patient should be positioned on the operative table toward the foot to allow for the surgeon and, if
present, trainee to both stand on the patient’s right. Otherwise, routine cardiac surgical positioning is
appropriate.
Intraoperative transesophageal echocardiography is necessary for pre- and postoperative evaluation.
This is especially important if an intraoperative decision regarding valve repair versus replacement is
planned.
A pulmonary artery catheter is useful for postoperative care. It is helpful to note pulmonary artery
pressures preoperatively, especially if a right heart catheterization was not performed prior to the
operation.
Surgical Set-up and Cannulation

A standard sternotomy is used traditionally; however, minimally invasive and robotic approaches are
also acceptable. Regardless of the approach, the quality of the operation itself must be preserved, and if
threatened, conversion to the standard approach is recommended.
Arterial cannulation is performed on the distal ascending aorta. Venous cannulation is bicaval. With
vacuum drainage, the superior vena cava (SVC) cannula can be through the right atrium. External caval
tapes will allow right atriotomy and a tricuspid valve intervention if this is planned. The inferior vena
cava (IVC) cannula is placed through the right atrium at the inferior border. Care must be taken to
ensure this is not unintentionally placed in a hepatic vein.
Antegrade and retrograde cardioplegia are delivered through a combination of aortic root vent cannula
and retrograde cardioplegia cannula. Topical cooling may be used as an adjunct. Antegrade cardioplegia
can be redosed throughout the operation; however, when the Cosgrove retractor is in place, the aortic
valve is often incompetent, and thus the retractor may need to be released or retrograde cardioplegia
utilized. If the right ventricle is hypertrophied from years of elevated right-sided pressure, more frequent
antegrade cardioplegia is needed. Del Nido cardioplegia can be used in patients with normal coronary
artery perfusion undergoing minimally invasive procedures.
Concomitant Procedures
If coronary artery bypass grafting is planned, harvesting of the left internal mammary artery precedes
creation of the pericardial well and cannulation. The anastomoses are performed prior to valve
replacement. These are tested for patency and leaks when cardioplegia is redosed, as the heart cannot be
manipulated, especially to see left-sided grafts, after the valve has been placed. The left atrial appendage
can be oversewn through the left atriotomy at the time of valve replacement. If a tricuspid intervention,
for example, ring annuloplasty, is to be performed, this can be done after the mitral valve replacement
through a separate right atriotomy during rewarming or through a biatrial approach.
Mitral Valve Exposure Through Sondergaard’s Groove
Mitral Valve Exposure Through Sondergaard’s Groove
Exposing the mitral valve is the most important aspect of mitral valve surgery. The left atrium is
approached by developing Sondergaard’s groove. A left atriotomy is made and then this can be carried
onto the dome or inferiorly as needed to expose the valve. The Cosgrove retractor is used with a wider
basket elevating the anterior aspect and right atrium and a second narrower basket at 90 degrees
inferiorly to a side arm off the retractor. The SVC can be mobilized to allow for greater mobility of the
superior retractor (Fig. 17.1).
Transseptal Approach to the Mitral Valve

A biatrial transseptal approach can be used in the setting of a previous aortic valve replacement,
previous mitral operation, small left atrium, or deep chest making it difficult to access Sondergaard’s
groove and visualize the valve, but this is not the preferred approach.
A drop-in pump suction is placed in the pulmonary veins to scavenge returning pulmonary blood
flow. This is exchanged for a Ferguson left ventricular vent that is placed across the valve under direct
vision, as the left atrium is closed, to assist with deairing and prevent left ventricular distension.
Beginning to place the valve stitches with gentle traction will sequentially allow for better
visualization. The initial stitches may need to be replaced as visualization improves if they are found to
be placed suboptimally.
Figure 17.1 Mitral valve exposure through Sondergaard’s groove.
Figure 17.2 Transseptal approach to the mitral valve.
If visualization is still poor, the pericardial well can be loosened to drop the left ventricular apex and
ice-cold laparotomy sponges or the assistant can apply gentle pressure to the left ventricle to help orient
the annulus toward the surgeon (Fig. 17.2).
Chordal-Sparing Mitral Valve Replacement With Resection of the Belly of the

Anterior Mitral Leaflet
A chordal-sparing replacement has been shown to be the safest and provides better outcomes relative to
complete excision of the mitral subvalvular apparatus with less risk for atrioventricular rupture.
The mitral annulus has two components: The fibrous portion between the trigones supporting the
central anterior leaflet and the muscular portion that makes up the majority of the annulus supporting the
lateral aspects of the anterior leaflet and the entire posterior leaflet. Histologically, the muscular annulus
is the junction where the left atrium and ventricle meet and where the posterior leaflet hinges with the
left circumflex artery (anterolateral) and the coronary sinus (posterolateral) wrapping around the surface.
There is little strength to this tissue. The transvalvular pressure gradient across the mitral valve is the
highest of all the heart valves, as the mitral annulus and valve serve as a piston assisting with systolic
contraction of the left ventricle. Patients with heavily calcified mitral annuli that require debridement are
at greater risk for atrioventricular rupture, as more of the tissue between the left ventricle and atrium is
lost and the quality of the tissue wherein the sutures are placed is suboptimal. Maintaining continuity
between the papillary muscle heads and the mitral annulus, through a chordal-sparing technique,
provides an important structural connection between the left ventricle and atrium.
Chordal-sparing valve replacement has been shown in rigorous animal models and clinical studies to
improve left ventricular function. In a canine model, sham surgery versus anterior chordal-sparing mitral
valve replacement showed no difference in left ventricular wall strain; however, deleterious effects on
LV torsion and left ventricular myocardial strain were observed when anterior chordal attachments were
cut, leaving only the posterior attachments. This was born out clinically in a prospectively randomized
trial where patients undergoing mitral replacement underwent either total or partial chordal-sparing
operation. In those patients with complete retention of their subvalvular apparatus, early outcomes
showed reduced left ventricular chamber size and systolic afterload. At 1 year, left ventricular ejection
fraction continued to improve suggesting ongoing favorable remodeling. Given the complex role played
by the papillary muscles, chordae, mitral valve, and annulus it is not surprising that maintaining as much
of this architecture as possible is desirable.
Practically, some of the anterior mitral leaflets, especially if bulky, must be resected to avoid
impediment to mitral prosthesis opening (especially mechanical) and left ventricular outflow tract
obstruction. The central belly of the leaflet, which is unsupported by chordal attachments, can be
resected. Once this tissue is removed, the attachments from the papillary muscles can then be more
easily visualized with the assistance of a blunt nerve hook or cat’s paw retractor. At a minimum, both
papillary muscles must retain attachments to both the fibrous (anterior) and muscular (posterior)
portions of the annulus. In situations where continuity between the papillary muscles and the annulus
cannot be maintained, Gore-Tex neochords may be used.
The retained leaflet is then gathered in the valve sutures as they are placed. 2-0 Ethibond, or
equivalent braided permanent suture, is used. Pledgets can be used as needed either for all sutures,
alternating to prevent a solid ring of pledget, or selectively. In most cases sutures are placed in an
everting fashion; however, inversion is acceptable. When placing the valve sutures, care must be taken
to avoid catching the LV myocardium. Slotting the myocardium can result in an intramyocardial
hematoma, which can ultimately rupture.
Once the valve sutures are placed, they are brought up through the valve-sewing ring. It is useful to
premark the sewing ring to lay out the spacing of the sutures relative to the annular spacing. Usually,
four stitches are placed between the trigones with approximately 8-mm stitches and then 10-mm stitches
in the muscular portion. The valve is then brought down and seated in the annulus. A dental mirror is
used to ensure there are no loops below the valve. The sutures are then secured down either by tying or a
securing device. The retractor is then loosened slightly and the valve is tested with a combination of
infusion of antegrade cardioplegia, which will fill the root and likely the left ventricle, and forceful
instillation of cold saline through the valve.
The left atrium is then closed in a running fashion from each end. The atrial wall should be everted,
ensuring endocardium to endocardium, to avoid the prothrombotic myocardium from being exposed to
the left atrium. The Ferguson left ventricular vent is placed under direct vision through the valve. When
the inferior and superior suture lines meet at the vent, the needles are removed and a Rummel tourniquet
is used to temporarily close the left atrium. If a mechanical valve is placed, direct deairing can be
performed and no vent used. Ventricular pacing wires are placed, deairing is performed, and the
cross-clamp is then removed with both the root and left ventricular vents on suction. The heart is slowly
allowed to work. The valve is evaluated with transesophageal echocardiography. Particular attention
should be paid to perivalvular leaks, transvalvular gradient, and systolic anterior motion of any of the
retained anterior leaflet or other left ventricular outflow tract obstruction such as can be caused by the
valve struts.
Once satisfied with the valve’s function and deairing, the left ventricular vent is removed with some
volume in the heart and the atrial suture line tied down. The patient is then weaned off cardiopulmonary
bypass and decannulated. Care must be taken to avoid lifting the heart when looking for sites of
bleeding to avoid placing stress on the atrioventricular junction and risking disruption. Prior to chest
closure, care should be taken to ensure there is no bleeding from the atrial suture line and interatrial
dissection (Fig. 17.3).
Stitch Placement With Mitral Annular Calcification

Mitral annular calcification significantly complicates mitral valve operations. It most commonly
presents as a bar of calcium in the posteromedial annulus, but in severe cases can be circumferential and
can extend into the leaflets. A “less-is-more” approach to decalcification is recommended. Attempting to
remove all of the calcium will result in weakening the atrioventricular junction and risk catastrophic
disruption. Mayo scissors, ronguers or, in some cases, an ultrasound dissector can be used for
conservative removal of calcification. The goal of the dissection is to remove just enough calcium to
allow placement of the valve sutures and seat the valve without leaving irregularities that will result in
perivalvular leaks. The calcium histologically is just deep to the annulus and placing sutures deep to the
calcium risks injury to the circumflex artery. The suture is placed optimally such that it gathers the free
edge of the posterior leaflet, and then as the needle passes through the annulus it passes superficially and
on the atrial aspect of the annulus, or vice versa if everting the suture line (Fig. 17.4).
Figure 17.3 Chordal-sparing mitral valve replacement with resection of the belly of the anterior mitral leaflet. A:
Planned area of anterior leaflet resection. B: Area resected with chordal sparing. C: Placement of valve sutures with
pledgets on atrial side.
Decalcification results in calculus debris that must be collected actively. The assistant uses an
open-ended off-table suction to scavenge any debris that is generated so that it is not retained and is at
risk for embolization. An emerging approach is using an aortic cannula with a deployable net that can be
used when the cross-clamp is removed to help catch any debris that may have been retained and is then
ejected.
The postoperative course will be determined by the patient’s general state and physiology
preoperatively.
Pre-op left ventricular dysfunction in the setting of mitral regurgitation will appear to worsen as
the heart previously had a low afterload pop-off in the form of regurgitation and now must
pump against systemic vascular resistance. The combination of inotropic agents, optimal
preload and afterload reduction will need to be determined. A pulmonary artery (PA) catheter
with continuous or intermittent cardiac output measurements will be helpful.
Pre-op pulmonary hypertension will need to be managed. If preoperative testing indicated that
there is a reversible component, then inhaled NO can be used in the operating room to assist
with weaning off cardiopulmonary bypass and help optimize right ventricular function. In this
setting monitoring pulmonary artery pressure is useful. Acidosis should be avoided to prevent
vasoconstriction and minimize pulmonary vascular resistance.
Patients rarely require intra-aortic balloon pump to support their LV and minimize afterload
while preserving perfusion.
Once postoperative bleeding is stable, as early as postoperative day one, a heparin infusion is
initiated in patients with mechanical prostheses. Once stable with no additional anticipated
interventions, heparin infusion is transitioned to Coumadin with a goal INR of 2.5 to 3.5.
Figure 17.4 Stitch placement with mitral annular calcification.
Structures Surrounding the Mitral Annulus

Mitral valve replacement is subject to all of the complications of open heart surgery including death,
stroke, bleeding, renal failure, arrhythmias, infections, respiratory failure, and perioperative myocardial
infarction. Specific complications encountered with mitral valve replacement will be discussed.
Atrioventricular rupture is a complication that cannot be repaired epicardially. Cardiopulmonary
bypass must be reinstituted, the heart arrested, and the left atrium reopened. The valve is
removed completely and bovine pericardium is sewn as a patch across the annulus. Pledgeted
valve sutures are then used through the patch, not the annulus, to place a new valve. The
smallest valve the patient will tolerate should be selected to reduce stress on the annulus.
Left circumflex artery injury or obstruction with valve sutures will be reflected on the EKG
after removal of the cross-clamp. This will require reapplication of the cross-clamp and bypass
grafting.
Coronary sinus obstruction directly due to suture placement or valve oversizing can be
encountered. The retrograde cardioplegia cannula can be snared by a valve suture. If these are
encountered, the valve will need to be replaced.
The valve sutures in the fibrous annulus can catch the aortic leaflets and snare or injure them,
resulting in aortic insufficiency. This may necessitate replacing the mitral valve and, in some
cases, also addressing the aortic valve.
Heart block can be caused due to snaring of the artery to the atrioventricular node or direct
injury to the node. If persistent complete heart block is encountered after removing the
cross-clamp, temporary atrial pacing wires, in addition to ventricular pacing wires, should be
placed to allow for sequential pacing (Fig. 17.5).
Figure 17.5 Structures surrounding the mitral annulus.
RESULTS
Mitral valve replacement is associated with higher 30-day mortality than mitral valve repair in
many studies, although this is confounded by the fact that higher risk patients are more likely to
have a valve replacement as opposed to a valve repair. A recent randomized, prospective study
comparing patients with ischemic mitral valve disease showed no difference in mortality
(30-day mortality 1.6% in repair group and 4% in replacement group; p = 0.26; 1-year mortality
14.3% in repair group and 17.6% in replacement group, p = 0.47). Perioperative outcome is
more closely predicted by preoperative NYHA functional class rather than the surgical approach
to the mitral valve.
When patients were randomized to repair versus replacement for ischemic mitral valve disease
performed at high-volume centers, rigorous echocardiographic follow-up revealed that 30% of
patients with repair had moderate to severe regurgitation at 1 month and 46% at 24 months.
Basal aneurysm or dyskinesia was associated with recurrence; thus, replacement should be
strongly considered in this subgroup of patients.
Patients who receive a mitral valve repair that is not functioning well will have worsening of
their left ventricular function on follow-up.
Conversely, patients who undergo mitral valve repair without recurrent regurgitation realize a
greater reduction in left ventricular volume compared with mitral valve replacement (22.6%
versus 6.8%), again confirming that mitral valve repair when durable is preferred to
replacement.
In degenerative mitral valve disease, repair is preferred; however, it is still unclear in ischemic
mitral regurgitation due to the lack of reversible etiology.
Mitral valve stenosis and rheumatic mitral valve disease often necessitate replacement.
CONCLUSIONS
The mitral valve should be repaired when a durable result can be expected and if not, replacement is
preferred utilizing a chordal-sparing technique.

Acker MA, Parides MK, Perrault LP, et al. Mitral valve repair versus replacement for severe ischemic mitral regurgitation. N
Engl J Med. 2014;370:23–32.
Carpentier A, Adams DH, Filsoufi F. Chapter 6: Pathophysiology, preoperative valve analysis, and surgical indications. In:
Carpentier’s Reconstructive Valve Surgery. Maryland heights, MO: Missouri, Saunders Elsevier; 2010:43–53.
Crawford MH, Soucheck J, Oprian CA, et al. Determinants of survival and left ventricular performance after mitral valve
replacement. Circulation. 1990;81:1173–1181.
David TE. Chordal preservation in mitral valve replacement. Oper Tech Thorac Cardiovasc Surg. 1998;2:130–133.
David TE, Uden DE, Strauss HD. The importance of the mitral apparatus in left ventricular function after correction of mitral
regurgitation. Circulation. 1983;68:II76–II82.
Gillinov AM. Is ischemic mitral regurgitation an indication for surgical repair or replacement? Heart Fail Rev. 2006;11:231–239
.
Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thor
Cardiovasc Surg. 2001;122(6):1125–1141.
Komeda M, David TE, Rao V, et al. Late hemodynamic effects of the preserved papillary muscles during mitral valve
replacement. Circulation. 1994;90:II190–II194.
Lillehei CW, Levy MJ, Bonnabeau RC Jr. Mitral valve replacement with preservation of papillary muscles and chordae
tendineae. J Thor Cardiovasc Surg. 1964;47:532–543.
Moon MR, DeAnda A Jr, Daughters GT 2nd, et al. Effects of mitral valve replacement on regional left ventricular systolic
strain. Ann Thor Surg. 1999;68:894–902.
Nishimura RA, Otto CM, Sorajja P, et al. 2014 AHA/ACC guideline for management of patients with valvular heart disease: A
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Jour Am Col
Card. 2014; 63(22):e57–e185.
Yun KL, Sintek CF, Miller DC, et al. Randomized trial comparing partial versus complete chordal-sparing mitral valve
replacement: Effects on left ventricular volume and function. J Thor Cardiovasc Surg. 2002;123(4):707–714.
18
Minimally Invasive and Robotic Approaches to Mitral Valve
Surgery
W. Randolph Chitwood, Jr.
Introduction
Over the past 15 years, minimally invasive cardiac valve surgery has gained worldwide traction as a
standard of care for many patients and surgeons. Early reports suggested that alternative incisions and
minimally invasive approaches to replace and repair mitral valves were safe and efficacious. Large
series as well as several meta-analyses have confirmed that minimally invasive mitral valve surgery
(MIMVS) is appropriate for many patients. Also, robotic mitral valve repair series at dedicated referral
programs have shown outcomes similar to operations done either through a sternotomy or a minimally
invasive incision. The economic costs often have been challenged; however, high-volume Mayo and
Cleveland Clinic robotic mitral valve repair programs have shown parity with other incisional
approaches.
INDICATIONS AND CONTRAINDICATIONS

