Minimally-invasive mitral valve repair: evolution of the technique to the standard of care for mitral regurgitation

Objectives: Minimally-invasive mitral valve repair (MVR) via a right anterior mini-thoracotomy has been recognized as a safe approach to mitral valve disease. We report on the technical refinements allowing for optimization of the technique from the beginnings until now. Methods: Between 2001 and 2009, at total of 250 patients underwent minimally-invasive MVR via a right anterior mini-thoracotomy at our center. A consecutive series of 50 early cases was identified (group 1) and compared to the latest 50 consecutive patients (group 2) in terms of patient characteristics, operative data and technical details. Results: As opposed to group 1, where cannulation of femoral and jugular veins was performed, a multistage cannula was used for bicaval drainage exclusively in group 2. Introduction of the arterial cannula by Seldinger's technique instead of arteriotomy simplified the procedure further. Patient characteristics and perioperative data differed significantly. In summary, patient age was significantly higher in group 2, while operative/extracorporeal-circulation/aortic-cross-clamping times decreased significantly as compared to group 1 (309.84±30.49 vs. 224.31 ±27.93/187.58±34.37 vs. 148.12±19.60/118.42±18.66 vs. 94.63±17.53 minutes). Regarding valve pathology, there was a clear trend towards more complex cases. In both groups one patient expired during the hospital stay and there was one conversion to sternotomy. Conclusions: With careful initial patient selection minimally-invasive MVR has found its way to clinical routine at our center. Technical advances have aided to simplify and shorten the procedure, allowing its application in older patients with more comorbidities and more complex mitral valve pathologies.