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    • Contributions of Minimally Invasive approaches to Mitral Repair

    Mitral valve surgery has been performed for over 100 years, since Elliot Cutler’s first operation in 19231. Progress in this field over the years has led to techniques with the most conservative approach possible, reducing side effects for patients2. Long-lasting repair techniques have gradually been developed, under the leadership of Dr Carpentier in the 1980s, and minimally invasive approaches were devised. The latest in these developments, the first robotic repair of the mitral valve was carried out by Carpentier’s team in 19982. 

    The management of patients with mitral regurgitation and insufficiency has improved considerably, with an increasingly wide range of treatments available to cardiac surgeons.  The goal is to adapt the surgical technique according to the risk profile of patients, in order to reduce the operative risks and recovery time and improve patient comfort (reduction in post-operative pain and scar size)3. 

     

    Multiple techniques available to surgeons

    The most frequently used minimally invasive technique is the right minithoracotomy2. Percutaneous approaches have developed around several available systems4. For the time being, robotic repair is limited to centres of excellence5. 

     

    Minimally invasive mitral repair 2, 4, 6Thoracic incision
    Visualisation with right minithoracotomyYES  10 to 15 cm
    Direct visualisation (right minithoracotomy) assisted by video-assisted thoracoscopic technique YES  4 to 6 cm
    Percutaneous approaches (edge-to-edge, tendinous chords repair, etc.)4NO 
    Surgery guided by video-assisted thoracoscopic technique and assisted by robot with micro incisions YES  1.5 to 4 cm
    Robotic repair (remote handling by computer) and endoscopic incisionsYES  <1.5 cm

    Table 1: the different minimally invasive mitral valve repairs, specifications and images – Image A: right minithoracotomy (Brüls 2020 7), Image B: Edge-to-edge percutaneous repair (Schmidt 2022 6) – Image C:  Robotic repair (Cuartas 2017 8). 

    The role of Minimally Invasive Mitral Valve Repair worldwide

    The minimally invasive approaches for mitral valve repair have hugely developed in the last twenty years because of their benefits in terms of surgical morbidity and mortality, even though their technical nature requires advanced training for surgeons2. The figures for minimally invasive versus traditional approaches vary widely around the world, from around 25% of surgeries in the United States to 50% in Germany2. In Europe, the percentage of minimally invasive mitral surgeries varies by country, but also the size and experience of the surgical centres3. In Asia, although the proportion of minimally invasive techniques is increasing compared to traditional techniques, there is also a large disparity between countries. 3 

    The robotic approach is also progressing, with more and more centres of excellence being opened in Europe (in 2020: 30 centres in 12 countries5) compared to the United States, where around 1,700 robotic procedures are carried out every year1. 

     

    Patient eligibility criteria for Minimally Invasive Mitral Repair

    Isolated mitral valve repair can be carried out in virtually all cases using a minimally invasive approach, provided that the surgeon and their team are trained in this technique. Minimally invasive surgeries provide limited operative visibility and surgeon mobility2, and generally longer clamping and extra-corporeal circulation times7. There are certain absolute and relative contraindications to minimally invasive approaches (as shown in Table 2). Each patient needs to be carefully assessed to determine the best repair method2.

    Table 2: Contraindications of minimally invasive mitral repair
    ABSOLUTEHistory of right thoracotomy
    Severe calcification of the mitral annulus
    Presence of more than moderate aortic regurgitation
    Concomitant coronary artery bypass
    RELATIVECalcification and/or dilation of the aortic root/descending aorta
    Severe peripheral arterial disease
    Severe irreversible pulmonary hypertension (>60 mmHg)
    Severe lung disease
    Reduced right ventricular ejection fraction
    Recent CVA (Cerebral Vascular Accident) or TIA (Transient Ischemic Attack) 
    Severe liver damage (Child-Pugh B or C)

    Table reproduced and translated from Table 2 from Cuartas et al, 2019. 2

     

    Medical devices with key properties throughout the procedure

    The different repair techniques and materials used can have a decisive impact on the results of mitral surgery9. The mini- and micro-incisions used in minimally invasive approaches to mitral valve repair require appropriate surgical and endoscopic equipment2. Here are some of the medical devices involved in mitral valve repair:

     

    Non-absorbable monofilament sutures: Sutures will be used at various stages of the surgery, and their technical nature is essential to guarantee lasting attachment and good resistance to tissue stress, while ensuring sufficient tissue flexibility1, 2. The cardiovascular sutures in the Peters Surgical range are the result of a long-standing collaboration with Prof. Alain Carpentier (Georges Pompidou European Hospital).

    Clamps and clips: Tools specific to minimally invasive approaches will be used to control blood flow during repair. They will have to be able to offer suitable shapes, materials, and sometimes adapters to provide a good anastomosis under direct vision or by endoscopy. 

    Annuloplasty rings: Implemented to remodel and stabilise the mitral valve, several ring shapes have been tested and proposed over the years with varying results9. 

    Endoscopic instruments: There are a range of instruments that are currently available to cardiothoracic surgeons specifically adapted to endoscopic procedures, including scissors, clamps, and specialised needle holders2. 