Patients should have the indications for mitral valve repair surgery as outlined in either the 2014
ACC/AHA (United States) or 2012 ESC/EACTS (European) Guidelines. The minithoracotomy incision,
with or without assisted vision or robotics, is indicated for both primary and reoperative mitral valve
surgery in patients with no or few comorbidities. Moreover, combined mitral and tricuspid valve
operations can be performed safely through a mini-thoracotomy. Nevertheless, some surgeons prefer to
use a hemisternotomy for MIMVS. Patients requiring either concomitant multivessel coronary
revascularization, an aortic valve replacement, or have a significantly dilated ascending aorta should
have a traditional sternotomy operation. General contraindications to the mini-thoracotomy approach
are listed in Table 18.1.
TABLE 18.1 Contraindications: Minimally Invasive Mitral Valve Surgery
Informed consent for a minimally invasive or robotic mitral repair should include the choice of a
traditional sternotomy operation as well as the possibility of conversion to a sternotomy for safety or to
achieve the operative goal. Either an excellent transthoracic echocardiographic (TTE) or
transesophageal echocardiographic (TEE) study should be done to determine operative necessity and to
guide the operative plan. In select patients computed tomographic (CT) images should be obtained to
determine the status of the peripheral vasculature and aorta as well as define any noncardiac thoracic
pathology. Patients at risk for coronary artery disease either should have coronary angiography or a CT
angiogram. After anesthesia preparations, a comprehensive 2D and 3D TEE study should be done in the
operating room to render the necessary planning information listed in Table 18.2.
At our center all minimally invasive, robotic, and traditional mitral repairs are considered, planned,
and directed from intraoperative TEE studies. To determine an appropriate annuloplasty ring or band
size, we have developed a TEE-based nomogram, which has been validated with actual leaflet
measurements and commercial ring sizers (Table 18.3). Because of accentuated leaflet curvilinearity
associated with extreme billowing in Barlow’s pathology, TEE can underestimate actual leaflet lengths.
Thus, in these patients direct linear measurements of each leaflet segment should be made after cardiac
arrest.
Long anterior leaflets (>30 mm A2), especially in the presence of a high (long) posterior leaflet (>20
mm), a narrow aortomitral plane angle (<120 degrees), or a thickened outflow interventricular septum,
may portend the development of postrepair systolic anterior motion of the anterior leaflet. This can
create a major hemodynamic problem when weaning from cardiopulmonary bypass (CPB). Preventative
structural repair measures should include: (1) Implantation of a large ring/band, (2) reduction of the
posterior leaflet height to 15 mm or less, and (3) achievement of an optimal leaflet coaptation surface (8
to 10 mm). In the arrested heart the saline ventricular pressure test, done after the final repair, is helpful
to determine the degree of leaflet coaptation level and symmetry.
TABLE 18.2 Transesophageal Echocardiographic Planning Data
TABLE 18.3 Echo-Based Annuloplasty Banda Sizing
Patient Positioning
In general preoperative patient positioning, anesthesia management, echocardiographic evaluation with
repair planning, the operative set-up, and perfusion techniques are the same for all of our robotic and
nonrobotic MIMVS. For both approaches the patient should be positioned with the right chest elevated
by 30 degrees on a commercial lift or a cloth roll. The right arm should be distracted laterally and
supported safely inferior to the posterior axillary line. The right axillary area should be exposed to insert
the transthoracic aortic cross-clamp. Standard skin preparation and draping should provide wide
exposure to the right chest, sternum, and both groins.
Anesthesia Management
In most operations our anesthesiologists prepare patients as shown in Figure 18.1. These preparations
include placing the following:
Either a double-lumen endotracheal tube or a right endobronchial blocker
A right radial arterial blood pressure monitoring catheter
Posterior-anteriorly placed Zoll defibrillator pads
A right internal jugular introducer for drug infusions and Swan–Ganz pulmonary artery catheter
insertion
A thin-walled (15-Fr or 17-Fr) Bio-Medicus (Medtronic, Inc., St. Paul, MN) right internal
jugular venous drainage cannula (double-puncture method)
A 3D transesophageal echocardiographic probe
Figure 18.1 Anesthesia preparation for videoscopic and robotic mitral valve surgery. TEE probe, transesophageal
echocardiography; ET tube, double lumen endotracheal tube; SVC, superior vena cava; SG, Swan–Ganz.
SURGERY
Working Incision
Today, most minimally invasive and robotic mitral valve operations are performed through a right-side
fourth intercostal mini-thoracotomy. The choices for visualization include a direct view through the
incision, 2D endoscopic, or 3D robotic. Recently 3-D non-robotic endoscopes have been developed. The
size of the working incision usually relates to both the visualization and operative method chosen by the
surgeon. For both direct vision and 2D endoscopic MIMVS, a 4- to 5-cm mini-thoracotomy is made in
the fourth intercostal space at the anterior axillary line. Smaller port-access incisions (2 to 3 cm) are
made in the same area for robotic operations. We place a flexible Alexis soft tissue wound protector
(Applied Medical, Inc., Rancho Santa Margarita, Calif.) in preference to using a rib-spreading retractor.
We have found that this minimizes postoperative pain and provides good working-incision exposure for
either direct vision, endoscopic, or robotic MIMVS.
Cardiopulmonary Perfusion
All perfusion cannulas are placed under echocardiographic guidance using the Seldinger guidewire
technique. The right femoral artery is cannulated with either a 17-Fr or 19-Fr Bio-Medicus cannula
through a 2-cm oblique groin incision. For inferior vena caval drainage, either a 22-Fr (single stage) or a
23-Fr/25-Fr (dual stage) RAP femoral venous cannula (Estech, San Ramon, CA) is passed into the right
atrium (Fig. 18.2). Vacuum-assisted venous drainage is used in all of these operations. Intrathoracic
carbon dioxide is insufflated throughout each operation to minimize the amount of intracardiac air
entrapment. To monitor adequate limb perfusion, during CPB, oxygen saturation levels are monitored
continuously in each leg using the Invos system (Somanetics Inc., Troy, MI). If a significant arterial
saturation decrease occurs in the cannulated leg during CPB, we place a distal superficial femoral artery
5-Fr catheter and connect it to the arterial perfusion circuit. To date, we have had no problems with
residual leg ischemia.
Figure 18.2 Arterial and venous perfusion cannulas. Through a 2-cm right groin incision, 4-0 polypropylene
purse-string sutures are placed along the anterior adventitial surface of the common femoral artery and vein. Using
the Seldinger guidewire technique and under echocardiographic guidance, either a 22-Fr (single stage) or a
23-Fr/25-Fr (dual stage) RAP femoral venous cannula (Estech, San Ramon, CA) (VC) is passed into the right atrium.
Similarly a 17-Fr or 19-Fr Bio-Medicus (Medtronic, Inc., St Paul, MN) arterial cannula (AC) is passed into the
common iliac artery.
Figure 18.3 Transthoracic aortic clamp.
Aortic Occlusion
For aortic occlusion, we use a transthoracic cross-clamp (Scanlan International, St. Paul, MN) as it has
been proven to be safe, reliable, economic, and simple to apply (Fig. 18.3). The posterior clamp tine
should be passed through the transverse sinus under either direct or videoscopic vision. The anterior tine
is positioned across the aorta until it reaches the main pulmonary artery (Fig. 18.4). Care must be taken
not to injure the right pulmonary artery, left atrial appendage, left main coronary artery, or aorta.
Some surgeons prefer to use endoaortic balloon occlusion. This technique has a steeper learning curve
than using the clamp. The balloon position must be precise and remain stable in the ascending aorta.
There is a potential for either innominate artery occlusion or intraventricular displacement. Therefore,
TEE monitoring of balloon position throughout the operation is mandatory. Also, balloon catheter
introduction through the femoral arterial cannula can limit perfusion flow. In this circumstance the
endoballoon catheter should be inserted through the other femoral artery. Despite these concerns, this
method can provide effective aortic occlusion, a route for delivering antegrade cardioplegia, and an air
vent without needing a separate aortic root cannula.
Myocardial Protection
As mentioned, we have always used the transthoracic aortic clamp method for both minimally invasive
and robot-assisted mitral valve surgery. A pledgeted diamond-shaped 4-0 PTFE purse-string suture is
placed in the ascending aorta and proximal to the fatty fold of Rindfleisch. For antegrade cardioplegia
administration, a long cardioplegia-vent catheter (Medtronic, Inc., St Paul, MN) is inserted through the
purse strung suture, secured and then passed either through a chest wall trocar or the working incision.
This catheter is inserted either under robotic, endoscopic, or direct vision (Fig. 18.5).
Figure 18.4 Transthoracic aortic clamp—positioned through the transverse sinus. TT-XCL, transthoracic
cross-clamp; Asc aorta, ascending aorta; MPA, main pulmonary artery; RPA, right pulmonary artery; CP,
cardioplegia/vent catheter; SVC, superior vena cava; Rt. atrium, right atrium. Note that the clamp is positioned
cephalad to the pericardial–SVC junction.
Figure 18.5 Cardioplegia/vent catheter insertion. The cardioplegia/vent catheter is placed in the ascending aorta
through a 4-0 pledgeted PTFE “purse-string” suture just proximal to the fatty aortic fold.
Recently, our group switched from blood cardioplegia to Custodiol–Bretschneider’s HTK solution
(Franz Köhler Chemie Bensheim GMBH, Germany) as it provides much longer myocardial protection
without requiring frequent reinfusions. For maximal myocardial protection, we combine this antegrade
cardioplegia with a systemic blood inflow temperature of 28°C. If blood cardioplegia is used, repeat
administrations should be delivered at 15- to 30-minute intervals. Multiple cardioplegia infusions,
requiring atrial retractor relaxation and repositioning, can entrain air into the aortic root.
For patients having had a previous sternotomy, we cool the patient systemically to 26°C and induce
ventricular fibrillation by rapid pacing with a custom Swan–Ganz catheter. In patients with mild aortic
insufficiency, additional intracardiac suction can be combined with dropping perfusion flow briefly for
difficult suture placement.
Cardiac Exposure
After going on CPB, the pericardium is opened longitudinally approximately 3 cm anterior to the
phrenic nerve, using either long-shafted endoscopic or robotic instruments. Two to three well-spaced
pericardial retraction sutures are placed along the inferior (dorsal) pericardial edge ( Fig. 18.6). By
passing the needle through the end loop, only one suture is withdrawn through the chest wall using a
crochet hook instrument. Care should be taken not to stretch or injure the phrenic nerve. The anterior
(ventral) pericardial edge is then suspended with two sutures that are brought through the working
incision.
2D Endoscopic MIMVS
After completing the above maneuvers and establishing cardiac arrest, we pass a 5-mm high-definition
2D endoscope (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) through a third intercostal
space trocar and attach it to a hand-positioned holder (Fig. 18.7). Alternatively, a larger incision can be
made for direct viewing of the mitral valve operative field. The left atriotomy is made just medial to the
right superior and inferior pulmonary veins.
A transthoracic atrial retractor arm (Atrial Lift System, ESTECH, San Ramon, CA) is passed through
the chest wall, just medial to the sternum in the fourth interspace, and coupled to the appropriate size
blade. This arm is then attached to a table-mounted support that facilitates lifting of the interatrial
septum. After adjusting the retractor for optimal exposure, the mitral valve repair or replacement is done
using long-shafted instruments. For annuloplasty band/ring and valve prosthesis suture organization, we
use Gabbay–Frater suture guides (Teleflex Medical, Research Triangle, NC), placed externally around
the working incision. Long-shafted instruments are used for endoscopic and direct vision MIMVS and
provide good rotational ergonomics, but remain without the advantage of full articulation.
Figure 18.6 Suture “loops” for pericardial retraction and left atrial closure. Tiny PTFE loops are created from or 2-0
Ti-cron sutures. A: After passing the needle through the pericardial edge, it is threaded through the loop. B:
Thereafter, the suture is withdrawn through the chest wall using a crochet hook instrument. C: Two or three sutures
are used to distract the pericardial edge (pericardium) laterally, exposing the right superior pulmonary vein (RSPV),
aorta (Ao), right atrium (RA), and superior vena cava (SVC). D: For left atrial closure, we use a 3-0 Gore-Tex suture
loop on a PH-21 needle (W. L. Gore & Associates, Inc., Flagstaff, Arizona).
3D Robot-assisted MIMVS
Robot-assisted cardiac surgery should be called surgical telemanipulation as the term “robot” means
autonomous. The da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) merely provides
access with superb visualization and enhanced ergonomics, which allows surgeons to perform complex
operations through small port-like incisions. When using long hand-held instruments, the working
incision becomes a fulcrum that can limit accurate suture placement and tissue manipulation. The
accuracy achieved with da Vinci instruments relates to wide freedom of motion at the operative plane.
The surgeon always has control of instruments by telemanipulation, as if they were activated directly by
his/her hands.
Figure 18.7 Videoscopic set-up. For nonrobotic mitral surgery a 5-mm Storz videoscopic camera (2D vision) is
placed via a trocar through the 3rd intercostal space and attached to a fixed holder. The transthoracic cross clamp
(TT-XCL) is shown placed through the fourth intercostal space. Non-rib–spreading soft tissue retractor is through the
4th intercostal space working incision. An intrathoracic carbon dioxide insufflation catheter and left atrial sump are
shown.
The Robotic Cardiac Team

An organized team is paramount for a successful robotic cardiac surgical program. This includes
anesthesiologists, surgeons, tableside assistants, scrub personnel, circulating nurses, and perfusionists.
Team and procedure training at an experienced robotic valve center has been very important when
launching successful programs. Surgeons should be accomplished at mitral and tricuspid repairs before
beginning this new trek. Before applying robotic methods, the team should master needed peripheral
perfusion techniques as well as operating through minimally invasive incisions. After team comfort has
been achieved, progression to robotic mitral valve operations is reasonable and gratifying. It is important
to remember that robotic instruments are only access tools and not the operation.
The da Vinci Surgical System

The da Vinci surgical system consists of telemanipulators with microinstrument (end effectors) that are
controlled remotely from the surgeon’s operating console. Currently, this device is the only robotic
system approved and available to perform intracardiac surgical procedures. Currently, we are using the
da Vinci SI HD (high-definition) dual console surgical system, which first was commercialized in 2009
(Fig. 18.8). A new da Vinci XI System (2014) has just been approved by FDA, but has not been used
widely for mitral valve surgery (Fig. 18.9). The new da Vinci XI has a laser targeting system that
facilitates docking and instrument engagement. Both systems are composed of an operating console, an
electronic vision cart, and a surgical instrument cart.
For mitral valve surgery the instrument cart should be positioned along the patient’s left side with the
instrument activators arching over to the right chest (Fig. 18.10). Individual instrument trocars are
inserted through specific intercostal spaces. After the two instrument arms, the 3D camera, and dynamic
retractor have been inserted, two hand-driven sensors transmit instructions from the surgeon to
instrument end effectors. A clutching mechanism enables frequent hand position readjustments to
maintain an optimal ergonomic attitude with respect to the visual field.
Both the da Vinci SI and XI have dual-console capability which enables surgeon collaboration during
complex cases and facilitates training. The robotic EndoWrist instruments have seven degrees of
ergonomic freedom, and allow tremor-free dexterity with both dominant and nondominant hands. Thus,
the wrist-like microinstrument articulations improve dexterity in tight spaces.
Figure 18.8 da Vinci SI surgeon operating console. A: Dual operating console. B: Surgeon’s “flight deck.” Instrument
activators (A). LHS, left hand sensor; RHS, right hand sensor; ICP, instrument control panel. The ICP effects
alterations in video magnification, transfers of instrument operation to the second console surgeon, and insertion of
echo images into the operative field via Tile-Pro software.
Figure 18.9 da Vinci XI surgical system (2014). A: da Vinci XI surgeon operating console. B: Patient side instrument
cart.
Trocar Placement and Instruments

Correct instrument arm trocar-port placement is paramount to achieve optimal robot-assisted
ergonomics. Thus, we mark a “topographic surface map” prior to patient positioning and skin
preparation (Fig. 18.11). Some surgeons guide trocar placement from a recent CT scan. However, most
often, these can be inserted through specific intercostal spaces and guided by camera visualization. The
goal is to provide the best converging trajectory at the mitral valve annular plane. During trocar
insertion, the most important anatomic landmark has been the right superior pulmonary vein.
Figure 18.10 da Vinci instrument cart positioning for mitral valve surgery.
Figure 18.11 Topographic surface map—robot-assisted mitral surgery. Topographic marks are placed along the
right hemithorax just before 30 degrees elevation and skin preparation. MSL, midsternal line; MCL, midclavicular
line; AAL, anterior axillary line; PAL, posterior axillary line; LA, left instrument arm; RA, right instrument arm; C,
camera port; WI, working incision; LAR, left atrial retractor.
Figures 18.12 and 18.13 show ideal trocar entry sites as well as instrument insertions. Most often, left
and right instrument trocars are inserted in the third and fifth intercostal spaces, respectively. The left
trocar is positioned near the anterior axillary line and the right one at the midaxillary line. The 3D
endoscopic camera is inserted either through the fourth interspace working incision or a trocar placed
anterior to it in the same interspace. The dynamic retractor is inserted through a midclavicular line trocar
placed in the fifth interspace. The most common EndoWrist instruments used for robot-assisted mitral
valve surgery are shown in Figure 18.14. The dynamic left atrial retractor provides ideal mitral valve
exposure and is very easy to reposition.
Robot-assisted Mitral Valve Repairs

