Circumflex Coronary Artery Injury during Modern Mitral Valve Surgery-A Review of Current Concepts and Perspectives

The devastating impact of a circumflex coronary artery (CX) injury during mitral valve (MV) surgery is well reported. Despite significant improvements in preoperative risk assessment, intraoperative diagnosis and perioperative treatment strategies of CX injury during MV surgery, recent reports re-emphasize the variability in presentation, the unpredictable mechanisms of injury and the conflicting evidence regarding perioperative management. The progressive transition from conventional sternotomy access to minimally invasive surgical and transcatheter (TC) interventions for MV disease are associated with significant learning curves and require additional single-shaft and robotic console suture manipulation skills with special attentiveness to the potential risk of CX injury. The introduction of hybrid theatres that facilitate single stage surgical and TC interventions also provides new intraoperative diagnostic and therapeutic options without transporting unstable patients for percutaneous coronary intervention (PCI) assessment. By utilizing a MeSH terms-based PubMed search, a total of 89 patients with CX injury that occurred during MV surgery was identified from 49 reports between 1967 and 2022. MV surgery was performed by conventional sternotomy (n = 76, 85.4%), endoscopic (n = 12, 13.4%) and robotic access (n = 1, 1.1%), with 35 injuries (39.3%) resulting in total CX occlusion. Rescue PCI was utilized in 40 patients (44.9%). This manuscript provides a systematic overview of all available historic and contemporary reports on CX injury during MV surgery, outlines recent refinements in CX injury mechanisms, describes current MV surgery associated CX injury prevention and diagnosis and treatment strategies and highlights important MV procedural aspects that may minimize the risk and consequences of CX injury.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.

Endoscopic mitral valve repair utilizing cavitron ultrasonic surgical aspirator for active endocarditis

Mitral valve repair for endocarditis in an acute setting is still challenging due to difficulties in debriding friable tissue and in leaving enough non-infected tissue for reconstruction. Endoscopic approaches for complex mitral valve procedures via a minimally invasive approach have been reported from high-volume programs. However, the role of endoscopic mitral valve surgery for acute infective endocarditis has not been clearly defined. We report our technique of endoscopic mitral valve repair using the cavitron ultrasonic surgical aspirator system for active endocarditis. The cavitron ultrasonic surgical aspirator with a low power setting provides enough debridement of the infective tissue and leaves healthy tissue adequate for repair under a totally endoscopic vision.

Systematic Review of Minimally Invasive Surgery for Mitral Valve Infective Endocarditis

OBJECTIVE

The scope of application of minimally invasive mitral valve surgery is expanding. However, the safety and efficacy of minimally invasive mitral valve surgery in the setting of infective endocarditis is not well known. We sought to identify the best evidence available to support a minimally invasive surgical approach for mitral valve infective endocarditis.

METHODS

A systematic review of minimally invasive mitral valve surgery for infective endocarditis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 6 manuscripts describing 271 patients were identified. Mean age was 60.4 ± 14.9 years old, and 60.1% patients were male. Mean EuroSCORE II was 24.6 ± 23.2. Mitral valve repair was achieved in 32.4% of cases. The average in-hospital mortality was 9.4%, and average length of hospital stay was 21.6 days. Survival was 89.1% at 30 days, and 1-year survival was 79.3%. Rate of conversion to sternotomy was 1.8%. Postoperative complications included: 6.9% postoperative bleeding, 9.3% new postoperative dialysis, 2.3% postoperative stroke, and 3.4% recurrence of endocarditis. Reoperation over the long-term was required in 9.3% of cases.

CONCLUSIONS

Minimally invasive mitral valve surgery for infective endocarditis has acceptable perioperative morbidity as well as short- and intermediate-term mortality at experienced centers. Minimally invasive mitral valve surgery may be an acceptable alternative approach to infective endocarditis and warrants further study.