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Right arrow Minimally invasive surgery

Ann Thorac Surg 2005;79:485-490
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Video and Robotic-Assisted Minimally Invasive Mitral Valve Surgery: A Comparison of the Port-Access and Transthoracic Clamp Techniques

Hermann Reichenspurner, MD, PhDa, Christian Detter, MDa,*, Tobias Deuse, MDa, Dieter H. Boehm, MD, PhDa, Hendrik Treede, MDa, Bruno Reichart, MDb

a Department of Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Hamburg
b Department of Cardiac Surgery, University Hospital Munich-Grosshadern, Munich, Germany

Accepted for publication June 11, 2004.

* Address reprint requests to Dr Detter, Department of Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Martinistr 52, D-20246 Hamburg, Germany (E-mail: detter{at}uke.uni-hamburg.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: In order to assess different surgical techniques for video-assisted minimally invasive mitral valve surgery, a retrospective study was undertaken comparing the Port-Access system (Cardiovations, Ethicon Inc, Somerville, NJ) and the transthoracic clamp technique.

METHODS: In 120 patients mitral valve surgery was performed through a small right minithoracotomy using either the Port-Access endovascular cardiopulmonary bypass system (Port-Access, n = 60) or the transthoracic clamp technique (MICRO, n = 60). Mean patient age was 61.5 ± 10.5 years (81 patients with isolated mitral valve insufficiency, 39 patients with combined mitral valve disease).

RESULTS: Eighty-one (67.5%) patients underwent mitral valve repair and 39 (32.5%) patients had valve replacement. Mean time of surgery was 4.5 ± 3.5 and 4.1 ± 3.2 hours (p = 0.07), aortic cross-clamp time 89 ± 69 and 78 ± 65 minutes (p = 0.08), mean intensive care unit stay 1.5 ± 2.1 and 1.6 ± 2.5 days (p = ns), and hospital stay 9.0 ± 10.5 and 9.2 ± 9.7 days (p = ns) in the Port-Access and MICRO groups, respectively. In the Port-Access group, there were 6 reexplorations for bleeding, one perforation of the right ventricle with the endopulmonary vent, and 2 reconstructions of the femoral artery necessary after femoral cannulation, compared to one reexploration for bleeding in the MICRO group. There was only one minor paravalvular leak after replacement and 2 cases of residual greater than or equal to grade II mitral valve regurgitation after mitral valve repair in the Port-Access group, necessitating reoperation. In both groups, there was no mortality, no cerebrovascular accident, no aortic dissection, and no conversion to sternotomy.

CONCLUSIONS: Minimally invasive mitral valve surgery has become a standard approach for isolated mitral valve operations at our institution. The MICRO technique tends to shorten the time of surgery and aortic cross-clamping and reduces perioperative costs by simplifying the operative procedure.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Several minimally invasive approaches to the mitral valve, such as partial sternotomy, parasternal incision, or minithoracotomy [1–3], have been described within the last few years. At both institutions, the right minithoracotomy penetrating the fourth intercostal space was used since it preserves the stability of the thoracic cage and produces superior cosmetic results. At the beginning, the Port-Access system (Cardiovations, Ethicon Inc, Somerville, NJ) was used; a peripherally based endovascular system for cardiopulmonary bypass with cardioplegic arrest [4, 5]. This endovascular cardiopulmonary bypass system consists of a Y-shaped femoral arterial return cannula, a femoral venous cannula for drainage of the right atrium, an endopulmonary vent catheter inserted to the right internal jugular vein, and an endoaortic balloon occlusion catheter (Endoclamp, Cardiovations, Ethicon Inc). Thus, the system uses femoral arterial and venous access for cardiopulmonary bypass (CPB). Later, the MICRO technique was used as described by Chitwood and colleagues [3]. It uses the same thoracic access and implicates the use of a transthoracic aortic clamp and application of direct antegrade cardioplegia. This article focuses on our total experience of minimally invasive mitral valve surgery and retrospectively compares the Port-Access mitral valve replacement (PAMVR) technique with the MICRO technique with regard to perioperative results and complications.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patient Selection
One hundred and twenty consecutive minimally invasive mitral valve operations were performed between May 1997 and November 2002. All of them included two-dimensional (2D) or 3D video assistance and most (n = 90) included the assistance of a camera-holding robotic arm (AESOP, Computer Motion Inc, Goleta, CA). The patient population was a selected low-risk group with no additional tricuspid valve insufficiency and no moderate to severe pulmonary hypertension. Patients with additional aortic valve regurgitation, coronary artery disease, and peripheral vascular disease were excluded from the study. Eighty-five patients were female and 35 were male with a mean age of 62.1 ± 10.5 years. Eighty-one patients (67.5%) suffered from isolated mitral valve insufficiency and 39 patients (32.5%) from combined mitral valve disease. Sixty patients underwent PAMVR between May 1997 and October 1999, until the MICRO technique was introduced in November 1999. Since then, another 60 patients were operated on using this technique. However, no other significant technical changes have been implemented during the study period.