After the da Vinci system instruments are “trocar-docked” at the operating table, CPB is begun, and the
pericardium is opened and distracted laterally as described previously. We place the aortic purse-string
suture and cardioplegia cannula using robotic instruments. We perform right-sided cryo-MAZE lesions
before going on CPB. After the left atriotomy is made, the dynamic retractor is manipulated to expose
lesion sites specific for a left atrial cryo-MAZE.
To establish a structurally sound repair, we generally follow the operative philosophy and techniques
prescribed by Carpentier. However, modifications and simplifications of these methods remain the
mainstay of our repair strategy. Table 18.4 shows our “Technique Toolbox” that we use for both robotic
and videoscopic mitral valve repairs.
Figure 18.12 Robotic instrument set-up. A: Instrument arm trocars are inserted around the working port. B: The
instrument cart has been docked at the patient just before beginning cardiopulmonary bypass and the mitral
operation. LA, left instrument arm (3rd intercostal space [ICS]); RA, right instrument arm (5th ICS); LAR, left atrial
retractor (4th ICS); C, 3D HD camera (4th ICS); S, intra-atrial suction catheter; CO2, carbon dioxide insufflation port.
The working incision is shown in the 4th ICS. The aortic cross-clamp (3rd ICS) has not been placed.
Figure 18.13 Robot instrument cart positioned. A: The instrument cart is shown docked at the operating table to the
robot instruments. B: The patient-side assistant is shown in the operative environment during a mitral valve repair.
Posterior Leaflet Repairs

Our practice has been to maintain the integrity of the leaflet-annular junction, when possible. For all
mitral leaflet repairs, we have used polyamide monofilament 4-0 Cardionyl sutures (Peters Surgical,
Paris, France) to close resection defects with interrupted figure-of-eight sutures. For thick leaflet tissue,
these can be closed either with a two-layer running monofilament or PTFE suture. For isolated scallop
prolapse or chordal ruptures, we prefer triangular/trapezoidal resections that do not extend to the annulus
(Fig. 18.15). In Barlow’s disease with multiple elevated posterior leaflet scallops, several triangular
resections can produce an effective repair. Also, PTFE neochord implantation (Gore-Tex—Gore, Inc.
Phoenix, AZ) has been very helpful to reduce prolapsing posterior leaflet segments. For very large
isolated P2 scallops, we use the “haircut” repair technique, amputating the leaflet tip to the desired
length. Good natural regional chords are then reimplanted along the coapting edge for support.
Figure 18.14 Robotic mitral operations: most frequently used instruments. A: Resano tissue forceps. B: Suture-cut
needle holder. C: Curved scissors. D: Dynamic left atrial retractor.
Figure 18.15 Posterior leaflet reduction: triangular leaflet resection. For isolated posterior leaflet prolapse, often a
small triangular resection is effective. This simple technique brings intact edge chords medially, reducing the level of
prolapse effectively. For larger leaflets a trapezoidal leaflet resection to the annulus can be done. We prefer to close
the remaining defect with interrupted monofilament sutures. A: Shows an isolated chord rupture with P2 prolapse. B:
A small triangular resection is done. C: Either interrupted or a continuous suture closes the defect. D: The completed
repair is shown.
Also, we have used various folding plasty and leaflet imbrication techniques when repairing the
posterior leaflet (Fig. 18.16). All of these methods have been used when single as well as multiple long
scallops require reduction to achieve even leaflet coaptation. For folding plasties, we pass a 4-0 PTFE
suture from the annulus, through the leaflet tip, and back through the annulus. After the annuloplasty
band/ring insertion, we adjust individual scallop lengths by folding to create a symmetric coaptation
line. In severe Barlow’s degeneration we have substituted large resections, requiring a sliding plasty,
with folding plasties, triangular resections, and neochord reductions. Nevertheless, there are times when
we still use the sliding technique for a complex posterior leaflet repair (Fig. 18.17).
TABLE 18.4 “Technique Toolbox” Used for Robotic and Endoscopic Mitral Valve Repairs
Figure 18.16 Posterior leaflet reduction: folding plasty. For prolapsing posterior leaflet segments (“scallops”), folding
plasties also have been effective. A: This illustration shows a 4-0 PTFE suture passing through the prolapsing leaflet
edge and through the annulus. B: The other suture end subtends the width of the leaflet edge, passing through it,
and back to the annulus. C, D: After the annuloplasty band has been implanted, individual segments are folded to
form an even line of coaptation. Thereafter, sutures are tied.
Figure 18.17 Posterior leaflet reduction: sliding plasty. A: For very long (high) posterior leaflets (especially Barlow’s
disease) a large resection with a sliding plasty may be indicated. B: In this illustration a large P2 has been resected
and transferred to the anterior leaflet to correct the A2 prolapse. C: Thereafter, radial leaflet incisions are made
leaving a 1- to 2-mm tissue strip along the annulus. Mural chords must be divided to mobilize the residual leaflet
medially. D: Thereafter, compression sutures may be used to reduce the muscular annular distance when residual
leaflets are (“slid”) medially. The remaining posterior segments are advanced along the annulus (4-0 PTFE
continuous suture) and reapproximated (5-0 monofilament interrupted sutures). E: Thereafter, an annuloplasty band
is implanted to support the repair.
Figure 18.18 Anterior leaflet reduction: chordal strip “translocation.” A: When the entirety of the anterior leaflet is
prolapsing, a strip of chord-bearing leaflet edge can be translocated and advanced along the remaining A1-A2-A3
segments. B, C: The illustration shows that the segment is being transferred along the anterior surface and
reattached using 4-0 monofilament sutures. In this way anterior chords are “de facto” shortened, reducing the
prolapse symmetrically. D: Thereafter, an annuloplasty band is implanted.
Anterior Leaflet Repairs

For all anterior leaflet repairs, we have abandoned Carpentier’s chordal shortening method that tucked
an elongated chord into a papillary trench. Our focus now is correction at the leaflet edge. Currently, the
most common methods used include small triangular leaflet edge resections, chordal transfers, and
prosthetic PTFE chord replacements. The da Vinci 3D high-magnification camera and microscissors
also allow us to detach anterior leaflet secondary chords and transfer them directly to a flail or prolapsed
edge.
When the entirety of A1 through A3 is prolapsed, a wide A1, A2, and A3 chord-bearing leaflet strip
can be translocated (shifted) along the anterior leaflet and toward the aortomitral hinge ( Fig. 18.18).
This will provide a symmetric corrective reduction of the anterior leaflet and restore natural coaptation.
For single-site anterior prolapse, any resected chord-bearing posterior leaflet part can be transposed
anteriorly. Residual commissural prolapse can be corrected either by the edge-to-edge method or other
methods described below. Small isolated areas of anterior leaflet prolapse or chordal rupture also can be
treated effectively by a limited triangular resection.
Segmental and global anterior or posterior leaflet prolapse can be reduced effectively by inserting
either 5-0 or 4-0 PTFE neochords. Here, we prefer the Frater–David technique with one 5-0 or 4-0 PTFE
suture passed through an adjacent papillary muscle head and a second suture passed in the opposite
direction, creating a tendon repair type of “sling” (Fig. 18.19). Thereafter, both sutures are brought
side-by-side through the ventricular aspect of the prolapsing leaflet. Then, they are looped over the edge
and passed back through the leaflet. This locks the loop and helps when adjusting neochord final lengths
using the saline test. Proper neochord lengths can be estimated from measurements of adjacent normal
chords. To achieve symmetric leaflet coaptation, we implant the annuloplasty band/ring before final
neochord adjustment. Other institutions have used the “Leipzig Loop” PTFE technique with great
success.
Figure 18.19 Anterior or posterior leaflet reduction: PTFE neochord. Insertion. Neochord implantation is a very
effective technique to reduce both anterior and posterior leaflet prolapse. A: Either a 5-0 (posterior leaflet) or 4-0
(anterior leaflet) PTFE suture is passed at an angle through the head of an adjacent papillary muscle. The other end
is passed back through the papillary head in the opposite direction affecting a “tendon-like repair” suture sling. B, C
and D: Then, each end of the suture is passed through the prolapsing leaflet. Thereafter, each suture is looped
around the leaflet edge and passed back through the leaflet body, creating a locking arrangement. After an
annuloplasty band has been implanted each set of neochords are adjusted using adjacent normal chord lengths and
the saline pressure test.
Commissure Repairs
There are several strategies for severe either P1-A1 or P3-A3 commissural prolapse. These include suture
commissure closure, papillary muscle shortening, and neochord implantation. For limited prolapse the
commissure can be closed. Severe bileaflet (A3 and P3) posterior commissure prolapse can result from
either thin elongated or separate mobile papillary muscle heads, where multiple chords support both
leaflets. Shortening either a single or multiple papillary muscle heads can reduce both prolapsing
commissure leaflets simultaneously. Figure 18.20 shows a PTFE suture first introduced through the
papillary muscle fibrous head and then passed through the base. Upon tying the suture, the papillary
muscle becomes shortened, reducing multiple A3 and P3 chords simultaneously and rendering better
commissural leaflet coaptation. Anterior commissure prolapse from this anatomy is less common as
most papillary muscles have a single head with all chords supporting effectively both commissural
leaflets.
Annuloplasty Techniques
Annular dilatation is present in most patients with degenerative mitral valve disease. We perform an
adjunctive annuloplasty in all repairs to restore the native geometry, reduce the annular size, prevent
further dilatation, and reinforce the repair. Reducing the anterior–posterior annular diameter increases
the leaflet coaptation surface. As mentioned before, annuloplasty band sizes are selected from our
intraoperative echocardiographic nomogram shown in Table 18.3. For consistency and ease of
implantation, we use the Cosgrove–Edwards Annuloplasty Band System (Edwards Lifesciences, Irvine
Calif.) in most robotic and minimally invasive mitral repairs. Generally, a “Trigone-to-trigone” posterior
band provides optimal coaptation while preserving a “saddle-shaped” systolic configuration.
Figure 18.20 Commissure reduction: papillary muscle shortening— reducing multiple chords. A: This illustration
shows a large posterior commissure prolapse involving both A3 and P3 segments. Here chords, attached to both
prolapsing segments, emanate from a single and often elongated or mobile papillary muscle head. Both leaflet
segments can be reduced along with all chordal lengths simultaneously by shortening the culprit papillary muscle. B:
Generally, this is done by making a small triangular resection in the midpapillary muscle and C: then folding the tip
toward the defect with interrupted sutures. Attaching a mobile papillary muscle to either the adjacent ventricular wall
or another “fixed” papillary muscle can stabilize it and prevent prolapse during systole.
We first place sutures at the right fibrous trigone, and continue in a clockwise direction. Previously,
we instrument tied interrupted either 2-0 Ti-Cron (Covidien, Mansfield, MA) or 2-0 Cardioflon (Peters
Surgical, Paris, France) sutures to secure annuloplasty bands. The Cleveland Clinic group has shown
great success in using a continuous annuloplasty band suturing technique. For over a year, we have used
the automated Cor-Knot (LSI Solutions, Victor, NY) device to suture secure annuloplasty bands (Fig.
18.21). After passing both 2-0 Ti-Cron sutures through the band, they are brought through a wire loop.
The suture-bearing loop is withdrawn through both the applier and the titanium shim. After applying
countertraction at the annuloplasty band, either through the working incision or inside the chest, the
device secures and cuts the suture. This method has reduced our cross-clamp times dramatically.
Robot-assisted Mitral Valve Replacements

Although tissue excision and suturing methods are similar in robotic and all of our MIMVS operations,
there are differences in the operative conduct. In some rheumatic valves, leaflet and chordal excision can
be difficult using the robotic technique. Current articulated instruments do not have the necessary force
to cut very thick or calcified tissue. In this circumstance we make a larger 5- to 6-cm working incision
and excise the thick leaflet and chordal tissue using long manual instruments. We then place all
subvalvular valve pledgeted sutures and neochords using da Vinci system. Chord-sparing replacements
are done either by excising the anterior leaflet midportion and leaving natural chords intact or by
removing them to increase the prosthesis valve size and replacing them with PTFE neochords. We
attempt to preserve all native posterior leaflet chords by passing sutures through the leaflet edge and
back through the annulus. In patients with a severely calcified rheumatic valve or annulus, we may defer
to either the 2D endoscopic or direct vision method for a replacement.
Figure 18.21 Cor-Knot suture fixation: annuloplasty band. A: A braided 2-0 suture is passed first through the
annuloplasty band (AB) and tissue. Thereafter, suture ends are withdrawn through the steel wire loop (loop), which
passes through the Cor-Knot applier (CK applier). (Cor-Knot LSI Solutions, Victor, NY). B: The loop with the
entrapped suture is withdrawn through the device, loaded with a tiny titanium shim, and out through a side hole.
Then, suture tails are pulled tight while applying countertraction to the band. Thereafter, the device is fired, crimping
the shim on to the suture and cutting it. C: Completed annuloplasty. RNH, right needle holder.
Gabbay–Frater guides are placed around the working incision to organize sutures securely as they are
placed. Valve sizers are then passed through the working incision, and the appropriate prosthetic valve is
selected. Thereafter, sutures are passed extracorporeally through the prosthetic valve sewing ring before
lowering it valve into the native annulus. After confirming valve seating, sutures are secured using the
Cor-Knot technique (Fig. 18.22). A ventricular vent is placed before closing the left atrium and
removing residual air. Currently, for all endoscopic and robotic mitral valve operations, we use 4-0
PTFE sutures with pretied end loops to close the left atrium. This technique provides a secure closure
and saves operative time (Fig. 18.6).
Figure 18.22 Robot-assisted mitral valve replacement. A: After robotic chord-sparing (or PTFE replacement)
anterior leaflet excision, subannular pledgeted 2-0 braided sutures are placed circumferentially and exteriorized.
These are arranged around the working incision in suture guides. After passing sutures through the valve sewing
cuff, the prosthesis is lowered into place. B: Using the Cor-Knot suture fixation technique, the table-side assistant
secures the prosthetic valve in place. This method can be used with either mechanical or biologic prosthesis.
Robot-assisted Mitral Valve Reoperations

In general, these operations have been done in patients having had prior coronary artery bypass surgery
in the presence of an intact internal thoracic artery. Some of these patients have classic Carpentier type
3B ischemic insufficiency and others have a dilated annulus (type 1). We have done a minority of
reoperations in patients with a failing mitral bioprosthesis.
As mentioned before, we systemically cool these patients to 26°C and induce ventricular fibrillation
by rapid pacing. In the presence of a normal aortic valve, intra-atrial pulmonary vein blood can be
managed with a single sump sucker. In patients having type 3B ischemic insufficiency, we use a
complete Edwards ETlogix IMR annuloplasty ring to re-establish leaflet coaptation (Edwards
Lifesciences, Inc., Irvine, Calif.). With a symmetrically dilated posterior annulus, we either implant an
Cosgrove-Edwards Annuloplasty Band or a complete Physio II Annuloplasty Ring. In patients with
severely tethered chords from a dilated ventricle, we recommend valve replacement.
When replacing a failed mitral bioprosthesis, it is best to excise the old valve prosthesis using direct
vision and long instruments. As mentioned, robotic instruments do not have the strength to cut very
fibrotic or calcified tissue. Using either direct vision, endoscopic, or da Vinci visualization, new
prosthetic valve sutures are placed, beginning along the anterior annulus. It very important to keep
sutures well organized, as they exit from the working incision, in Gabbay-Frater suture guides. The
advantage of the robotic method in these reoperations resides in the ability to use minimal atrial
retraction, which maintains aortic valve competency. This avoids creating aortic insufficiency when
placing left fibrous trigone, anterior annular, and commissural sutures. Perfusion flow can be decreased
temporarily to facilitate placement of these sutures.
The postoperative management of our minimally invasive mitral valve patients is similar to those having
a sternotomy-based operation. Generally, the chest tubes and silastic drains are removed on the second
postoperative day. Pacing wires are discontinued on the third postoperative day. In the absence of prior
or postoperative atrial fibrillation, we have not anticoagulated most mitral repair patients
postoperatively. We do recommend that they remain on aspirin therapy for life. For patients having had
a cryomaze ablation for atrial fibrillation with an atrial appendage closure, we reinitiate their
anticoagulation regimen on the third postoperative day. If patients remain in a normal sinus rhythm 6
weeks after surgery, we suggest that their cardiologist discontinue anticoagulation therapy. Most often,
those having a repair only are discharged on the fourth postoperative day. Patients having had a
cryomaze take 1 to 2 days longer before discharge. Most discharge medications usually include a
beta-blocker, aspirin, and either antiarrhythmic or anticoagulation agents, if needed. Amiodarone has
been our first choice for treating cryomaze patients who develop postoperative atrial fibrillation. We
cardiovert these patients rarely in the hospital, especially if they are rate controlled and stable
hemodynamically. We consider left atrial appendage closure very important to decrease the risk of
future neurologic events.
COMPLICATIONS AND SOLUTIONS