    Robotic systems: All the systems used for robotic methods, including robotic arms and control consoles, are state-of-the-art equipment used in centres of excellence in cardiac surgery1, 5

    Inset: Cardionyl® is a non-absorbable nylon 6.6 monofilament suture. Cardionyl® has been used in various types of minimally invasive or more traditional mitral surgery (see Table 3). Its good flexibility, combined with good resistance to tissue stress, makes it easy to handle and ensures reliable suturing.  

     

    StudyProcedureIndicationUtilisation of Cardionyl® during the procedure
    Felger .et al, 2001 10Mitral valve repair (minithoracotomy with video-assisted thoracoscopic technique with manual or robot-assisted repair)Isolated mitral valve condition✓
    Doss M. et al, 2006 11Mitral valve replacement (right sternotomy or minithoracotomy)Mitral regurgitation✓
    Sierra J. et al, 2008 12Mitral valve repair (sternotomy)Symptomatic rheumatic mitral insufficiency✓
    Chu M.W.A.  et al, 2008 13Robotic repair of the mitral valveSevere mitral regurgitation✓
    Myers P.O. et al, 2010 14Mitral and aortic valve repair Aortic insufficiency with/without mitral insufficiency✓

     

    Surgical techniques are constantly evolving for the benefit of patients and the comfort of surgeons2. The medical devices that come with these advances, from sutures to the most advanced robotic systems, play a crucial role in the success of operations. Reliability, handling, and continuous innovation are key to improving clinical outcomes and providing the best possible care for patients with mitral disease.

     

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    2. Cuartas MM, Davierwala PM. Minimally invasive mitral valve repair. Indian J Thorac Cardiovasc Surg. 2020 Jan;36(Suppl 1):44-52. 
    3. Thuan PQ, Chuong PTV, Dinh NH. Adoption of minimally invasive mitral valve surgery: single-centre implementation experience in Vietnam. Ann Med Surg (Lond). 2023 Sep 13;85(11):5550-5556. 
    4. Fassa A.A, Himbert D, Brochet E, Bouleti C, Vahanian A. Approches percutanées des valvulopathies mitrales. Rev Med Suisse 2015 ; 11 : 537-42
    5. Cerny S, Oosterlinck W, Onan B, Singh S, Segers P, Bolcal C, Alhan C, Navarra E, Pettinari M, Van Praet F, De Praetere H, Vojacek J, Cebotaru T, Modi P, Doguet F, Franke U, Ouda A, Melly L, Malapert G, Labrousse L, Gianoli M, Agnino A, Philipsen T, Jansens JL, Folliguet T, Palmen M, Pereda D, Musumeci F, Suwalski P, Cathenis K, Van den Eynde J, Bonatti J. Robotic Cardiac Surgery in Europe: Status 2020. Front Cardiovasc Med. 2022 Jan 20;8:827515. 
    6. Schmidt T, Kowalski M, Bjarnason-Wehrens B, Ritter F, Mönnig G, Reiss N. Feasibility of inpatient cardiac rehabilitation after percutaneous mitral valve reconstruction using clipping procedures: a retrospective analysis. BMC Sports Sci Med Rehabil. 2022 Jul 5;14(1):120. 
    7. Brüls S, Kerzmann A, Durieux A, et al. Apport de l’approche moins invasive en chirurgie cardiovasculaire et thoracique. Rev Med Liege 2020; 75 : 5-6 : 292-299
    8. Marin Cuartas M, Javadikasgari H, Pfannmueller B, Seeburger J, Gillinov AM, Suri RM, Borger MA. Mitral valve repair: Robotic and other minimally invasive approaches. Prog Cardiovasc Dis. 2017 Nov-Dec;60(3):394-404
    9. Can T, Kirov H, Caldonazo T, Mukharyamov M, Färber G, Doenst T. Surgical mitral valve repair technique considerations based on the available evidence. Turk Gogus Kalp Damar Cerrahisi Derg. 2022 Apr 27;30(2):302-316. 
    10. Felger JE, Chitwood WR Jr, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach. Ann Thorac Surg. 2001 Oct;72(4):1203-8; discussion 1208-9. 
    11. Doss M, Aybek T, Wood JP, Martens S, Wimmer-Greinecker G, Moritz A. Left ventricular remodeling impacts the function of the Quattro stentless mitral valve bioprosthesis (a 4-year experience). Am Heart J. 2006 Apr;151(4):943.e1-4. 
    12. Sierra J, Lahlaïdi NH, Christenson JT, Kalangos A. Mitral valve insufficiency: suspension of the posterior leaflet to the mitral annuloplasty ring. Ann Thorac Surg. 2008 Feb;85(2):e6-8
    13. Chu MW, Gersch KA, Rodriguez E, Nifong LW, Chitwood WR Jr. Robotic “haircut” mitral valve repair: posterior leaflet-plasty. Ann Thorac Surg. 2008 Apr;85(4):1460-2. 
    14. Myers PO, Tissot C, Christenson JT, Cikirikcioglu M, Aggoun Y, Kalangos A. Aortic valve repair by cusp extension for rheumatic aortic insufficiency in children: Long-term results and impact of extension material. J Thorac Cardiovasc Surg. 2010 Oct;140(4):836-44.