The left ventricular ejection fraction ranged from 35% to 84% with a mean of 55.8% (Table 1). Thirty-nine patients (32.5%) showed severely destroyed postrheumatic mitral valve pathologies and underwent mitral valve replacement. Seventy-one patients (59.2%) suffered from a prolapse of the posterior mitral valve leaflet with or without annular dilatation, ten patients (8.3%) from an additional prolapse of the anterior mitral leaflet, and all of them underwent mitral valve repair. In the beginning, no complex mitral valve diseases and only isolated posterior valve leaflet pathologies were selected for minimally invasive techniques. With growing experience, anterior leaflet pathology and more complex mitral valve disease, including both leaflets, were also included.


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  		Table 1. Patient Demographics
 
Preoperatively, Doppler ultrasound of the abdominal aortic, iliac, and femoral arteries was used routinely. Evidence of a major peripheral vascular disease served as a contraindication for both minimally invasive techniques using retrograde arterial perfusion. In addition, the condition and diameter of the ascending and descending aorta as well as the morphology of the aortic valve were evaluated by transesophageal echocardiography (TEE). A severely atherosclerotic aorta and a diameter of greater than 4 cm, as well as a moderate or major aortic valve incompetence, served as further contraindications for minimally invasive procedures.

Minimally Invasive Mitral Valve Surgery
Patients were intubated with a double-lumen endotracheal tube or a regular endotracheal tube. Both radial arteries were used in the PAMVR group for invasive blood pressure monitoring to detect partial or total occlusion of the brachiocephalic trunk by the endoaortic balloon. Patients were placed in a supine position with slight elevation of the right hemithorax to about 30 degrees. Initially, an 8 to 10 cm skin incision was made; with growing experience, a 4.5 to 8 cm incision was performed in the right inframammary groove and the fourth intercostal space was entered. A soft tissue retractor (Cardiovations, Ethicon Inc) was used to open the intercostal space and retract the subcutaneous tissue and underlying muscle.

A thoracic port was inserted cranially of the thoracic incision to allow thoracoscopic axial vision of the mitral valve apparatus. The 5 mm 2D endoscope (Karl Storz GmbH, Tuttlingen, Germany) or 3D endoscope (Vista Cardiothoracic Systems Inc, Westborough, MA) was attached to the voice controlled robotic arm (AESOP) for camera guidance (Fig 1). The robotic arm was mounted onto the operating table adjacent to the left shoulder of the patient and reached over the patient’s chest.



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  		Fig 1. Intraoperative setup for the MICRO technique. The placement of the transthoracic clamp is facilitated by the two or three-dimensional image provided by the robotically guided endoscope (Vista Cardiothoracic Systems, Inc, Westborough, MA).

 
After general heparinization, venous cannulas were inserted into the right femoral vein forwarded into the right atrium, and into the right internal jugular vein. Arterial cannulation was done through the right femoral artery. For positioning of the venous femoral cannula and, in the PAMVR group, for positioning of the endoclamp, TEE was used. Venous drainage was augmented by a centrifugal pump or vacuum assistance connected to the heart-lung machine.

In the PAMVR group, aortic occlusion was achieved by inflation of the endoaortic balloon about 2 cm above the aortic valve. Ventricular fibrillation was induced electrically to allow correct balloon placement monitored by TEE. Antegrade cold crystalloid cardioplegia was delivered at the tip of the balloon.