Tables 18.5 to 18.7 list some of the major pitfalls and preventative measures associated with either
direct vision, videoscopic, and robot-assisted MIMVS. Traditional mitral valve repair and replacement
complications are also possible with MIMVS. These include inferior valve repairs, which have been
shown to be dependent on individual surgeon experience and institutional clinical volume.
Complications specific to MIMVS are often related to peripheral CPB cannulation/perfusion, aortic
occlusion, and myocardial protection techniques. Some reports have shown the right lateral pericardial
entry approach to be associated with increased phrenic nerve injuries (1%). In several clinical series the
use of cold ventricular fibrillation has been implicated as a risk factor for adverse neurologic events;
however, our series has shown this not to be a complicating factor. In a large meta-analysis Sunderman
et al. showed similar results with minimally invasive mitral repair to the traditional sternotomy
approach. The careful analysis of Modi et al. suggested that in patients carefully screened for peripheral
vascular disease, the stroke risk with retrograde perfusion is no higher than with antegrade inflow.
TABLE 18.5 Perfusion and Aortic Clamping: Pitfalls and Prevention
Clinical Outcomes
In our early series, we performed over 600 minimally invasive nonrobotic videoscopic mitral valve
repairs and replacements with an overall operative mortality of 0.2%. Our last published report detailed
540 consecutive robotic mitral repair patients with 86 undergoing a concomitant cryo-MAZE to ablate
atrial fibrillation. The 30-day mortality was 0.2% for an isolated mitral repair and 3.6% for a
replacement. Between May 2000 and July 2014, the author performed 906 robotic mitral valve repairs
with 231 of repairs having a concomitant cryomaze procedure. Of these patients 98% had degenerative
pathology with a 100% repair rate for these. Degenerative mitral valve pathology was protean and
patients required both simple and complex mitral reconstructions. Our repair “toolbox” included, among
others, leaflet sliding plasties, leaflet folding plasties, neochord replacements, chordal transfers,
papillary muscle shortening, and cleft closures as well as band annuloplasties (Table 18.4). Immediately
after the repair, 98% of patients had either no or trace mitral regurgitation by TEE. For the entire
robot-assisted mitral repair series, the overall 30-day mortality was 1.3%, but for patients having a repair
alone was 0.25%. Follow-up of the 906 patients revealed a 2.9% overall failure rate requiring a
reoperation. Others have reported similar mortality, morbidity, and repair quality in addition to
decreased perfusion and cross-clamp times. Thus, today large-volume reference centers have shown that
robotic mitral valve surgery is safe, efficacious, and can provide excellent repair results as well as other
patient benefits.
TABLE 18.6 Pulmonary: Pitfalls and Prevention
TABLE 18.7 Ventricular Dysfunction: Pitfalls and Prevention

Carpentier A, Adams DH, Filsoufi F. Carpentier’s reconstructive valve surgery. Maryland Heights, MO: Saunders Elsevier;
2010: 1–353.
Chitwood WR Jr. Atlas of robotic cardiac surgery. London: Springer, 2014:1–326.
Chu MW, Gersch KA, Rodriguez E, et al. Robotic “haircut” mitral repair: Posterior leaflet-plasty. Ann Thorac Surg. 2008;85
:1460–1462.
Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing
costs of cardiac valve replacement and repair. Ann Surg. 1997;226:421–426; discussion 427–428.
Cosgrove DM 3rd, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg. 1998;65:1535–1538.
Falk V, Cheng DC, Martin J, et al. Minimally invasive versus open mitral valve surgery: A consensus statement of the
international society of minimally invasive coronary surgery (ISMICS) 2010. Innovations (Phila.) 2011;6:66–76.
Falk V, Seeburger J, Czescia M, et al. How does the use of polytetrafluoroethylene neochordae for posterior mitral valve
prolapse (loop technique) compare with leaflet resection? A prospective randomized trial. J Thorac Cardiovasc Surg. 2008
;136(5):1205–1206.
Galloway AC, Schwartz CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: Long-term outcomes. Ann
Thorac Surg. 2009;88:1180–1184.
Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive
mitral valve operations: trends and outcomes from the society of thoracic surgeons adult cardiac surgery database. Ann Thorac
Surg. 2010;90:1401–1408.
Iribarne A, Easterwood R, Russo MJ, et al. Comparative effectiveness of minimally invasive versus traditional sternotomy mitral
valve surgery in elderly patients. J Thorac Cardiovasc Surg. 2012; 143:S86–S90.
Mihalijevic T, Jarrett CM, Gillinov AM, et al. A novel running annuloplasty suture technique for robotically assisted mitral
valve repair. J Thorac Cardiovasc Surg. 2010;139:1343–1344.
Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches:
Potential realized. J Thorac Cardiovasc Surg. 2011;141:72–80.
Mihaljevic T, Koprivanac M, Kelava M, et al. Value of robotically assisted surgery for mitral valve disease. JAMA Surg. 2014;
149:679–686.
Modi P, Chitwood WR Jr. Retrograde femoral arterial perfusion and stroke risk during minimally invasive mitral valve surgery:
is there cause for concern? Ann Cardiothorac Surg. 2013;2:E1.
Modi P, Hassan A, Chitwood WR Jr. Minimally invasive mitral valve surgery: A systematic review and meta-analysis. Eur J
Cardiothorac Surg. 2008;34:943–952.
Modi P, Rodriguez E, Hargrove WC 3rd, et al. Minimally invasive video-assisted mitral valve surgery: A 12-year, 2-center
experience in 1178 patients. J Thorac Cardiovasc Surg. 2009;137:1481–1487.
Murphy DA, Miller JS, Langford DA, et al. Endoscopic robotic mitral valve surgery. J Thorac Cardiovasc Surg. 2006;132
:776–781.
Navia JL, Cosgrove DM 3rd. Minimally invasive mitral valve operations. Ann Thorac Surg. 1996;62:1542–1544.
Nifong LW, Rodriguez E, Chitwood WR. 540 Consecutive robotic mitral valve repairs including concomitant atrial fibrillation
cryoablation. Ann Thorac Surg. 2012;94:38–42.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart
disease: executive summary: A report of the American college of cardiology/American heart association task force on practice
guidelines. J Am Coll Cardiol. 2014;63:2438–2488 and Circulation. 2014;129:2440–2492.
Sunderman SH, Sromicki J, Rodriguez Cetina Biefer H, et al. Mitral valve surgery: Right lateral mini-thoracotomy or
sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2014;148(5):1989–1995.
Suri RM, Burkhart HM, Daly RC, et al. Robotic mitral valve repair for all prolapse subsets using techniques identical to open
valvuloplasty: establishing the benchmark against which percutaneous interventions should be judged. J Thorac Cardiovasc
Surg. 2011;142:970–979.
Suri RM, Schaff HV, Meyer SR, et al. Thoracoscopic versus open mitral valve repair: A propensity score analysis of early
outcomes. Ann Thorac Surg. 2009;88:1185–1190.
Suri RM, Thompson JE, Burkhart HM, et al., Improving affordability through innovation in the surgical treatment of mitral
valve disease. Mayo Clin Proc. 2013;88:1075–1084.
Svensson LG, Atik FA, Cosgrove DM, et al. Minimally invasive versus conventional mitral valve surgery: A
propensity-matched comparison. J Thorac Cardiovasc Surg. 2010;139:926–932.
Vahanian A, Alfieri O, Andreotti F; Joint Task Force on the Management of Valvular Heart Disease of the European Society of
Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular
heart disease (version 2012). Eur Heart J. 2012;33:2451–2496.
19
Open and Closed Mitral Commissurotomy for Rheumatic
Mitral Stenosis
Bhagawan Koirala
Introduction
Rheumatic heart disease is still very common in the developing world. It affects mostly children and
young adults. The pathophysiology of rheumatic fever and rheumatic heart disease is well described in
the literature. The antibodies formed against the streptococcal antigen also attack the endocardial tissue
(molecular mimicry), thereby causing inflammation of the target tissue. It involves the endocardium and
the valves of the heart, joint surfaces and serosal surfaces of the pericardium, and pleura. Most
commonly involved valves in order of frequency are mitral, mitral and aortic valve combined, and aortic
valve alone followed by tricuspid valve. The pulmonary valve is almost never involved by the rheumatic
process, and so, any involvement of this valve is considered to be of congenital origin unless proven
otherwise.
The initial stage of mitral valve involvement always starts from at least some degree of mitral
regurgitation (MR). That is because of chordal lengthening and some degree of associated myocarditis.
As the process progresses the leaflets start to adhere to each other, thereby creating stenosis. In general,
mixed stenotic and regurgitant lesions are more common than pure mitral stenosis (MS).
The symptoms and signs of mitral stenosis are similar to those of any mitral valve disease.
Palpitations, exertional dyspnea, and occasionally, hemoptysis are the commonest symptoms at
presentation. Paroxysmal nocturnal dyspnea (PND) and orthopnea may be present in severe cases.
Typical examination findings are soft tapping apex beat, presence of an opening snap, and middiastolic
rumbling murmur with presystolic accentuation. The presence of an opening snap usually denotes that
the valves are pliable and indicative of a likely successful commissurotomy: open or closed.
As the stenosis becomes tighter the murmur generally increases in intensity and duration. However,
with increasing fibrosis of the valve apparatus, the audibility of the opening snap and intensity of the
murmur may decrease. Chest x-rays are a routine tool of investigation and give important information.
In isolated mitral stenosis the left heart border is straightened because of left atrial appendage
enlargement, but the left ventricle looks normal in size. Left atrial enlargement also leads to a double
contour shadow in the right heart border and splaying of the carinal angle. The rhythm can be sinus or
atrial fibrillation in many cases. Echocardiography is the mainstay of diagnosis and can give full
information of the anatomy and function of the mitral valve. A transthoracic echocardiography can
demonstrate the valve orifice area, degree of valve thickening, involvement of the subvalvar apparatus,
the presence of mitral regurgitation, and left atrial thrombus, if any (Fig. 19.1). If there is any doubt
about the presence of a left atrial thrombus, a transesophageal echocardiography (TEE) may be required.
Figure 19.1 2D echocardiographic image of a typical mitral stenosis in parasternal long-axis view. Typical doming of
the anterior mitral leaflet and small mitral orifice is seen. Also seen in the image is the left atrial thrombus.
The American Heart Association/American College of Cardiology have defined four stages of
rheumatic mitral stenosis:
Stage A: At risk of mitral stenosis: mitral valve doming during diastole, but normal transmitral
flow velocity.
Stage B: Progressive mitral stenosis: progressive commissural fusion, doming of the valve with a
mitral valve area (MVA) more than 1.5 cm2.
Stage C: Asymptomatic severe (or very severe) mitral stenosis: commissural fusion, diastolic
doming with MVA <1.5 cm2 (or <1 cm2).
Stage D: Symptomatic severe (or very severe) mitral stenosis: commissural fusion, diastolic
doming with MVA <1.5 cm2 (or <1 cm2), and symptoms of heart failure.
The above mentioned parameters constitute the main basis for indication of intervention. However,
other factors such as the quality of valve leaflets, involvement of the subvalvar apparatus, and presence
of thrombus are important considerations in selection of a surgical procedure.
Closed Mitral Commissurotomy

Closed mitral commissurotomy (CMC) is one of the early surgical procedures performed in the history
of cardiac surgery and has given quality life to many of the patients.
INDICATIONS
CMC used to be a very common procedure in many countries in the past but now has been almost
entirely replaced by percutaneous transcatheter balloon dilatation (PTBD).
The typical indications for CMC or PTBD are:
Symptomatic severe mitral stenosis with MVA less than 1.5 cm2
Asymptomatic very severe mitral stenosis with MVA of less than 1 cm2
Asymptomatic severe mitral stenosis with MVA <1.5 cm2 with new onset of atrial fibrillation
Mitral stenosis with history of PND or pulmonary edema.
Echocardiographic mean diastolic gradient across mitral valve more than 10 mm Hg is
indicative of significant mitral stenosis but not considered as an indication independently
because of its variability.
The only indication for CMC in the current era could be the need for commissurotomy when there are
no PTBD facilities. It may also be performed when balloon dilatation is not feasible in small children.
Mitral stenosis with failed PTBD is also an indication for CMC but usually requires an open procedure.
Detailed preoperative study of valve anatomy with 2D and color flow echocardiography are
mandatory. Echocardiography will demonstrate the quality of the valve tissue, degree of stenosis,
presence of subvalvar involvement, presence of left atrial thrombus, size of the left atrium, left
ventricular function, and degree of mitral regurgitation. Wilkins score is a useful guide to identify
patients suitable for a closed or open procedure. This is calculated based on the severity of changes in
each component of the mitral valve apparatus, namely leaflet thickening, calcification, leaflet mobility,
and involvement of the subvalvar apparatus. Wilkins score of less than 8 out of total 16 offers high
chance of having a successful closed procedure.
CONTRAINDICATIONS
The contraindications for a closed procedure (CMC or PTBD) are:
Presence of left atrial thrombus
Presence of more than mild mitral regurgitation
Presence of severe subvalvar involvement
Heavy calcification of the valve
Slight calcification of the tips of the leaflets is not a contraindication. Presence of a giant left atrium is
a relative contraindication for CMC. Presence of atrial fibrillation per se is not a contraindication but
needs detailed and careful evaluation for the possible presence of a left atrial thrombus.
PREOPERATIVE PREPARATION
Routine blood work including complete blood count, renal function test, serum electrolytes, routine
urine examination, ECG, and chest x-ray are done before procedure. Echocardiography is performed a
day before surgery to ensure that no new thrombus has formed in the left atrium. If a patient is on
warfarin, it needs to be stopped for about a week before the procedure and have the international
normalized ratio (INR) below 1.5. Medicines including beta-blockers or digoxin are continued until the
day of surgery. While obtaining informed consent, the patient and the family need to understand that this
procedure is not a curative one, and restenosis or regurgitation in the future are possible.
SURGERY
The patient is placed in a semilateral position with the left shoulder lifted approximately at 45 degrees
and left hip slightly lifted with a sand bag. The left arm is lifted off and supported to a screen bar in a
relaxed position (Fig. 19.2). A routine skin preparation and draping is done.
An anterolateral thoracotomy is performed along the fourth or fifth intercostal space. In females the
breast tissue is carefully mobilized off the chest wall. The left lung is retracted and a vertical
pericardiotomy is made about an inch anterior to the left phrenic nerve. The incision should reach the
diaphragm below and main pulmonary artery above. Three to four stay stitches are placed along each of
the margins of the incised pericardium. The left atrial appendage and left ventricle come into perfect
view at this time.
Figure 19.2 The most typical position and incision for closed mitral commissurotomy. Semilateral position with left
hip only slightly lifted off the table. Left arm is suspended on the screen bar in a comfortable position.
A purse-string suture is placed around the left atrial appendage using a 3-0 polypropylene on a 26-mm
round body needle and taken into a snugger. Then the apex of the left ventricle is lifted off its bed and
two 4/4 gauzes placed underneath. This will keep the left ventricular apex lifted and well exposed.
Another purse-string suture using 3-0 polypropylene on a 26-mm needle is placed in a least vascular
area of the left ventricular apex. This is also taken into a snugger and left loose. At this time a small
epicardial incision is made within this purse string. The muscle fibers are split using a small Hegar
dilator and the track gradually dilated with increasing size of the dilator reaching up to 8 to 10 mm and
the purse string gently snugged. The apex is dropped to the pericardial well at this time and the attention
drawn to the left atrial appendage. The appendage is palpated to see if there is any thrombus in it.
Presence of thrombus will make it feel boggy. If not, an appropriately sized Satinsky clamp is applied to
the left atrial appendage keeping the purse-string suture free. The left atrial appendage is incised and
inspected for any thrombus. Two to three stay sutures are taken on either of the edges of the incised
appendage. This helps in keeping the edges open during insertion of the index finger into the left atrium
and also to provide gentle countertraction. The right index finger is inserted into the left atrial appendage
and the Satinsky clamp simultaneously released. At this time the assistant gently snugs the snare down
to prevent any bleeding from the appendage. Once the finger is well into the left atrium, the surgeon
starts evaluation of the mitral valve, feeling for mitral regurgitation, if any, any calcification, a rough
estimate of the mitral valve orifice, and degree of subvalvar involvement. If, during incision of the atrial
appendage, a thrombus is seen, then one can try to flush it out by releasing the Satinsky clamp and the
procedure repeated few times. The surgeon and the team should be aware of the blood loss at this time.
Figure 19.3 Tubb’s dilator in a closed position.
Figure 19.4 Tubb’s dilator in an open position.
If the valve is pliable, oftentimes, the commissures of the mitral valve can be split using the index
finger. At this time the apex of the left ventricle is lifted using the surgeon’s three fingers and palm of
right hand and a gauge is placed underneath to bring the LV apical purse string into view. The scrub
nurse has by now set the opening of the blade of the Tubb’s dilator ( Figs. 19.3 and 19.4) to the desired
limit by using the setscrew on the dilator. The usual initial setting is 2.5 cm going up to 3 and 3.5 cm in
subsequent dilatations. The Tubb’s dilator with minimal opening is first selected and in a closed mode is
passed through the purse string into the left ventricle. Using the right index finger as a guide, the Tubb’s
dilator is passed through the mitral valve keeping the blades anteroposteriorly. Now the Tubb’s dilator is
opened using the left hand and released quickly (Fig. 19.5). The dilator should not be open before
crossing the mitral valve. This may cause rupture of the chords causing severe mitral regurgitation. The
dilator is now withdrawn in closed position and the purse string snugged down by the assistant. Now,
the mitral valve is evaluated with the index finger for any regurgitation and degree of valve opening.
The whole process can be repeated if the valve is not adequately open. Further dilatations should not be
attempted if there is significant mitral regurgitation. The index finger is now withdrawn from the left
atrial appendage and the snare tightened. If there is bleeding around the purse string at the appendage, a
Satinsky clamp may be applied. Redundant edges of the appendage are excised and reinforcing sutures
used to secure hemostasis. Similarly, two to three interrupted epicardial stitches are placed within the
purse string of the LV apex and the original purse string may be removed or tied down. Hemostasis is
secured and the pericardium closed with a few interrupted sutures. Pacing wires are generally not
necessary but one may place two temporary ventricular wires. An intercostal block is given with 0.25%
bupivacaine or an extrapleural catheter is placed for postoperative pain control. The chest is closed in
layers with a drain. The patient may be extubated in the operating room if the preoperative status and
intraoperative hemodynamics are stable. More often, they are transferred to intensive care unit (ICU)
intubated and ventilated for a variable period of time.
Figure 19.5 The schematic diagram of closed mitral commissurotomy. The diagram shows the site of introduction of
Tubb’s dilator and right index finger guiding the passage of Tubb’s dilator through the mitral valve.
Open Mitral Commissurotomy

