Preprocedural Computed Tomography Evaluation for Minimally Invasive Mitral Valve Surgery: What the Surgeon Needs to Know

Evaluation of Patients for Percutaneous Edge-to-edge Mitral Valve Repair: Comparison of Cardiac Computed Tomography Angiography With Transesophageal Echocardiography

PURPOSE

We sought to compare parameters derived from cardiac computed tomography angiography (CCTA) with those from transesophageal echocardiography (TEE) for the evaluation of patients with severe mitral regurgitation (MR) before percutaneous edge-to-edge mitral valve repair (PE2E). TEE is the mainstay for PE2E, although it has specific limitations. CCTA enables measurements in any arbitrary plane with high spatial resolution and offers good calcium visibility.

MATERIALS AND METHODS

Patients who underwent TEE and CCTA before scheduled PE2E at 2 medical centers were included in this retrospective analysis. Quantitative parameters relevant for PE2E were obtained from TEE and CCTA in a blinded manner and the intrareviewer variability was assessed.

RESULTS

All 30 patients (15 female, 76±10 y) had secondary MR attributable to ischemic (60%) or nonischemic cardiomyopathy (40%). On comparing parameters from TEE and CCTA, left ventricular end-diastolic diameter was 60±11 versus 64±11 mm (r=0.90), intercommissural mitral annulus was 35±5 versus 35±5 mm (r=0.88), long-axis annulus was 33±5 versus 33±5 mm (r=0.74), the distance between the fossa ovalis and the leaflet coaptation was 42±5 versus 41±5 mm (r=0.81), the anterior mitral leaflet was 21±6 versus 20±7 mm (r=0.81), the posterior mitral leaflet was 13±2 versus 13±2 mm (r=0.91), and the median mitral calcification was 1 (interquartile range: 0 to 2) versus 0 (interquartile range: 0 to 1; r=0.53), respectively. Intrareviewer agreement was good and excellent for continuous and categorical variables, respectively.

CONCLUSIONS

Our data suggest that evaluation of the mitral valve apparatus with CCTA in patients considered for PE2E is feasible, correlates well with TEE, and offers improved calcium visibility. In selected cases, additional information from CCTA may be helpful for achieving optimal interventional results.

Minimally invasive tricuspid valve surgery

Tricuspid valve disease carries a very unfavorable prognosis when medically treated. Despite that, surgical intervention is still underperformed for tricuspid valve disease due to the reported high morbidity and mortality from a sternotomy approach. This had led to a shift towards maximizing medical therapy for right ventricular failure and, as a result, a more significant delay in surgical referrals with surgical risks when patients are finally referred. Tricuspid valve patients usually have other co-morbidities resulting from their systemic venous congestion and low flow cardiac output. Minimally invasive tricuspid valve surgery provides less tissue injury and, as a result, less trauma during surgery. This provides a hope for both patients and treating doctors to be more open for providing this procedure with less complications. Isolated minimally invasive tricuspid valve surgery is still not performed as widely as expected. This can be partly due to the adverse outcomes historically labelled to tricuspid valve surgery or by the long journey of learning the surgical team would need to commit to with a minimal access approach. In this article we will review the perioperative pathway, and outcomes of isolated minimally invasive tricuspid valve surgery in the available English literature.

Pilot study of totally thoracoscopic periareolar approach for minimally invasive mitral valve surgery. Towards even less invasive?

Introduction

Minimally invasive mitral valve surgery (MIMVS) has become a widely accepted alternative to the standard sternotomy approach for treatment of mitral valve (MV) disease. Because the extent and location of mini-thoracotomies employed for MIMVS vary from center to center, the conclusions regarding superior cosmesis are not generalizable. The totally thoracoscopic periareolar (TTP) – MIMVS technique has been used at our department for minimally invasive cardiac surgery since 2015.

Aim

To report early surgical data as well as mid-term outcomes in patients undergoing TTP-MIMVS.

Material and methods

Between 2015 and 2017, 48 consecutive patients (mean age: 65.4 ±10; 83% men; EuroSCORE II: 5.1 ±4%) underwent TTP-MIMVS due to mitral and mitral/tricuspid valve (TV) disease; patients’ demographics and clinical outcomes were prospectively collected. Kaplan-Meier estimates of survival and freedom from re-intervention were analyzed as well.

Results

Mean follow-up was 1.7 (max 2.5) years. Of 48 patients, 33 (69%) underwent isolated MV repair, 4 (8%) isolated MV replacement and 11 (23%) MV/TV repair. The cardiopulmonary bypass and aortic cross-clamp time was 166 ±70 and 103 ±39 min respectively. There was no conversion to either full sternotomy or a mini-thoracotomy approach. Median (interquartile range) duration of intensive care unit stay was 1.2 (1.0–2.0) days. There was one in-hospital death (2.1%) in the TTP-MIMVS group. No strokes or wound infections were observed. Within the investigated follow-up, the freedom from reoperation rate was 96.4%; remote survival was estimated at 96.9%.

Conclusions

The study proved that TTP-minimally invasive surgery was safe and feasible in mitral and tricuspid valve surgery. It has been associated with superior esthetics. Mitral repairs performed through TTP access are durable in mid-term observation.

Integrate imaging approach for minimally invasive and robotic procedures

Over the past two decades, robotic and minimally invasive cardiac surgery has been continuously refined and is currently an alternative to traditional open-heart surgery for some patients. The parallel evolution of imaging modalities has made robotic surgery safer and more efficient. Here, we review the pre- and post-operative use of computed tomography (CT) in minimally invasive and robotic cardiac procedures.

Totally Endoscopic Robotic Mitral Valve Surgery

Mitral valve dysfunction can seriously impair patients' lives and may require valve repair or replacement. Surgery can be performed using techniques including sternotomy; right thoracotomy with or without robot assistance; and the totally endoscopic robotic technique, which requires percutaneous techniques, femoral cannulation, and endovascular aortic cross-clamping. The totally endoscopic robotic technique has been facilitated by minimally invasive surgical techniques, the evolution of endoscopic techniques, and the development of surgical robots. These advances have enhanced the view of the surgical field and provide better exposure for the repair or replacement of the mitral valve and subvalvular apparatus. This article describes the totally endoscopic robotic approach to mitral valve surgery as performed at Temple University Hospital, Philadelphia, Pennsylvania.