For the MICRO technique, a transthoracic aortic clamp (Fig 2) was used, introduced by a separate 5 mm incision in the midaxillary line. Antegrade cardioplegia was applied directly into the ascending aorta by a needle-vent catheter (Fig 3).



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  		Fig 2. The transthoracic aortic clamp.

 


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  		Fig 3. For the MICRO technique, the ascending aorta is directly clamped by the transthoracic aortic clamp and antegrade cardioplegia is applied by a needle-vent catheter.

 
The left atrium was opened above the origin of the right upper pulmonary vein as done in conventional mitral valve surgery. The minimally invasive mitral valve procedure was performed under video and robotic assistance (Fig 4). The 2D or 3D camera was used to facilitate mitral valve evaluation with regard to potential reconstructive surgery. Although video assistance was used in all cases, parts of the operation were performed under direct vision. The endoscopic picture has proven to be especially helpful in examining the mitral valve pathology, the subvalvular apparatus, and in checking sufficient knot tying.



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  		Fig 4. Minimally invasive mitral valve surgery is performed under video and robotic assistance through a right anterolateral minithoracotomy approach.

 
In case of a posterior mitral valve prolapse, a quadrangular resection was done and a partial Cosgrove ring (Edwards Lifescience, Irvine, CA; n = 21) or a complete Physio ring (Edwards Lifescience; n = 60) was implanted. In 14 patients, a large leaflet resection was necessary, and a sliding plasty was performed. Thereafter the valve was again tested for competence. In 6 patients, an additional chordal shortening of the anterior leaflet was done; in 4 cases with an anterior valve prolapse, a chordal replacement was done using expanded 4-0 or 5-0 polytetrafluoroethylene (ePTFE, Goretex) to adjust the free edge of the leaflet to the plane of the mitral valve annulus.

In case of mitral valve replacement, the posterior and, in most cases, also the anterior leaflets were preserved. The valve was then measured and replaced by a mechanical (n = 11) or biological (n = 28) valve prosthesis using interrupted annular valve sutures (Table 2).


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  		Table 2. Surgical Procedures
 
The left atrium was closed using a 4-0 Prolene running suture (Ethicon). Before the suture was tied, careful antegrade and retrograde deairing was done through the atrium and the ascending aorta through the needle vent. Air was removed by inflating the lungs and simultaneous reduction of venous drainage with the patient in the Trendelenburg position. Deairing techniques included antegrade deairing through the needle vent and left ventricular venting monitored by TEE. No carbon dioxide insufflation was used. Ventricular and atrial pacing wires were inserted and after reperfusion patients were weaned from cardiopulmonary bypass and the femoral cannulas were removed. All patients had intraoperative TEE control to assess the result of mitral valve reconstruction and to detect any paravalvular leak after mitral valve replacement. We routinely use intercostal nerve blockade with injection of bupivacaine. However, excessive spreading of the ribs was avoided. All patients had postoperative echocardiography at the time of discharge and patients were asked to grade their wound pain in four categories: no pain, mild, moderate, or severe postoperative pain. Three months after surgery, patients were rescheduled for follow-up echocardiography, interview, and physical examination.

All surgeons had prior experience with mitral valve repair as well as with Port-Access technology for coronary artery bypass graft (CABG) and atrial septal defect closure. Additional operative costs per patient were around $3,000 (Endo-CPB system) in the PAMVR group versus $200 (venous cannula) in the MICRO group apart for videoscopic and special instrument equipment, which were used in both groups.

Statistical Analysis
Continuous data were analyzed using the unpaired Student’s t test, categorical data using the {chi}2 test. Values were expressed as mean ± standard deviation. Probability values (p) of less than 0.05 were considered significant. Statistical analysis was performed using the SPSS statistical software package 10.0 for Windows (SPSS Inc, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The minimally invasive mitral valve procedure was completed in all 120 patients; two additional patients had to be converted immediately after the start of the procedure due to severe pleural adhesions. There was no hospital mortality in both groups. Total surgery time (4.5 ± 3.5 hours), duration of CPB (138 ± 29 minutes), and duration of aortic occlusion (89 ± 69) were markedly prolonged in the PAMVR group, compared to the MICRO group (4.1 ± 3.2 hours, 120 ± 25 minutes, and 78 ± 65 minutes, respectively). No significant differences in operative data were found, as listed in Table 3, but there was a trend towards shorter surgery times (p = 0.07) and aortic cross-clamp times (p = 0.08) in the MICRO group.