Open mitral commissurotomy (OMC) used to be a popular procedure for isolated mitral stenosis when
techniques of open heart surgery were well established. OMC is seldom used these days for isolated
pure mitral stenosis because most of them would have been dealt with by PTBD. The technique of open
commissurotomy, however, is still a useful procedure today in various situations.
INDICATIONS
The general indications for open commissurotomy are similar to those for closed intervention; however,
as mentioned before most of the pure MS would have been dealt with by PTBD. There are certain
specific conditions where OMC is particularly suitable as summarized below:
Symptomatic severe mitral stenosis with MVA <1.5 cm2 and left atrial thrombus that does not
disappear with anticoagulation.
Complicated PTBD with leaflet tear causing severe MR or a failed PTBD.
Calcific symptomatic severe mitral stenosis where PTBD is not feasible or contraindicated.
Symptomatic moderate mitral stenosis (MVA >1.5 cm2) when a cardiac surgical procedure is
being undertaken for another condition.
OMC is frequently performed as part of combined procedures when severe mitral stenosis is present
along with a condition that independently requires surgical intervention. They include aortic valve
procedures, closure of atrial septal defect, or repair of severe tricuspid regurgitation among others.
CONTRAINDICATIONS
Open commissurotomy alone is generally not sufficient when the leaflets are calcified, or the subvalvar
apparatus severely affected. In such conditions, either a more complicated repair procedure should be
performed by a surgeon experienced in rheumatic valve repair or a more straightforward valve
replacement should be carried out.
PREOPERATIVE PREPARATION
All the preoperative preparations are similar to those for CMC as described above.
SURGERY
Positioning, Incision and Cannulation
Patient is placed in supine position and large bore peripheral venous line, arterial line and a central
venous line are placed. Preoperative antibiotic is given. A median sternotomy is usually performed,
although a right thoracotomy may also be done depending upon the surgeon’s preference. Aortic and
bicaval cannulation are performed. A single two-stage venous cannula may also be used if no other
combined procedure is planned. Antegrade cold blood cardioplegia is instituted; retrograde cardioplegia
is also added if there is associated aortic work to be done.
Intracardiac Procedure
Once the heart is arrested, a left atriotomy is performed just anterior to the right pulmonary veins. If the
left atrium is small, Sondergaard’s groove is developed and the left atrium incised, a transseptal
approach is appropriate if there is an associated atrial septal defect (ASD) that needs closure or if the
tricuspid valve needs to be repaired. The left atrium is retracted using a Cooley retractor. The left atrial
appendage is inspected for presence of thrombus, and evacuated, if any. The left atrial appendage is
ligated from outside using a no. 2 silk. Alternatively, it is closed from inside using a 3-0 polypropylene
suture. Typically in rheumatic mitral stenosis, the valve commissures are fused, the leaflets and the
chords are thickened to a variable degree, and the chords are shortened (Fig. 19.6). Calcification may be
present in many cases. The decision whether to preserve the valve or to go ahead with replacement
should generally be done by preoperative assessment; however, a final decision is made after
examination of the valve on the operating table.
First, the line of commissural fusion is identified. Using two nerve hooks (or two stay stitches) the
leaflets are retracted near the anterolateral commissure. This generally exposes the raphe—the fusion
line. This line is located at the center of fan chords that arise from the anterolateral papillary muscle (
Fig. 19.7). Using a no. 11 blade the commissure is incised from the free edge taking care not to divide
the fan chords. This incision is carried towards and one mm short of the annulus ( Fig. 19.8). If the
chords are fused they are freed and sometimes the papillary muscle is also incised vertically. Similar
steps are taken to perform the posteromedial commissurotomy. Usually, the secondary cords of the
posterior leaflet are divided to improve the mobility of the leaflet. Decalcification may be required if the
leaflets are calcified. Some surgeons prefer incising the commissure starting near the annulus and
coming toward the free edge. Saline is injected into the left ventricle to assess mitral regurgitation. I
prefer placing a band or a ring to support the valve after the OMC ( Fig. 19.9). Many surgeons combine
open commissurotomy with commissural stitches only.
Figure 19.6 Intraoperative picture of a typical rheumatic mitral stenosis. Note the commissural fusion and thickening
of the valve.
Figure 19.7 Intraoperative picture of a mitral stenosis. Note the clear line of fusion of the commissures after the
anterior and the posterior leaflets are retracted by nerve hooks.
If the procedure was undertaken for leaflet tear due to PTBD, I prefer to repair the tear site first. The
free edges of the leaflet on either side of the tear are approximated and the tear is repaired using
interrupted 5-0 polypropylene sutures. Then, the commissurotomy is performed as described above.
Figure 19.8 Open commissurotomy using a no. 11 blade scalpel, starting from the free edge.
Figure 19.9 Placement of a mitral ring, after completing open commissurotomy.
The left atrium is closed in two layers. Routine deairing is done and the aortic cross-clamp is released
and the patient is weaned off cardiopulmonary bypass. If other procedures are to be combined, then the
sequence of steps will vary accordingly. TEE is performed routinely to assess the heart function, valve
opening, degree of mitral regurgitation, if any, and also to help with deairing. Valve rerepair or
replacement is warranted if there is more than mild mitral regurgitation. Heparin is then reversed and
decannulation is done in routine fashion. Hemostasis is secured and the chest is closed with pacing wires
and chest drains.
Patients are transferred to the ICU after the procedures. Fundamentals of postoperative care are similar
in both CMC and OMC. Hemodynamically stable patients after closed commissurotomy generally are
extubated in the OR, whereas, those who are sicker or those after an open procedure are ventilated in the
ICU for several hours. Assessment of cardiac rate, rhythm, cardiac function and output, volume status,
renal function, coagulation status, neurologic function all are closely assessed. Use of inotropes is
usually not necessary after a straightforward CMC, but may be needed for a sick patient or after an open
procedure. All preoperative medications are resumed after appropriate adjustments. In young patients
with rheumatic heart disease secondary prophylaxis is resumed in the form of penicillin or
erythromycin. Those patients who are on warfarin need to have therapeutic INR before discharge from
the hospital.
COMPLICATIONS OF CLOSED AND OPEN MITRAL

COMMISSUROTOMY
The most common complication after mitral commissurotomy, closed or open, is mitral regurgitation.
Embolization is infrequent but a serious complication among the patients who have undergone CMC.
Likewise, arrhythmias and persistent heart failure are seen in patients who are in a more severe function
class preoperatively. Routine use of TEE is mandatory before accepting the result of OMC. Any MR
more than mild warrants either rerepair of the mitral valve or replacement of the valve. Residual mitral
stenosis generally is mild, if present, and is usually not a major concern in the early postoperative
period. Other complications of this procedure are those seen for any open heart procedure, including
postoperative bleeding, stroke, arrhythmias, low cardiac output, post operative wound infection, and
dysfunction of other target organs.
RESULTS OF CLOSED AND OPEN MITRAL

COMMISSUROTOMY
The early results of closed commissurotomy and an isolated OMC procedure are excellent. Operative
mortality for a CMC varies according to the preoperative functional class. Stanley John, et al., in one of
the largest series of CMC, reported 1.5% hospital mortality. Closed commissurotomy using a dilator
gives an excellent postoperative MVA. Although restenosis of the valve is a common phenomenon,
most commonly seen 10 to 15 years after CMC, long-term survival is excellent. Survival up to 84% at
24 years is reported. A total of 5% to 10% of the patients after CMC may develop significant MR and
may need early reintervention using an open procedure.
OMC for isolated mitral stenosis carries a low mortality, nearing zero. The procedure achieves good
postoperative valve orifice, reaching up to 3.4 cm2 and 87% freedom from significant MR or MS at 10
years. Since the intraoperative TEE is available in most centers, significant residual MR should not be
accepted in the current era. The comparative benefits of CMC or OMC are even more striking for
patients who have difficulty in managing warfarin after mechanical valve implantation.
The risk factors for restenosis after open or closed procedure are the quality of valve leaflets and
degree of subvalvar involvement at the time of intervention. In general, approximately 20% and 50% of
the patients after commissurotomy, either closed or open, may require mitral valve replacement at 10
and 20 years respectively.
CONCLUSION
Rheumatic heart disease is still very prevalent in the developing world. Historically a very common and
a life-saving procedure, –CMC is now largely replaced by percutaneous balloon dilatation. This
procedure can, however, be useful in certain areas of the world where catheterization laboratory
facilities are not available and where PTBD is not available and transfer of patients may not be practical.
Open commissurotomy is still a useful procedure and is applicable in a variety of valvular heart
conditions. The early results of CMC or OMC are excellent with good long-term results. The knowledge
and skills of these two procedures can still be useful for a cardiac surgeon in the contemporary world.

Abascal VM, Wilkins GT, O’Shea JP, et al. Prediction of successful outcome in 130 patients undergoing percutaneous balloon
mitral valvotomy. Circulation. 1990;82:448–456.
Choudhary SK, Dhareshwar J, Govil A, et al. Open mitral commissurotomy in the current era: Indications, technique, and
results. Ann Thorac Surg. 2003;75:41–46.
Cox WA, Fisher GW. The place of closed commissurotomy in the treatment of rheumatic mitral stenosis. Ann Thorac Surg.
1968; 6:253–261.
Cunningham MW. Streptococcus and rheumatic fever. Curr Opin Rheumatol. 2012;24(4):408–416.
John S, Bashi VV, Jairaj PS, et al. Closed mitral valvotomy: Early results and long-term follow-up of 3724 consecutive patients.
Circulation. 1983;68:891–896.
Keith TA 3rd, Fowler NO. Closed mitral commissurotomy complications and their effect on survival. Chest. 1972;61:24–32.
Kouchoukos NT, Blackstone EH, Hanley FL, et al. Kirklin/ Baratt Boyes Cardiac Surgery. 4th ed. Philadelphia, PA: Elsevier
Saunders; 2013:474–524.
Kumar AS. Techniques in valvular heart surgery. 2nd ed. New Delhi: CBS Publishers and Distributors; 2010:2–16.
Kumar AS. Surgical Options in rheumatic mitral valve disease in children: A surgeon’s perspective. World J Pediatr Congenit
Heart Surg. 2014;5(1):80–84.
Montoya A, Mulet J, Pifarre R, et al. The advantages of open mitral commissurotomy for mitral stenosis. Chest. 1979;75
:131–135.
Mullin EM Jr, Glancy DL, Higgs LM, et al. Current results of operation for mitral stenosis: Clinical and hemodynamic
assessments in 124 consecutive patients treated by closed commissurotomy, open commissurotomy or valve replacement.
Circulation. 1972; 46:298–308.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart
disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J
Thorac Cardiovasc Surg. 2014;148(1):e1–e132.
Palacios IF. Farewell to surgical mitral commissurotomy for many patients. Circulation. 1998;97:223–236.
Salerno TA, Neilson IR, Charrette EJ, et al. A 25 year experience with the closed method of treatment in 139 patients with
mitral stenosis. Ann Thorac Surg. 1981;31:300–304.
20
Mitral Valve Repair for Rheumatic Disease
Arkalgud Sampath Kumar
Introduction
Acute rheumatic carditis produces valvulitis of all four valves, in addition to pericarditis and
myocarditis. It is most often seen in children, who present with gross CHF, arrhythmia, mitral, tricuspid
and aortic regurgitation. It is best to treat these children conservatively with decongestive therapy,
arrhythmia control, aspirin, and steroids. Surgery carries a high risk of mortality and failure.
Chronic RHD affects the MV more often than the AV and TV. Involvement of all four valves is not
uncommon. MS with or without MR is the usual manifestation.
INDICATIONS
MS; pure, noncalcific, isolated MS in normal sinus rhythm can undergo balloon mitral valvotomy
(BMV) or CMV. Patients with AF, intracardiac thrombus, calcification, or restenosis will require
(OMC). The techniques for closed and open mitral commissurotomy and repair for pure MS are
described in Chapter 19. This chapter will focus on MV repair for rheumatic MR and for MS with
regurgitation. Patients with combined MS and MR or with pure MR require correction under direct
vision. MV repair is the operation of choice. With experience, nearly 70% of patients with MR can
undergo successful repair with good long-term results.
Before heparinisation a complete TEE is performed to assess:
MV cusps; thickness, mobility, fusion, and calcification. The anterior mitral leaflet (AML) length
from annulus to free edge in the four-chamber view at the P2 level is measured. If this length is 26 mm
(18 mm/m2 body surface area) then the likelihood of successful repair is high.
The presence of LA/left atrial appendage (LAA) thrombus, LA size, MS prolapse, and subvalvular
apparatus are also thoroughly assessed.
The TV and AV need to be carefully assessed. However, a decision to do TV repair is best taken on
the basis of TTE performed before surgery. Assessment of TR can be fallacious under anesthesia. If the
tricuspid annulus diameter exceeds 40 mm and TR is moderate or severe, then TV repair will be
necessary. TS is commonly seen in RHD and will always require correction.
SURGERY
Median Sternotomy
This is the standard approach for most open heart procedures. For cosmetic purposes the incision in the
skin can be made from the sternal angle to xiphoid, especially in young women. The sternum is divided
in a lazy S-shaped incision (interlocking sternotomy, Fig. 20.1). This provides better healing, less pain,
and improved postoperative respiratory function. A 4 inch piece of sterile plastic tubing(venous line) is
split longitudinally and placed around the sternal edge to protect the sternum on both sides.
The pericardium is opened in the midline for routine exposure of the heart. In a redo sternotomy, care
must be taken to separate the heart from the back of the sternum before using a retractor. Pericardial stay
sutures are placed to expose the aorta and the right chambers. The left pericardial flap is not pulled up as
it may hamper MV exposure. The heart may be adherent to the pericardium and needs to be completely
freed. This helps to get better exposure, allows proper surface cooling, and complete de-airing.
Right Thoracotomy: For better cosmesis especially in young females a right thoracotomy can be used
for MV repair (see Chapter 19 for details).
Cardiopulmonary Bypass
For MV and TV surgery the technique used is warm body, cold heart. This technique has several
advantages.
It saves time (cooling/rewarming)
Reduces coagulation abnormalities
Reduces inflammatory reaction to CPB by reducing CPB time
The SVC and IVC are cannulated through the appendage and body of the RA. If the RA is to be opened,
then the SVC and IVC are taped. The ascending aorta is cannulated at its highest point. An aortic vent
cannula to deliver cardioplegia and to de-air is placed on the highest point of the ascending aorta. It must
be placed with sufficient space between it and the aortic cross clamp to clamp the aorta or to work on
the AV if necessary.
Figure 20.1 Interlocking sternotomy. Note the curved incision in the sternum.
Myocardial Protection
Cold blood cardioplegia is the preferred method. It is delivered into the ascending aorta after clamping.
The dose is 15 mL/kg body weight. This is combined with topical ice slush cooling of the heart
externally. In patients with AV disease the cardioplegia solution is delivered antegrade into the coronary
ostia, 70% into the left coronary artery (LCA), and 30% to the right coronary artery (RCA).
Cardioplegia is repeated every 20 to 25 minutes. The last dose of cardioplegic solution is administered at
a temperature of 32º to 34ºC. This effectively rewarms the heart and spontaneous cardiac rhythm returns
when the aortic clamp is released. Defibrillation is rarely necessary.
Blood Conservation
It is important to avoid homologous blood transfusion when possible. In primary valve surgery, nearly
80% of patients can undergo safe surgery without blood/blood product transfusion.
Autologous donation of 300 to 500 mL of blood is an extremely useful method in adults. It must be
done cautiously. In patients with a hemoglobin level of 12 g% or more and 40 kg body weight this can
be completed before heparinization.
The CPB circuit is primed with crystalloid solution. A minimum quantity is retained, discarding the
excess before beginning cannulation. If the patient’s blood pressure permits, the aortic cannula is
drained retrograde into the oxygenator while discarding the crystalloid prime (retrograde priming). This
way CPB can be conducted with a blood prime (higher viscosity) reducing hemodilution. A pump flow
of 70 to 80 mL/kg body weight is maintained during perfusion. The systemic perfusion pressure should
be maintained above 50 mm Hg throughout perfusion.
Exposure of the Mitral Valve

