Avoiding the Breastbone
Mitral valve surgery, whether repair or replacement can be performed in two different ways. Sternal-sparing or via a sternotomy approach. Sternotomy means, opening the sternum in half. This is the conventional approach that has existed for many decades. Some surgeons prefer this approach, as it may be more familiar to them.
Positioning in the operating room for a minimally invasive mitral valve operation. Both repairs and replacements can be performed with this approach as well as as combined valve operations like mitral valve repair and tricuspid valve repair simultaneously. Other operations that can be performed with this approach are resection of cardiac tumors, cardiac ablations for atrial fibrillation (Maze procedures) and closures of holes in the heart or atrial septal defects.
Take Home Points:
Mitral valve disease is best treated with a minimally invasive approach.
The right minithoracotomy approach is the most time tested minimally invasive approach
Minimally invasive approaches are performed by less than 30% of all cardiac surgeons
The Right Minithoracotomy or Keyhole Approach
A right minithoracotomy approach in a woman. The right minithoracotomy approach has 1-2 5mm incisions (if done with a 5mm fiberoptic camera 2, if with a head camera 1). There is a 2 inch incision on the right chest through which the surgeon works.
A sternal sparing approach implies going through a different trajectory to the heart. The most common and most published sternal-sparing approach is the right minithoracotomy through the fourth intercostal space. The incision in this case can be as small or as big as the surgeon feels comfortable with. Some make the incision 1¼ inch while some make it 4 inches. This approach implies making the skin incision and then going between the ribs without cutting them. Large muscle groups such as the pectoralis major are not cut, but reflected or moved aside to allow access. With this approach a small 1 ¼ to 2-inch incision is also made in the groin for femoral artery and vein cannulation for the heart lung machine. In the right minithoracotomy approach the surgeon performs all the work directly in the heart using long-shafted instruments and more advanced techniques to perform the operation.
Minimally invasive mitral valve surgical instrumentation. These instruments can be 12 to 14 inches in length and using them relies on a different set of skills than those using standard open heart instruments.
Cardiovascular anatomy
A right minithoracotomy approach in a man. The right minithoracotomy approach has 1-2 5mm incisions (if done with a 5mm fiberoptic camera 2, if with a head camera 1). There is a 2 inch incision on the right chest through which the surgeon works.
In some cases surgeons may use a 5mm Thoracoscopic camera to show the progress of the operation to the staff and in others to perform the operation wile looking at the screen and not directly into the chest. In all, when the operation is performed through a right minithoracotomy the patient will have a 1 ¼ inch incision on the right chest, a 5mm small incision in the front right chest and a second 5mm incision on the right upper chest. There is a 5mm incision for a chest drain that is removed after surgery. This is the most common approach used by minimally invasive mitral valve surgeons.
Other Minimally Invasive Mitral Valve Surgery Approaches
Robotic assisted mitral valve surgery typically has a series of 8mm port incision between the ribs and often times a larger 1.5-2 inch incision on the right chest.
Another sternal-sparing operation is the robotic assisted operation. Although much hype is created by advertisements of robotic mitral surgery, in reality it offers no advantages to a right minithoracotomy. The operation is conducted internally in a similar fashion with the exception that many surgeons using the robot will implant an incomplete ring or band when doing robotic mitral valve repair a point of controversy as some have demonstrated that this is inferior to a complete ring. The number of incisions measuring 8mm is between 3 and 4 and are accompanied by a main working incision of 1.5-2 inch. A drain is also left in place after surgery.
The last sternal-sparing approach is the fully Thoracoscopic operation using a camera to guide the operation and using instruments via ports in the chest. In the purest form of this technique the implanted annular ring is either a complete ring and flexible or a partial ring to allow its delivery into the chest. This operation also does not provide an advantage over a right minithoracotomy in terms of better outcome.
A three dimensional computerized axial tomography illustration showing the location of the heart and the approach via the right minithoracotomy.
In all, studies on minimally invasive mitral valve surgery have been overwhelmingly done using the right minithoracotomy technique. The data supporting its safety of use, effectiveness, short and long-term successes are as good as that supporting the tried and true median sternotomy approach. Mitral valve repair performed minimally invasive by expert surgeons is known to decrease postoperative pain, blood transfusions, and hospital stay. Although the durability of a repair is not necessarily associated to the approach, inexperienced surgeons may sacrifice quality of repair of the sake of maintaining the minimally invasive approach, a flawed consideration.
Minimally invasive mitral valve operation and the heart-lung machine
Operating room setup and equipment for mini mitral surgery
This is a common setup for minimally invasive mitral valve surgery in the operating room. At the center is the patient; to the left of the image is the surgical assistant and the perfusionist (person who runs the heart lung machine). To the right is the surgeon and the scrub technician. At the top of the image is the anesthesiologist who is also operating the transesophageal echocardiogram, a modern standard in cardiac surgery monitoring.
Positioning in the operating room for mini mitral surgery
Typical positioning of the patient a the time of minimally invasive mitral valve surgery. The incision is shown in black and below it is the chest drain. In the neck is the monitoring IV line called a Swan Ganz catheter. The right groin shows a small incision for the heart lung machine.
What to Expect after a Minimally Invasive Mitral Valve Operation?
Recovery:
One of many benefits of minimally invasive mitral valve surgery is faster recovery. This concept includes time spent in the intensive care unit and hospitalized overall. This also means that pain levels are lower than with a median sternotomy approach. Once home, the time to return to regular activities such as driving, working (even mild to moderate physical work) is shorter. On average, patients return to regular activities by 3 weeks compared to 8 weeks with a sternotomy. While recovering in the hospital patients are encouraged to walk several times a day, they can groom themselves and shower by the end of the hospital stay. At home patients will be very independent and a few days with a caretaker available around the clock is recommended (usually 3-5 days). After this early period at home patients are very independent and will be able to care for themselves. Driving is usually allowed after the first week home provided no narcotics are being used. The major of patients stop taking narcotics the first week home, the rest do not take narcotics after leaving the hospital and the pain control relies on over the counter acetaminophen and ibuprofen.
There are no real restrictions specific to recovering from mitral valve surgery with the exception of a low sodium diet with careful watching to the fluid intake so as to prevent fluid retention which is common after all open heart surgeries.
Most patients go through mild fatigue, and at times slight shortness of breath while walking inclines or stairs in the first few days of getting home. Soreness of the incision on the right chest is common, but it is usually not moderate nor severe.
Most surgeons follow-up patients after minimitral surgery within a month of the operation. By this time patients are close to returning to their regular life activities. Many times a cardiac rehabilitation course is recommended for a period from 1 month to 6 months depending on the preoperative and postoperative status of the patient.
For the most part there are very few activities a person should not do after minimally invasive mitral valve surgery. One is not to submerge in any body of water during the first month. This includes bathtubs, swimming pools, jacuzzis, ocean, ponds and lakes. The other is not to lift heavy objects over 10 pounds for the first two weeks of recovery.