Leaflet Preserving Mitral Valve Repair With Atrial Septal Defect Closure Via Endoscopic Assisted Minithoracotomy
K. Okamoto, A. Yoshitake, M. Kudo, H. Shimizu. Keio University, Tokyo, Japan,
Objective: Although resection and suture technique is a golden standard in mitral valve repair of posterior leaflet prolapse , resection of optimal and effective size is not always easy considering minimally invasive approach. To accomplish complex mitral valve repair via minithoracotomy, a vertical plications of the leaflet combined with multiple neochordal creations were used to fix the prolapse of the posterior leaflet as a functional alternative of resection and suture.
Methods: Mitral valve repair, patch closure of atrial septal defect, and tricuspid annuloplasty with minithoracotomy approach was performed to treat severe mitral valve regurgitation and atrial septal defect in a 49-yaers-old man. Cardiopulmonary bypass was established with peripheral cannulation to the right femoral artery, the right femoral vein, and the right jugular vein. A minithoracotomy was done at the fourth intercostal space under one lung ventilation. Surgical manipulations were performed under endoscopic assistance. The heart was arrested with antegrade cold blood cardiopledgia with direct cross clamp with a Chitwood clamp. The mitral valve was exposed with a left atrial retractor attached to a small thoracotomy retractor with a flexible arm. After three neo-choardal creations with ePTFE sutures using the Loop-in-Loop technique in order to fix the prolapsed leaflet, deep gaps between leaflets were plivcated vertically with interrupted sutures with 5-0 Prolene without resection of the leaflet. Mitral annuloplasty was completed with a 30mm CG Future ring. Bicaval control was done with a hemo-clip to the superior vena cava and snugging down of taping to the inferior vena cava. The atrial septal defect was closed with a fresh autologous pericardial patch. Tricuspid annulo-plasty was completed with a 28mm MC3 annulo-plasty ring.
Conclusions: Leaflet preserving mitral valve repair with combination of multiple neocordal creation using the Loop-in-Loop technique and vertical plications of gaps was a convenient and secure technique in a limited working space and manipulations with long shaft instruments in an endoscopic assisted minithoracotomy approach.