If the LA is enlarged, a generous incision behind the Waterston groove provides the best exposure. In
patients with an atrial septal defect (ASD) or requiring a TV repair, the MV may be approached through
a transseptal incision.
Assessment
As soon as the cardioplegic solution is delivered the LA incision is enlarged. A Cooley mitral retractor
is placed and the assistant retracts the atrial septum. The LA cavity is inspected for (a) thrombus and (b)
McCallum patch (jet lesion). The jet lesion is a sign of prolapse and is usually found behind the PML in
patients with AML prolapse. Any thrombus is completely removed and the LA is thoroughly irrigated.
The thickened endocardium of the jet lesion is peeled off (it can be a source of thrombus formation). An
LA vent is now placed in the left inferior pulmonary vein and connected to the vent line.
Two hooks are placed through the mitral orifice—one behind the AML and another behind the PML.
If the leaflets are not thickened, the tip of the hook can be easily seen through the leaflet tissue. The
commissural fusion lines easily identify MS if present. Look for calcification, especially at the
commissures and any soft thrombus. An open commissurotomy needs to be performed before further
assessment can be done. With the hooks retracting the cusps, an incision is made with the tip of a no. 11
blade just inside (2 to 3 mm) from the mitral annulus at the commissures (see videos).
A fine right-angled forcep is inserted through this incision to separate the cusps from the subvalvular
fusion. The commissural fusion line is now gently incised separating the two cusps. Fused chordae are
separated by incising with a no. 11 blade. A fused papillary muscle is divided with sharp Potts scissors
down to its base allowing the LV cavities come into view.
If there is no MS, the posterior hook pulls up the P1 segment of the PML. This will be the reference
point. Any prolapse of the A1/A2/A3 or P2/P3 segments is assessed. Chordal elongation and/or rupture
are identified. Ruptured chordae are excised. Saline is injected into the LV to assess prolapse and
mobility of the cusps.
Figure 20.2 The technique of cusp thinning. The fibrous peel is separated at the annulus and peeled toward the free
edge of the cusps, and excised.
Cusp Thinning
This procedure is extremely useful in RHD. It releases the normal imprisoned cusps, makes them thin
and improves mobility, enlarges the cusps, and increases coaptation. It is especially useful in the AML
(see video and Fig. 20.2).
The belly of the AML is grasped with a Russian forceps. With the Debakey tissue forceps, the fibrous
peel is grasped firmly at the annulus and with a downward traction it is separated from the normal AML
which appears glistening (see video). This is now peeled toward the free edge of AML all around. The
resultant peel is excised at the free edge.
A similar procedure is performed for the PML also. The thickened endocardial peel is grasped just
behind the annulus and peeled toward the free edge. Care must be taken not to tear the cusps. It is then
excised at the free edge.
Fenestration
Fused chordae from the free edge to the papillary muscle need to be freed. A right-angled clamp is
placed at the tip of the papillary muscle and held by an assistant. Alternately, a hook is placed behind
the thickened chordae. Using a no. 11 blade the thick fibrocalcific material is shaved carefully until the
chordae become visible. The fusion between the chordae is also incised with the knife to separate them.
This improves the mobility of the cusp and abolishes a secondary orifice.
The valve is now assessed by injecting saline into the ventricle. It may be necessary to grasp the
posterior annulus and to push it forward during a saline test. With the LV filled, gentle pressure from the
outside by gently squeezing the LV will show cusp movement and a residual leak if present.
Acquired clefts between the P1-P2 and P2-P3 scallops may need to be closed using a 5-0 Prolene
horizontal mattress suture.
Chordal Shortening
Any prolapse of the AML that is identified can be corrected by shortening the elongated chordae (Fig.
20.3). The part of the AML that is prolapsing is pulled up with a stay suture on the free edge. A stay
suture is placed on the tip of the corresponding papillary muscle and pulled up gently to the drapes. This
clearly shows the chorda or chordae that are elongated. A silk tie is passed around the elongated chordae
and the normal chorda of the PML and pulled up (Fig. 20.3A). This will clearly demonstrate the chordal
length that needs to be shortened (Fig. 20.3B). The chorda is now plicated to the free edge using a 5-0
Prolene suture (Fig. 20.3C,D).
Figure 20.3 The technique of chordal shortening at the cusp level. The length of chordal to be shortened is
measured (A). A 5-0 polypropylene suture impales the elongated chorda (B) and is sutured to the free edge (C and
D). Note how the chorda remains shortened at the cusp level.
This procedure of chordal shortening at the cusp level is easy to perform and corrects a prolapsed MV
effectively. It can be undone and redone without much difficulty if necessary. This is easy to perform in
RHD because of the thickened chordae.
Annuloplasty
The above procedures may correct the MR. However, some form of annuloplasty (suture, partial ring or
complete ring) is necessary to support the repair, and to ensure superior long-term outcomes (Fig. 20.4).
A “C”-shaped piece of thick Teflon felt (Bard 7838) is eminently suitable ( Fig. 20.4A) and
inexpensive. One 6 × 6 in piece of felt will provide six such rings. A partially flexible ring is preferred
to a completely rigid ring.
Sizing
Two hooks are placed to retract the AML chordae and to stretch the AML. The AML is measured with
any valve sizer. Precut rings are best obtained by making these in the OR from a fresh piece of felt,
which may then be packed and sterilized. They may also be cut at surgery (see video).
Figure 20.4 A and B: The C-shaped Teflon collar.
Suturing
Nine 2-0 braided (17- or 25-mm needle) polyester sutures are required (5 green and 4 white). The
selected Teflon felt collar is clipped to the drapes with a mosquito forceps. The first green suture is
placed at the left fibrous trigone. A dimple can identify this as also a lighter color, at about the 11
o’clock position on the mitral annulus as the surgeon sees it. A horizontal mattress suture through this
fibrous trigone is taken and both needles are passed through the left horn of the Teflon ring.
The right fibrous trigone can also be identified similarly. This is more easy to identify and is at 2
o’clock position on the mitral annulus. Another green suture is now placed through this trigone
(horizontal mattress) and taken through the right horn of Teflon ring.
The third green suture is placed at about 6 o’clock position on the posterior annulus and passed
through the corresponding part of the ring. The fourth green suture is exactly midway between the first
and third suture about 9 o’clock position and the fifth green suture is placed at about the 4 o’clock
position on the mitral annulus and both needles are passed through corresponding position on the felt
ring.
Four white sutures are now passed through the mitral annulus. Each white suture is a horizontal
mattress covering the distance between the green sutures. These sutures are passed through the Teflon
felt in the corresponding position. The felt ring is now pushed into the LA and all sutures are pulled taut,
the sutures are tied in the same sequence as they were placed to get a symmetrical annuloplasty (Fig.
20.4B). A saline test is now performed keeping the aortic vent open (to evacuate air). Gentle pressure on
the LV will demonstrate competence of the MV. Any prolapse or residual MR can be corrected at this
time.
De-airing
A 28-F chest tube is passed through the MV into the LV. Ensure that the last side hole of the tube
remains in the LA.
The left atrial incision is now closed around this tube. The suture is not tied. A tissue forceps is placed
beside the tube to keep the LA open. The vent cannula is removed and the negative suction line is
connected to the aortic vent. If CO2 is in use, it may now be opened to flood the pericardial cavity. The
ascending aorta is de-aired and the clamp is removed. Strong (300 mL/min) negative suction is
maintained at this time. In a few seconds the heart resumes beating. The anesthetist is asked to manually
ventilate the lungs. The SVC cannula is withdrawn into the RA and clamped. While blood fills the
pericardial cavity the heart is gently massaged by the surgeon. One may also vigorously shake the chest
of the patient holding the sternal retractor. The TEE is monitored for residual air in the LA/LV. Holding
the breath in inspiration, the tube in the LA is gradually withdrawn and LA suture is tied under a blood
level in the pericardium. The lungs are now deflated and the clamp on the SVC cannula is removed. All
pericardial blood is returned to pump. The LA suture line is completed. With the heart empty the LAA is
clamped and ligated. (In the right thoracotomy approach the LAA can be ligated by pulling it up through
the transverse sinus behind the aorta.)
Weaning from CPB

Patient’s temperature is 36.5º to 37ºC
De-aring is completed and confirmed on TEE
Heart is beating in stable sinus rhythm (NSR)
Pacing wires are placed and heart rhythm is stable
All cardiotomy sites are inspected and free from surgical bleeding
When the above points are confirmed, the IVC cannula is clamped and the perfusionist is warned. The
surgeon closely observes the heart beat and ventricular contractility. Inotropic support with dopamine,
adrenaline, or other drugs is best withheld at this time. The heart usually recovers to a stable rhythm and
begins to take the load of systematic circulation. CPB can be discontinued with a systematic pressure of
70 mm Hg or above, on pacing (atrial/ventricular), or in NSR. With a CVP of 6 to 8 mm Hg, no
arrhythmia, and the aortic vent removing 300 mL/min pump blood, the patient is transfused with the
aortic line to maintain a systematic pressure of 70 mm Hg or above. An anesthetist now performs a TEE
assessment of the following.
LV contraction
Air in LA/LAA/pulmonary veins
MR—absent, mild, moderate or severe, are there any eccentric jets hugging the LA wall
Coaptation length, 8 mm or more
While this assessment is being done the perfusionist returns all pump blood to the patient slowly. The
venous cannulae may be removed if the MV repair is satisfactory and the cardiac action is stable, and
there is no arrhythmia or bleeding. By now the arterial pressure usually stabilizes to preoperative levels
(at least above 100 mm Hg). The cannulation sites are reinforced with suture pieces left over from LA
suture line. Pacing wires, usually two, are placed on the RV epicardium and RA appendage, if not
already placed. The RA appendage may be ligated if all is satisfactory, after tying the purse-string
suture. If 5 minutes after weaning from CPB there is no residual air, the aortic vent is clamped. Blood in
the venous line may be returned to the pump reservoir and retransfused. When the aortic vent is clamped
the blood pressure usually improves. The anesthesiologist and surgeon may now decide if inotropic
support is required. A second atrial wire is usually placed near the IVC cannulation site or LA suture
line for the atrial pacing. Cardioversion is rarely required. However, if the rhythm is AF, a synchronized
DC shock (10 to 30 J) may be used for cardioversion and capture of atrial pacing.
A second and final TEE assessment is again performed to assess the valve repair. If satisfied, heparin
may now be reversed with protamine. The aortic cannula may be removed and cannulation site
reinforced with a suture at this time. All suture lines are meticulously checked for bleeding.
Closing
While protamine is being infused, the pericardial edge is cauterized. Incisions are made for drainage
tube placement. The pacemaker wires are secured. By now all residual blood volume is returned to the
patient or collected in a transfusion bag. The sternal retractor is removed and the plastic tubing on the
sternal edges are also removed. Generally it can be seen that there is virtually no bleeding from the
sternal marrow, and a soft clot is adherent to the sternum. Any periosteal or mediastinal bleeding is now
controlled. The pericardial cavity is washed with saline. The pericardium is closed completely with
interrupted sutures. A drain is placed on the diaphragmatic surface and directed behind the LV apex.
Complete pericardial closure is necessary to protect the heart at subsequent reoperations, which may be
required in the majority of patients. This step also helps to retain normal diastolic function of the
ventricle. There is neither any cardiac embarrassment nor higher incidence of tamponade. At reoperation
the ease of redo sternotomy and dissection of the heart is obvious when the pericardium is completely
closed. If there is no mediastinal bleeding and blood clots are observed, the sternum may be closed after
placing a drain. No bone wax is used. Additional drainage tubes may be placed in the pleural cavity if it
has been opened. Braided polyester no. 2 (for children) and no. 5 (for adults) sutures are used to
approximate the sternum with figure-of-eight stitches. The sponge and needle counts are confirmed
before closing the sternum. The subcutaneous tissue and skin are closed in routine fashion. The TEE
probe is now removed.
Great care must be taken in transferring the patient to the ICU. All invasive lines, chest tubes, the
endotracheal tube, pacing lines, and the urinary catheter must be properly and firmly fixed to avoid any
mishaps. On arrival in the ICU the patient is connected to the monitor and ventilator. The chest drainage
bottles are placed on the floor, the clamps removed. The patient warmer is placed and switched on.
Negative suction is connected to the chest drainage bottles for a few seconds to begin the flow of
mediastinal and pericardial blood and suction is discontinued. It is not necessary to keep continuous
negative pressure on the drainage tubes. A dose of chosen antibiotic is usually administered at this time.
The anesthetist/intensivist checks for air entry and ventilation parameters and the first arterial blood gas
report. Standard ICU protocols are now initiated. These may be different for each operation. 20%
dextrose with 20 mEq of potassium and 20 units of insulin (GIK/PIG solution) is infused at 1 mL/kg
body weight. Blood and blood products are withheld and transfused only when indicated. A
postoperative hemoglobin of 8 gm% is the lower limit of tolerance for blood (packed RBCs) transfusion.
The ICU nurse takes over the patient care when all parameters are checked and found satisfactory. A
single-chamber pacemaker is usually connected to the temporary pacing wires with demand pacing
turned on.
Anticoagulant protocol: If a successful repair is performed, no anticoagulant or antiplatelet agents are
prescribed.
Results (early): Operative mortality is usually under 3%. It may be higher in patients undergoing redo
surgery, emergency surgery, multiple valve surgery, and those with comorbidities.
Successful MV repair can be achieved in 85% of patients of RHD and in 100% of patients with
myxomatous prolapse or congenital cleft. It may be possible to repair 50% of MV in patients with
infective endocarditis.
We prefer not to perform an atrial ablation procedure for AF in the regulation of patients. If the LA
diameter exceeds 7.5 cm, the LA wall is thin with loss of muscle, and AF is long standing (6 months or
more) it is unlikely to achieve successful long-term conversion to NSR by any means. For patients with
recent onset of AF, LA size 5 cm or less, and LA wall thickness (observed at surgery) is normal, a
simple cardioversion shock with atrial pacing usually achieves conversion to NSR. With the use of
calcium channel blockers this can be maintained in the long term. Published data showed successful
10-year conversion of AF to NSR with electrical cardioversion in 34% of patients which were similar to
results published by other methods.
Other complications such as bleeding requiring reexploration, atrial tachycardias, hemolysis, and
sternal or other wound complications are less than 2% in experienced centers.
RESULTS
Late mortality of 2% to 3% may be expected in patients who have long-standing CHF or other
comorbidities (Figs. 20.5 and 20.6).
Figure 20.5 Actuarial survival following mitral valve repair. (From Kumar AS, Talwar S, Saxena A, et al. Results of
mitral valve repair in rheumatic mitral regurgitation. Interact Cardiovasc Thorac Surg. 2006;5(4):356–361, with
permission.)
Figure 20.6 Reoperation-free survival. (From Kumar AS, Talwar S, Saxena A, et al. Results of mitral valve repair in
rheumatic mitral regurgitation. Interact Cardiovasc Thorac Surg. 2006;5(4):356–361, with permission.)
Ten to fifteen percent of patients may return within 1 year with residual significant MR (moderate or
severe). This is usually due to technical error or recurrent rheumatic activity. Such patients with severe
MR will require reoperation and valve replacement.
Asymptomatic patients with moderate MR may be managed with medical treatment (digoxin,
diuretics, calcium channel blockers, beta-blockers) and followed up at six months with
echocardiography.
The 15- to 20-years actuarial survival is above 90% (see Figure 20.5). However, the reoperation-free
survival shows a gradual decline after 10 years and is 80% at 15 years. This is due to the natural history
of RHD and is influenced negatively by age at operation.
CONCLUSION
MV repair may be attempted in 100% of patients with noncalcific MR. Immediate success can be
expected with the above techniques in about 85% of patients. Reoperation-free survival at 15 years is
expected to be 81% in adults and 65% in children. The operation provides a cost-effective
anticoagulant-free life for the majority of patients.
ABBREVIATIONS
AF—Atrial fibrillation
AV—Aortic valve
BMV—Balloon mitral valvotomy
CHF—Congestive heart failure
CMV—Closed mitral valvotomy
CPB—Cardiopulmonary bypass
IVC—Inferior vena cava
LA—Left atrium
LAA—Left atrial appendage
LV—Left ventricle
MR—Mitral regurgitation
MS—Mitral stenosis
MV—Mitral valve
NSR—Normal sinus rhythm
OMC—Open mitral commissurotomy
RA—Right atrium
RHD—Rheumatic heart disease
RV—Right ventricle
SVC—Superior vena cava
TEE—Transesophageal echocardiography
TTE—Transthoracic echocardiography
TR—Tricuspid regurgitation
TS—Tricuspid stenosis
TV—Tricuspid valve