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  		Table 3. Intraoperative and Postoperative Data
 
All patients were weaned from CPB without major inotropic support in stable hemodynamic condition. No differences were found for transfusion requirements.

The complications are listed in Table 4. There were less reexplorations for bleeding (6 vs 1, p = 0.11) and a lower incidence of delayed wound healing (4 vs 0, p = 0.12) and lymphatic fistula development (2 vs 0, p = 0.50) in the groin using the MICRO technique; however, these were not significantly different. In addition, there was one perforation of the right ventricle with the endopulmonary vent, which was solved through the minithoracotomy and two reconstructions of the femoral artery necessary after femoral cannulation in the PAMVR group. One injury of the trachea occurred during placement of the double lumen endotracheal tube in the MICRO group. However, no major complications occurred, particularly no cerebrovascular accident, and no aortic dissection in both groups. No differences were found for the length of postoperative ventilation (15.2 ± 23.4 vs 14.8 ± 19.6 hours, p = ns), total intensive care unit (ICU) stay (1.5 ± 2.1 vs 1.6 ± 2.5 days, p = ns), and hospital stay (9.0 ± 10.5 vs 9.2 ± 9.7 days, p = ns) between the PAMVR and the MICRO groups (Table 3).


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  		Table 4. Intraoperative and Postoperative Complications
 
All patients had intraoperative TEE and postoperative TTE control of the operative result. At the time of discharge, the majority of patients showed no mitral valve regurgitation after valve repair (PAMVR: 75.0%; MICRO: 76.7%). Mitral valve regurgitation grade I was apparent in 13 (21.7%; PAMVR) and 14 (23.3%; MICRO) patients, respectively (Table 5) and two patients in the PAMVR group had residual grade greater than or equal to II mitral valve regurgitation after mitral valve repair. There was one minor paravalvular leak after replacement in the PAMVR group.


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  		Table 5. Results at Discharge
 
Forty-three patients (71.7%) and 44 (73.3%) patients had only minor or no complaint of postoperative pain, 17 (28.3%) and 15 (25.0%) patients reported moderate postoperative pain in the PAMVR and MICRO groups, respectively; there was no difference apparent among groups (p = ns). The rate of new onset of atrial fibrillation was 11 (18.3%) after the PAMVR and 9 (15.0%) after the MICRO operation (p = ns).

At three month follow-up, mortality was 0%. Eighty-five percent and 86.7% of patients were in New York Heart Association (NYHA) class I, and there were no patients in NYHA classes equal to or greater than III (p = ns). No new onset mitral valve grade II insufficiencies were observed by transthoracic echocardiography. Two patients with residual grade III mitral valve regurgitation after mitral valve repair in the PAMVR group underwent subsequent reoperation and conventional mitral valve replacement 6 weeks and 3 months postoperatively. Both patients had an uneventful postoperative recovery.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The right anterolateral minithoracotomy is an excellent approach because the incision provides a straight access towards the left atrium and the mitral valve. Furthermore, this surgical approach carries a cosmetic advantage over midline incisions (Fig 5). However, it requires the assistance of an endoscopic video camera to improve the illumination of the operative field and for sufficient mitral valve evaluation. A 2D or even a 3D system with screen display or head-mounted display was chosen in specific cases for better depth perception to allow complex mitral valve repair; the head-mounted display allows direct vision of the surgical field through surgical loops as well as a view onto the 3D video screen without moving the head. With the latest camera systems the visualization of different structures of the mitral valve apparatus is excellent and even better than with direct vision. However, the surgeon has to be familiar with camera-assisted visualization and endoscopic instruments. The voice-controlled robotic arm facilitates the use of the videoscopic camera during the operative procedures leading to a steadier visual field and shortens the time of surgery [6].