Bisoi AK, Srivastava S, Tripathy P, et al. Blood conservation in open heart surgery. Asian Cardiovasc Thorac Ann. 1996;4
:212–214.
Chauhan S, Gaurishankar R, Choudhary SK, et al. Normothermic cardiopulmonary bypass and post operative blood loss. Indian
J Med Res. 1998;108:66–70.
Chauhan S, Ramesh G, Saxena N, et al. Comparison of normothermic cardiopulmonary bypass with conventional hypothermic
bypass. Asian Cardiovasc Thorac Ann. 1997;5:199–202.
Choudhary SK, Dhareshwar J, Govil A, et al. Open mitral commissurotomy in the current era: Indications, technique, and
results. Ann Thorac Surg. 2003;75:41–46.
Choudhary SK, Talwar S, Dubey B, et al. Mitral valve repair in a predominantly rheumatic population. Long term results. Tex
Heart Inst J. 2001;28:8–15.
Gupta A, Gharde P, Kumar AS. Anterior mitral leaflet length: Predictor for mitral valve repair in a rheumatic population. Ann
Thorac Surg. 2010;90(6):1930–1933.
Joshi R, Abraham S, Sampath Kumar A. Interlocking sternotomy: Initial experience. Asian Cardiovasc Thorac Ann. 2004;12
:16–18.
Kumar AS. Surgery for rheumatic heart disease in children: Essential aspects. I A.P J Pract Paed. 1997;5:125–130.
Kumar AS. Techniques in Valvular Heart Surgery. 2nd ed. Delhi: CBS publishers & distributors; 2006:1–2.
Kumar AS. Repair of rheumatic mitral regurgitation in children. Ann Pediatr Cardiol. 2011;4(1):47–52
Kumar AS. Surgical options in rheumatic mitral valve disease in children: A surgeon’s perspective. World J Pediatr Congenit
Heart Surg. 2014;5:80–84.
Kumar AS, Kumar RV, Shrivastava S, et al. Mitral valve reconstruction: Early results of a modified cooley technique. Tex Heart
Inst J. 1992;19:107–111.
Kumar AS, Prasad S, Rai S, et al. Right thoracotomy revisited. Tex Heart Inst J. 1993;20:40–42.
Kumar AS, Rao PN. Mitral valve reconstruction: Intermediate term results in rheumatic mitral regurgitation. J Heart Valve Dis.
1994; 3:161–164.
Kumar AS, Rao PN. Restoration of pliability to mitral leaflets during reconstruction. J Heart Valve Dis. 1995;4:251–253.
Kumar AS, Rao PN, Saxena A. Mitral valve reconstruction in children with rheumatic heart disease. Ann Thorac Surg. 1995;60
:1044–1047.
Kumar AS, Rao PN, Saxena A. Mitral valve reconstruction: Eight years experience in 531 patients. J Heart Valve Dis. 1997;6
:591–593.
Kumar AS, Saxena A. Intraoperative transoesophageal echocardiography (ITEE) in mitral valve surgery. Ind J Thorac
Cardiovasc Surg. 2009;25:107–111.
Kumar AS, Talwar S, Saxena A, et al. Results of mitral valve repair in rheumatic mitral regurgitation. Interact Cardiovasc
Thorac Surg. 2006;5:356–361.
Mohanty SR, Choudhary SK, Ramamurthy S, et al. Isolated congenital mitral leaflet cleft: A rare cause of mitral insufficiency. J
Heart Valve Dis. 1999;8:67–70.
Murala JS, Kumar AS. Long-term results of cusp-level chordal shortening for anterior mitral leaflet prolapse. Tex Heart Inst J.
2004;31(3):246–250.
Pavankumar P, Venugopal P, Kaul U, et al. Closed mitral valvotomy during pregnancy. A 20-year experience. Scand. J. Thor.
Cardiovasc. Surg. 1988;22:11–15.
Reddy SM, Talwar S, Velayoudam D, et al. Multi-modality blood conservation strategy in open-heart surgery: An audit. Interact
Cardiovasc Thorac Surg. 2009;9:480–482.
Talwar S, Jayanthkumar HV, Sharma G, et al. Quadrivalvular rheumatic heart disease. Int J Cardiol. 2006;106(1):117–118.
Talwar S, Rajesh MR, Subramanian A, et al. Mitral valve repair in children with rheumatic heart disease. J Thorac Cardiovasc
Surg. 2005;129:875–879.
21
Catheter-based Mitral Valve Procedures: Balloon Mitral
Valvuloplasty and MitraClip
Michael S. Kim and John D. Carroll
Part 1. Balloon Mitral Valvuloplasty
INDICATIONS
Balloon mitral valvuloplasty (BMV) or valvotomy is recommended for symptomatic and some
asymptomatic patients with pulmonary hypertension who have rheumatic mitral stenosis (MS). An
alternative name for BMV is percutaneous transcatheter balloon mitral commissurotomy and the
indications for BMV are analogous to those used for surgical commissurotomy.
Severe MS: A mitral valve area <1.5 cm2, typically producing a resting transmitral gradient well
above the 5 to 6 mm Hg range
MS primarily produced by fused commissures
No more than mild (2 plus) mitral regurgitation
Before the widespread use of echocardiography, valve morphology was assessed by physical
examination. The constellation of findings denoting a patient likely to benefit from commissurotomy
include a loud first heart sound, the presence of a crisp opening snap (OS), a short S2-OS interval, and
the absence of signs of important mitral regurgitation including an apical systolic murmur and signs of
significant left ventricular volume overload.
Echocardiography confirms the diagnosis of MS, characterizes the anatomic factors contributing to
obstruction, and rules out contraindications to BMV therapy. The Wilkins score (Table 21.1) is derived
from echocardiographic features of the mitral valve and is often predictive of long-term outcome. The
score ranges from 4 to 16 by summing four anatomic characteristics each of which receive a grade of 1
to 4, with higher scores indicative of more extensive disease. A Wilkins score 8 portends a favorable
long-term result of BMV. The Wilkins score does not include an assessment of commissural fusion.
TABLE 21.1 Wilkins Echocardiographic Score
Patients with elevated Wilkins score may undergo BMV if they are at prohibitive risk for open
surgery. These MS patients are often elderly, have advanced valve deformities, undergo BMV to
achieve goals of palliation of symptoms, and are often treated in the United States or other countries
where rheumatic fever has been eradicated for years. The clinical pearls in this group of patients include:
(1) the reduction in mitral gradient is often less that those with optimal mitral anatomy for BMV; (2) the
risk of producing severe mitral regurgitation remains low, a blessing since surgical valve replacement is
not an option; (3) the durability of benefit is often only 2 to 5 years, clearly less than the 10 years or
more following BMV in the optimal commissurotomy candidate.
CONTRAINDICATIONS
BMV is contraindicated in the following patients:
Surgically eligible patients with extensive mitral valve deformities including extensive
subvalvular disease.
Moderate to severe mitral regurgitation.
MS due to mitral annular calcification.
MS due to bioprosthetic valve deterioration.
Left atrial appendage (LAA) or interatrial thrombus.
Clinical pearls have emerged in defining patients in whom BMV is relatively contraindicated due to
suboptimal features of the commissures.
If only one commissure is fused since the expanding balloon is less likely to result in splitting.
If either commissure has markedly increased echocardiographic density including calcification
since it may not split and the force of the expanding balloon could tear the anterior leaflet away
from the annulus.
There are several important preoperative preparations.
Is transseptal catheterization expected to be feasible and straightforward? IVC filters may
preclude transseptal catheterization especially if there is evidence of thrombus or chronic
occlusion of the filter. Patients with scoliosis may have distortion of the intrathoracic position of
the interatrial septum in relationship to the IVC making transseptal catheterization difficult.
Pacemaker leads are not an obstacle to transseptal catheterization but if recently placed they can
be displaced if care is not taken. Finally, some patients have a very thick septum that may make
puncture difficult. The use of radiofrequency energy may or may not be effective versus needle
puncture.
Are there abnormalities of the left atrium that may affect the safety of the procedure? Thrombus
in the left atrium must be excluded by transesophageal echocardiography (TEE) before BMV.
While care can be taken in manipulating catheters within the left atrium especially by using 3D
TEE imaging, inadvertent excursions of a catheter into the LAA may occur and result in
systemic embolization. Therefore, finding an LAA thrombus usually results in delaying BMV
until full anticoagulation has dissolved the thrombus.
Scheduling the time and location of BMV is important because of the potential complication of
inducing severe mitral regurgitation. BMV should be performed in centers that have immediate
access to mechanical left ventricular assistance and the ability to convert the patient to open
surgery. BMV has not traditionally been performed in hybrid operating rooms because it is
possible to stabilize most of these patients who develop severe mitral regurgitation with a
combination of intra-aortic balloon counterpulsation and sodium nitroprusside infusion.
The type of image guidance to be used must be defined as well as the type of anesthesia. There
are multiple ways of performing and guiding BMV. Conscious sedation and using only
fluoroscopic guidance may be done but the lack of echocardiographic guidance of the
transseptal puncture increases the risk of cardiac perforation and tamponade. Centers may
utilize intracardiac ultrasound, transthoracic echocardiography, or TEE to visualize the septum,
guide transseptal puncture, and use in subsequent steps of the procedure. Echo Doppler has
replaced catheter-based assessment of changes in the transmitral gradient and changes in the
degree of mitral regurgitation. We have moved to a model of general anesthesia with 3D TEE
guidance for most of our patients because of these safety issues as well as the principle that a
successful procedure has an anatomical endpoint of as complete of a commissurotomy as
possible. This endpoint is best assessed with 3D TEE. Furthermore, using 3D TEE decreases the
use of fluoroscopy and this reduces radiation exposure.
SURGERY
BMV may be performed either in the antegrade or retrograde approach and may utilize either a single-
or double-balloon technique. The most common approach, however, is the antegrade approach using the
Inoue balloon catheter. Dr. Kanji Inoue, a Japanese cardiac surgeon, developed the Inoue catheter that
was first used in 1982. A subsequent clinical trial in the United States and Canada lead to FDA
approval. The Inoue balloon is unique in that it is a self-positioning balloon composed of three sections
with distinct elastic properties (Fig. 21.1). The balloon catheter allows for both rapid inflation and
deflation such that the transient hypotension is not typically sensed in the conscious patient.
The Inoue kit consists of the Inoue balloon catheter, a stretching tube that elongates the balloon at the
tip of the catheter, a dilator for dilating the subcutaneous tissue and interatrial septum, a stainless steel
guidewire for guiding the insertion of the dilator and Inoue catheter, a stylet that helps direct the Inoue
catheter across the valve, and a calibrated syringe used to inflate the balloon to a desired diameter. The
3D TEE guidance to perform these steps is illustrated in Figure 21.2.
The BMV procedure utilizing the Inoue balloon catheter consists of the following steps:
A general diagnostic evaluation (right heart catheterization and possible coronary angiography)
may be needed. This is preferably done in the conscious, sedated patient.
Figure 21.1 Inoue percutaneous transcatheter balloon mitral commissurotomy. This four-panel figure of x-ray
images shows the sequential balloon shape changes. In the final panel the indentation in the middle section of the
balloon has disappeared due to the splitting of the commissures by the inflated balloon. (From Vahanian A, Himbert
D, Brochet E, et al. Percutaneous mitral commissurotomy. In: Carroll JD, Webb J, eds. Manual of Structural Heart
Disease Interventions. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.)
A transseptal puncture is used to obtain direct access to the left atrium. This is guided by
echocardiography and fluoroscopy. The location of the transseptal puncture on the atrial septum
need not be precise but should be located in the fossa ovalis. If a patent foramen ovale is present
this may be used with caution since a rigid tunnel can prevent catheter manipulation needed to
cross the mitral valve and align it properly.
Following successful transseptal puncture, the patient is anticoagulated (most commonly with
heparin) with an ACT of 250 to 300 seconds as the target.
A 12-Fr dilator dilates the interatrial septum.
The guidewire is positioned in the left atrium and used to remove the diagnostic transseptal
sheath and to insert the Inoue catheter.
The slenderized Inoue balloon catheter is advanced across the septum into the left atrium over
the wire. Care must be taken to not forcefully push the catheter through the septum and cause a
tear. A gentle rocking motion is usually effective.
Once the balloon portion of the catheter is across the septum, it is unslenderized by removal of
the balloon stretching tube with the subsequent ability to advance the curved and flexible
catheter down to the mitral valve.
Crossing the stenotic valve is completed using a combination of fluoroscopic and ultrasound
guidance. A stylet is inserted into the central lumen of the Inoue balloon catheter and advanced
to the tip. By pulling back the stylet a few inches the catheter moves forward. If the trajectory is
correct the catheter passes into the left ventricle.
Figure 21.2 Intraprocedure guidance of BMV shown in 3D TEE images. A: The Inoue catheter entering from the
inferior vena cava (IVC) into the right atrium (red asterisk) passing through the fossa ovalis (FO) and ending in the
left atrium (yellow asterisk). B: The Inoue catheter has been advanced into the left atrium over the stainless steel
wire. C: The catheter with deflated balloon (red arrow) is being directed toward the narrow mitral valve. D: The
catheter has entered the mitral valve orifice. E: The Inoue catheter is seen from a four-chamber perspective through
the mitral orifice and is well aligned in the left ventricle. F: The inflated balloon (B) overriding the mitral annulus; a
waist is formed by the stenotic mitral valve. AV, aortic valve; LA, left atrium; RA, right atrium; SVC, superior vena
cava. (From Salcedo EE, Carroll JD. Echocardiography in patient assessment and procedural guidance in structural
heart disease interventions. In: Carroll JD, Webb J, eds. Manual of Structural Heart Disease Interventions.
Philadelphia, PA: Lippincott Williams & Wilkins; 2011.)
Before performing balloon inflation, care is taken to be sure the tip of the catheter is freely
moving and aligned with the centerline through the valve orifice. Partially inflating the distal
portion of the Inoue balloon may assist in determining the central location of the balloon, away
from chordal structures.
The balloon is inflated with a calibrated syringe after positioning to insure the central portion of
the balloon, the last portion to be fully expanded, is locked on the valve over the fused
commissures. During the final part of the inflation sequence there is often a sudden and distinct
expansion of the central portion of the balloon expands corresponding to commissures being
split.
After the initial inflation the mitral gradient and the degree of mitral regurgitation are
determined using echocardiography and Doppler. If moderate to severe mitral regurgitation has
been produced, then the procedure is over. On the other hand if mitral regurgitation is not a
problem and a significant gradient persists and the commissures are not completely split then
another inflation is performed with a larger volume of the saline-contrast mixture. This is
referred to as the step-wise inflation of the balloon starting at an inflation volume that produces
a balloon diameter approximately 4 mm less than the nominal diameter.
When the best result has been achieved, that is, maximum reduction in gradient with least
increase in mitral regurgitation, the Inoue catheter is removed over the guidewire after
slenderizing the catheter.
Before the venous access site is closed it is important to assess the interatrial septum. It is
expected that a small atrial septal defect has been created and this typically seals within a few
months. Occasionally, a larger defect is created or there is right to left shunting through the
defect that causes systemic oxygen desaturation. The defect is then closed with the
commercially available septal closure devices.
The venous access site can be closed by manual compression, with or without reversal of the
heparin. Alternatively, suture closure techniques can be used.
Videos of the procedure are available online.
Postprocedure monitoring after BMV is similar to other transcatheter procedures. Most major
complications occur during the procedure, but postprocedure monitoring of vital signs, heart rhythm,
access site, and the patient’s symptoms are key for the first 6 to 12 hours after the procedure. After a
successful uncomplicated procedure the patient does not have to be in an intensive care unit. Most
patients are discharged the next morning. A postprocedure transthoracic echocardiogram is essential to
establish the final result. Anticoagulation is resumed in those with atrial fibrillation or a history of
thromboembolic events.
COMPLICATIONS
The major potential complications during BMV are outlined in Table 21.2. In experienced centers the
overall major complication rate from BMV remains <1% of cases with the exception of moderate to
severe mitral regurgitation that occurs in 5% to 7%.
While some degree of MR following BMV is both understandable and clinically acceptable (up to
30% of patients undergoing BMV demonstrate an increase in MR associated with a net clinical benefit
overall through reduction in stenosis), severe MR remains the most serious complication of BMV.
Severe acute MR following BMV remains a relatively uncommon complication (occurring in <3%) but
may require urgent/emergent surgical mitral valve replacement.
RESULTS
The long-term clinical impact of BMV is heavily contingent on several factors including baseline patient
characteristics, derived Wilkins score, prior history of BMV or other mitral valve intervention, and
technical results of the procedure itself (i.e., final valve area, quality of commissural splitting/opening,
presence/absence and degree of MR). Randomized trials established the role of BMV versus surgical
commissurotomy. The overall long-term results of BMV have an event-free survival approaching 70%
at 5 years in “ideal” patients (e.g., low Wilkins score). If the immediate procedural/anatomic results of
BMV are favorable with demonstration of bicommissural splitting with a calculated mitral valve area
>1.5 cm2 in the absence of significant MR, survival rates are excellent and functional improvement is
often prolonged. In contrast, patients with severe leaflet deformities and/or subvalvular disease (e.g.,
high Wilkins score) demonstrate 5-year event-free survival rates of 50% at best following BMV.
TABLE 21.2 Complications of Balloon Mitral Valvuloplasty
CONCLUSIONS
BMV is used throughout the world as the initial treatment of MS that is rheumatic in nature with fused
commissures, the therapeutic target for the force exerted by balloon inflation. The procedure is
performed in the cardiac catheterization laboratory and the patient usually can go home the next day.
The results are highly dependent on the degree of valve deformity with a spectrum of an excellent
long-term result as with traditional surgical commissurotomy to a palliative and shorter-term reduction
in MS in patients with no other therapeutic options. The major complication is the induction of mitral
regurgitation in 5% to 7% of patients. As rheumatic fever continues to be prevented throughout the
world, rheumatic MS will become rare although it will take decades for the pool of affected individuals
to diminish.
Part 2: MitraClip
INDICATIONS/CONTRAINDICATIONS
The indications for MitraClip are evolving. In the United States, MitraClip is only approved for use in
patients with degenerative mitral regurgitation (DMR) who are prohibitive risk for mitral valve surgery.
Use of MitraClip in patients with functional mitral regurgitation (FMR) remains investigational. Outside
of the United States, MitraClip use is expanding and in most countries is being used for the treatment of
both DMR and FMR.
While there are many common themes between the indications for DMR and FMR, this chapter will
focus on the specifics of indications for DMR.
Symptomatic patients with DMR who are at prohibitive risk for mitral valve surgery are
candidates for MitraClip if the valve characteristics are suitable for this edge-to-edge clipping
technique. Strict criteria were used to determine anatomical eligibility during clinical trials.
Presently in real world use there are evolving modifications to these criteria. The following
characteristics with potential modifiers should be considered:
The degree of mitral regurgitation should be at least moderately severe using the
criteria established by echocardiographic professional societies.
The location of the mitral regurgitation should be primarily in the A2-P2 segment since
placement of MitraClip in this location avoids chordae tendinae. More experienced
operators, however, have successfully placed MitraClip more medially and laterally
without becoming entrapped in the subvalvular apparatus.
The clip must grasp the leaflets and thus there should not be excessive thickening or
calcification.
Flail leaflets, especially those whose edge is more than 10-mm deep in the left atrium,
are a relative contraindication because of the inability to grasp the pathology.
Experienced operators may place a first clip in an adjacent segment that can be grasped
and potentially reduce the extent of flail. Additional clips are then placed in the major
flail segment. A similar strategy may be used in prolapsing segments.
Contraindications include the following patient and anatomical characteristics:
Patients with baseline resting elevated mitral gradients should be excluded since MitraClip
reduces the mitral orifice and clinically important MS may be produced. Mitral annular
calcification, prior surgical annular ring implantation, and small annuli are scenarios where
MitraClip may be contraindicated.
Some patients may have such a burden of comorbid conditions that reduction in the degree of
mitral regurgitation may be of little to no benefit. Until objective data are available from the
TVT registry and other sources, physician judgment is the major mechanism of making this
determination.
Inability to perform a safe transseptal catheterization.
Leaflet abnormalities precluding secure grasping.
The planning for MitraClip includes the following key steps:
The patient must be evaluated by a multidisciplinary team that can make a determination of the
following:
Surgical risk.
Nature and degree of mitral regurgitation.
Anatomical suitability for MitraClip.
Likelihood of patient benefitting from the procedure at an acceptable risk.
The role of both transthoracic and TEE is central to patient selection and planning.
The location of the transseptal puncture is based on determination of both the plane of
the mitral annulus but also the location of leaflets to be grasped. In DMR this may be
above the annulus and in FMR it often is below.
The likelihood of one or two clips.
The optimal location for placement of the first clip.
Identifying potential challenges including leaflet grasping, and production of a mitral
gradient making a two-clip strategy not feasible.
Many patients undergoing MitraClip will be frail, have major comorbidities, and other
characteristics that need to be considered in terms of pre-, intra-, and postprocedure planning.
During the preprocedure period, some patients may need careful discontinuation of
anticoagulation, optimization of medical therapy, and hydration to prevent contrast
nephropathy.
Intraprocedure planning involves knowing what initial diagnostic imaging or
hemodynamic assessment is needed, whether monitoring with arterial pressure lines is
needed, whether a Foley catheter is needed, and the plan for closure of femoral venous
site of the 24-Fr catheter.
Postprocedure planning needs to determine the location for postprocedure care, the
likelihood of a timely discharge or the need for further medical treatment, and the
likelihood of discharge to home versus a rehabilitation facility.
SURGERY
Room Setup and Positioning
Patients undergoing MitraClip typically have three teams participating in the procedure and the room
setup must be optimized for these teams.
The interventional team typically consists of two individuals who are scrubbed and will perform
the MitraClip system manipulations.
The anesthesiology team will administer general anesthesia, maintain rhythm and hemodynamic
stability during the procedure, and administer medications rather than the cath laboratory staff.
Patient’s undergoing MitraClip are usually quite stable. The anesthesiology team needs to be
sure that arterial pressure is at sufficient levels to allow assessment of mitral regurgitation at
baseline and after leaflet grasping.
The echocardiography team consists of a sonographer and an expert echocardiographer with
experience in 3D TEE in guiding interventions. MitraClip guidance has been improved with 3D
TEE.
All parties should have shielding from radiation. All should have the ability to observe the ultrasound
and fluoroscopy images used during the procedure. The x-ray gantry system is placed to the right of the
patient to allow access to the patient’s head by the anesthesiology and echocardiography teams.
The MitraClip system is not handheld but is placed in a stabilizer that is placed on a lift that straddles
the patient’s right leg (Fig. 21.3). Before draping, a support plate for the lift and stabilizer is placed
under the patient’s leg. The lift is placed on the support plate such that the front is approximately 80 cm
from the patient’s midsternum. The draping is then completed.
Technique
Following patient preparation, draping, and anesthesia induction, vascular access is obtained from the
right femoral vein, left femoral vein, and an arterial location, either radial or femoral artery.
Figure 21.3 The MitraClip System. (From Cilingiroglu M, Feldman T. Percutaneous mitral valve repair: Edge-to-edge
approach. In: Carroll JD, Webb J, eds. Manual of Structural Heart Disease Interventions. Philadelphia, PA: Lippincott
Williams & Wilkins; 2011.)
The right femoral vein is used to insert the guiding catheter for the MitraClip clip delivery
systems (CDSs). The skin nick must be large enough to allow passage of this 24-Fr catheter.
Before insertion of the large guiding catheter, two Perclose sutures may be deployed for
“pre-closure” and isolated for later use.
The left femoral vein is used to return blood removed by a large volume syringe used to create
negative suction on the side port of the guiding catheter during removal of the dilator and CDS.
The arterial access is used for monitoring arterial pressure. Frequently the anesthesiology team
wants to hook up to the side port of this small caliper sheath to provide their monitoring
software with a continuous arterial pressure waveform.
An overview of the MitraClip system consists of the CDS that is introduced into the body through a
steerable guide catheter (Guide). The CDS consists of three components: The steerable sleeve, the
delivery catheter, and the MitraClip device (Fig. 21.3). The stabilizer supports and positions the
steerable guide catheter and CDS during the procedure.
The steps used to perform MitraClip are summarized from a checklist of over 100 distinct steps
described in the instructions for use. In addition to these technical steps there are numerous decision
nodes during the procedure when the team discusses progress, problems, and makes decisions regarding
the various manipulations, interpretation of changes in the ultrasound characterization of the mitral
regurgitation, and whether to proceed with a second clip or not. Figure 21.4 shows some of the key steps
as guided by 3D TEE. A video of an animated MitraClip procedure is available online.
Transseptal catheterization is performed at a location such that the delivery catheter will be
approximately 4.0 cm above the point of leaflet coaptation.
The patient is heparinized to an ACT between 250 to 300 seconds.
Endocarditis prophylaxis is given.
The delivery catheter and CDS are prepared to de-air all lumens, flush all ports and lines with
heparinized saline, and test the functionality of all components of the system.
The initial transseptal sheath is removed after placing a stiff, long exchange wire in the left
upper pulmonary vein. Often a right Judkins-shaped coronary catheter is used to direct the wire
into the pulmonary vein.
The skin entry point is dilated with an 18 or 20-Fr vascular dilator.
Figure 21.4 TEE guidance for MitraClip. A,B: Three-dimensional transesophageal echocardiography images
obtained during the MitraClip procedure shows important steps in aligning to clip to the leaflets. A: A view of the
mitral valve from the left atrium; note that the clip is over A2-P2 and is oriented perpendicular to the mitral leaflets
line of coaptation. B: The LVOT view shows the open arms and leaflets. C,D: The leaflets have been grasped
producing the double orifice mitral valve as seen from the left atrium (C) and from the left ventricle (D). E: The
presence of severe mitral regurgitation prior to MitraClip placement is contrasted to ( F) the presence of only mild
mitral regurgitation with MitraClip placement. AV, aortic valve. (From Salcedo EE, Carroll JD. Echocardiography in
patient assessment and procedural guidance in structural heart disease interventions. In: Carroll JD, Webb J, eds.
Manual of Structural Heart Disease Interventions. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.)
The steerable guide catheter–dilator assembly is inserted after turning the +/– knob to the
negative side to straighten the distal curve of the guide catheter.
The guide catheter–dilator assembly is advanced over the wire to the interatrial septum. The
straightening of the distal curve is reversed and the assembly is slowly advanced across the
septum avoiding excessive force that could rip the tissue.
The stabilizer is now placed on the lift and the guide is placed in the stabilizer.
The dilator is pulled back inside the guide to allow echocardiographic assessment of the amount
of guide across the septum.
The dilator and wire are removed from the guide while slowly suctioning the guide lumen with
a large syringe connected to the side port of the guide. The guide is then flushed.
The CDS is next inserted into the guide using the introducer to protect the MitraClip device.
The proper alignment of the CDS within the guide is important.
The CDS is advanced outside the guide into the left atrium until the two radiopaque markers on
the CDS are straddling the end of the guide. Care should be taken to prevent the tip of the CDS
from contacting the roof of the left atrium.
The CDS is deflected using the “M” knob on the sleeve paying careful attention to the
ultrasound image that the CDS clears the “warfarin ridge” (warfarian ridge—the ridge of atrial
tissue separating the left atrial appendage from the left upper pulmonary vein).
At this point the CDS is adjusted using the “M” knob, other positioning knobs, and the whole
system may be advanced or retracted to produce a straight trajectory of the CDS toward the
A2-P2 segment.
The clip is opened and the CDS is turned to align the open clip arms to be perpendicular to the
A2-P2 leaflets.
The CDS is then advanced across the mitral valve and below the open leaflets.
The clip is closed to 120 degrees, the grippers are in the raised position, and then the CDS is
slowly retracted until both leaflets continuously lay on each open arm of the clip.
At this point the grippers are lowered and the clip is partially closed (Fig. 21.5).
The assessment of the leaflet grasp is then performed with initial attention to the amount of
leaflet tissue grasped. Subsequently the effect of the leaflets being grasped and held by the
completely closed clip focuses on the degree of mitral regurgitation reduction and the mitral
pressure gradient in diastole that is produced.
If the result is acceptable, then the clip is released in a series of steps that verify the adequacy
and stability of the grasp before the CDS separates from the MitraClip.
The CDS is removed after reducing the sleeve and guide catheter curves and avoiding the distal
sharp tip of the CDS from touching the left atrial wall.
The result is assessed and a decision is made whether or not a second clip is placed.
If a second clip is placed, the technique is similar except for crossing the valve with the CDS.
During this step the clip is closed to minimize the chance of dislodging the first clip during
advancement into the left ventricle.
Once the final result has been achieved the guide is pulled back into the right atrium. Ultrasound
is used to assess the residual atrial septal defect.
The heparin is reversed with protamine and the guide is removed with simultaneous cinching of
the two predeployed sutures to achieve hemostasis of the right femoral vein.
Anesthesia is discontinued, the patient is extubated, and moved to a recovery or other clinical
unit.
Figure 21.5 MitraClip leaflet grasping. This schematic illustrates the MitraClip function with both the clip arms and
the grippers. The middle panel shows the mitral leaflets as they are captured between the grippers and the clip
arms. Note the leaflet tips are deeply imbedded in the MitraClip that is partially closed. The procedure often involves
both grasping the leaflets but also releasing them until an optimal result is obtained. The MitraClip is not released
from the CDS until success is achieved. (Modified from Cilingiroglu M, Feldman T. Percutaneous mitral valve repair:
Edge-to-edge approach. In: Carroll JD, Webb J, eds. Manual of Structural Heart Disease Interventions. Philadelphia,
PA: Lippincott Williams & Wilkins; 2011.)
The key issues in the initial postprocedure period are assessment of the patient’s hemodynamic and
clinical status. It is important to assess volume status since during the procedure the patient receives
continuous flushing of the MitraClip system. Oftentimes, administration of intravenous diuretic is
needed immediately post-procedure. Checks for access bleeding are frequent. Assessment of neurologic
status is routine. The patient is loaded with dual antiplatelet agents. This may be modified if the patient
must also take warfarin.
In the next 24 hours the patient should be ambulating and assessed for discharge planning. The
morning after the procedure, a transthoracic echocardiogram provides a good assessment of the result in
terms of the degree of residual mitral regurgitation, the mitral gradient in diastole, the estimated
pulmonary artery systolic pressure, and the location and stability of the MitraClip(s).
COMPLICATIONS
The complications that can occur with MitraClip therapy include partial clip detachment (resulting in
“single leaflet device attachment” [SLDA]), thrombus formation on the catheter, chordae tendinae
entrapment by the MitraClip, pericardial effusion or tamponade, persistent atrial septal defect, cardiac
arrhythmias, and air embolism. These complications can occur in those with either DMR or FMR.
The complications that may occur in a patient group classified as having DMR and prohibitive risk
for surgery were identified and quantified in data that have been published and were presented to the
FDA expert panel that voted to approve MitraClip for DMR. These patients had a mean age of 82 years
and the expected major burden of comorbid conditions making them prohibitive risk. The 30-day
complication rates were death (6.3%), myocardial infarction (0.8%), stroke (2.4%), renal failure (1.6%),
wound infection (0%), ventilation for more than 48 hours (3.1%), transfusion of 2 or more units
(12.6%), major vascular complications (5.5%), major bleeding complications (12.6%), need for
permanent pacemaker (0%), significant atrial septal defect (1.6%), and mitral valve stenosis requiring
intervention (0%).
RESULTS
The outcomes of patients undergoing MitraClip have been published and were presented to the FDA
expert panel that voted to approve MitraClip for DMR. The median procedure time of the prohibitive
risk DMR cohort was 134 minutes with a minimum of 39 and a maximum of 524 minutes. The
MitraClip device was successfully implanted in 95.3% of patient with 44% receiving one and 51%
receiving two clips.
At discharge 82.1% of surviving patients had mitral regurgitation that was 2 plus or less and 53.7%
had mitral regurgitation of 1 plus or less. 17.9% of patients had moderate to severe to severe mitral
regurgitation at discharge. At 12 months 83.3% of patients still had 2 plus or less mitral regurgitation.
Freedom from death and mitral regurgitation at 12 months was 61.4% and for 1 plus or less mitral
regurgitation was 27.2%. There was no evidence of worsening of MR severity from 12 months to 2
years in surviving patients.
In patients with paired data, left ventricular volume at end diastole declined from 125 + 40 to 108 +
38 mL at 12 months. Improvement in NYHA Class was noted at 30 days with 82.3% of surviving
patients reporting NYHA Class I or II symptoms. At 12 months the majority (86.9%) of surviving
patients reported NYHA Class I or II symptoms. There was a 73% reduction in the rate of
hospitalization for heart failure following discharge from the MitraClip procedure (0.67 to 0.18 per
patient-year).
CONCLUSIONS
MitraClip therapy has entered clinical use in the United States and multiple countries around the world.
For such a technically complex procedure the procedure-related complications are low. The majority of
patients have a successful procedure with placement of one to two clips without major complications.
They subsequently show objective evidence for a significant and sustained reduction of mitral
regurgitation that correlates with remodeling of the volume-overloaded left ventricle. The patients have
been demonstrated to have clear improvement in their functioned state, quality of life, and a major
reduction in hospitalization rates for heart failure. The 30-day and 1-year outcomes are significantly
influenced by the characteristics making the patient a prohibitive operative risk. The results of over
1,000 patients undergoing MitraClip in the United States after FDA approval will soon be reported
based on data gathered in the TVT Registry.

Beigel R, Wunderlich NC, Kar S, et al. The evolution of percutaneous mitral valve repair therapy: Lessons learned and
implications for patient selection. J Am Coll Cardiol. 2014;64:2688–2700.
Carroll JD, Feldman T. Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. JAMA. 1993;270
:1731–1736.
Eng MH, Salcedo EE, Kim M, et al. Implementation of real-time three-dimensional transesophageal echocardiography for mitral
balloon valvuloplasty. Cathet Cardiovasc Interven. 2013;82:994–998.
FDA executive summary for the March 20, 2013 meeting of the Circulatory System Devices Panel. Available at: http://www.fda
.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee
/CirculatorySystemDevicesPanel/UCM343842.pdf
Feldman T, Herrmann HC, Inoue K. Technique of percutaneous transvenous mitral commissurotomy using the Inoue balloon
catheter. Cathet Cardiovasc Diagn. 1994;Suppl 2:26–30.
Feldman T, Young A. Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 2014;63:2057–2068.
Kim M, Carroll JD. Valvuloplasty. In: Moscucci M, ed. Complications of Cardiovascular Procedures. Lippincott Williams &
Wilkins; 2011:343–355.
MitraClip instructions for use with summary of safety and efficacy data on degenerative mitral regurgitation. http://www
.abbottvascular.com/docs/ifu/structural_heart/eIFU_MitraClip.pdf
Quaife RA, Salcedo EE, Carroll JD. Procedural guidance using advanced imaging techniques for percutaneous edge-to-edge
mitral valve repair. Curr Cardiol Rep. 2014;16:452–461.
Singh GD, Smith TW, Rogers JH. Multi-MitraClip therapy for severe degenerative mitral regurgitation: “Anchor” technique for
extremely flail segments. Catheter Cardiovasc Interv. 2015;86(2):339–346.
Video of an animation of the MitraClip procedure. Available at: http://www.abbottvascular.com/us/products/structural-heart
/mitraclip.html
Video of the Inoue procedure. Available at: https://www.youtube.com/watch?v=coYqKQjpZhM
Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: An analysis of
echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60:299–308.

FrederickGrover 2016 PARTIVMITRALVALVEPROC MasterTechniquesInSur

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

FrederickGrover 2016 PARTIVMITRALVALVEPROC MasterTechniquesInSur

Uploaded by

Copyright:

Available Formats

Part IV

Mitral Valve Procedures

Surgical Technique in Type I Dysfunction

Surgical Technique in Type II Dysfunction

Posterior Leaflet Prolapse

In cases of concentrated myxomatous degeneration (isolated one-segment disease in an otherwise

Anterior Leaflet Prolapse

Surgical Technique in Type IIIA Dysfunction

Surgical Technique in Type IIIB Dysfunction

Systolic Anterior Motion (SAM)

Degenerative Mitral Valve Disease

Rheumatic Mitral Valve Disease

Secondary Mitral Valve Disease

Recommended References and Readings

AHA/ACC Guidelines 2014

Surgical Set-up and Cannulation

Mitral Valve Exposure Through Sondergaard’s Groove

Transseptal Approach to the Mitral Valve

Figure 17.1 Mitral valve exposure through Sondergaard’s groove.

Chordal-Sparing Mitral Valve Replacement With Resection of the Belly of the

Stitch Placement With Mitral Annular Calcification

Figure 17.4 Stitch placement with mitral annular calcification.

Structures Surrounding the Mitral Annulus

Figure 17.5 Structures surrounding the mitral annulus.

Recommended References and Readings

INDICATIONS AND CONTRAINDICATIONS

TABLE 18.1 Contraindications: Minimally Invasive Mitral Valve Surgery

TABLE 18.2 Transesophageal Echocardiographic Planning Data

TABLE 18.3 Echo-Based Annuloplasty Banda Sizing

Figure 18.3 Transthoracic aortic clamp.

The Robotic Cardiac Team

The da Vinci Surgical System

Trocar Placement and Instruments

Robot-assisted Mitral Valve Repairs

Posterior Leaflet Repairs

Anterior Leaflet Repairs

Robot-assisted Mitral Valve Replacements

Robot-assisted Mitral Valve Reoperations

COMPLICATIONS AND SOLUTIONS

TABLE 18.5 Perfusion and Aortic Clamping: Pitfalls and Prevention

TABLE 18.6 Pulmonary: Pitfalls and Prevention

TABLE 18.7 Ventricular Dysfunction: Pitfalls and Prevention

Recommended References and Readings

Closed Mitral Commissurotomy

Figure 19.4 Tubb’s dilator in an open position.

Open Mitral Commissurotomy

Figure 19.9 Placement of a mitral ring, after completing open commissurotomy.

COMPLICATIONS OF CLOSED AND OPEN MITRAL

RESULTS OF CLOSED AND OPEN MITRAL

Recommended References and Readings

Exposure of the Mitral Valve

Weaning from CPB

Recommended References and Readings

Part 1. Balloon Mitral Valvuloplasty

TABLE 21.1 Wilkins Echocardiographic Score

TABLE 21.2 Complications of Balloon Mitral Valvuloplasty

Recommended References and Readings

You might also like