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  		Fig 5. Postoperative cosmetic result after minimally invasive mitral valve surgery.

 
There are major differences with regard to the method of cardiopulmonary bypass. Minithoracotomies usually require femoral cannulation, but for aortic occlusion a specific transthoracic aortic clamp has been developed as well as the endovascular balloon occlusion technique as part of the Port-Access system [3, 5]. Both methods have shown to be a safe alternative for selected patients with good early results. In a recent study comparing midterm results after minimally invasive versus conventional cardiac surgery, earlier mobilization after minimally invasive procedures with lateral minithoracotomy were found, due to a better stability of the bony thorax, resulting in lower pain levels [7]. Schroeyers and colleagues [8] demonstrated excellent early results of the Port-Access technique with the same standards of results and quality as with conventional sternotomy. There were no cardiovascular events, no myocardial infarctions, and no wound infections in this series. Patients, after minimally invasive MVR, were especially satisfied with the surgical and cosmetic results [9]. The present study summarizes our experience with minimally invasive mitral valve operations and compares the MICRO and the PAMVR techniques with regard to perioperative results and economics.

The mortality in our series was 0%. No cerebrovascular accidents and no aortic dissections were observed in either group. To achieve good results with video-assisted minimally invasive mitral valve surgery (MIC-MVS), careful patient selection is crucial. Furthermore, the vast majority (>95%) of MIC-MVSs in this study were performed only by two experienced surgeons.

We found trends towards shorter surgery times and aortic cross-clamp times in the MICRO cases compared to the PAMVR technique. In addition, postoperative complication rates were slightly less with the transthoracic clamp procedure. Although none of the complication rates reached statistical significance comparing both groups, in total significantly less complications were found in the MICRO group. However, most complications in the PAMVR group were most likely not system related but rather due to the learning curve combined with the minimally invasive approach. Other groups also demonstrated major differences between the first patients during the learning curve and those who followed [10]. Mohr and colleagues [11] reported on a high mortality rate in their early Port-Access cases; partially procedure related. Two out of 62 patients suffered an aortic dissection; hospital mortality was 11%. After simplification of the surgical procedure and establishment of the solo surgical technique by using the AESOP robotic arm, their early mortality decreased to 3%. With the introduction of the MICRO technique, neurologic complications were significantly reduced [12].

However, the Port-Access system is a highly sophisticated technique originally developed for endoscopic cardiac surgery. It implicates retrograde balloon positioning with the potential risk of aortic dissection or balloon migration. It still is applied in redo-operations and totally endosurgical procedures. The transthoracic clamp technique is a useful simplification of the operative procedure during minimally invasive mitral valve surgery, reducing the risk of system-related complications, and is thus favored in our institution.

Echocardiography at discharge demonstrated excellent results after mitral valve repair with 75.0% and 76.7% of patients showing no mitral valve regurgitation in the PAMVR and MICRO group, respectively, and two patients in the PAMVR group retaining greater than or equal to grade II regurgitation. These two patients had to be reoperated 6 weeks and 3 months following mitral valve repair. Both patients had a conventional mitral valve replacement with an uneventful postoperative recovery. These results are similar to those of other experienced groups [13]. Three months after surgery, mortality remained at 0% and there were no new onset mitral valve regurgitations greater than or equal to grade II. The majority of patients in both groups regained physical function according to NYHA class I.

We did not observe differences in postoperative recovery as documented by ventilation time, length of ICU stay, and hospital stay between the groups. However, mean extra costs were found to differ markedly between both minimally invasive procedures in favor of the MICRO technique. When compared to conventional mitral valve operations through median sternotomy, the PAMVR technique results in about $3,000 in extra costs per patient. The generated MICRO technique comprised only extra costs of $200 per patient. In addition, time of surgery was lower with the MICRO technique, resulting in lower operating room costs. No differences in the costs of the postoperative course were found between the groups since patients in both groups had a comparable fast postoperative recovery and hospitalization.

In conclusion, minimally invasive mitral valve surgery with a right anterolateral minithoracotomy can be performed successfully with excellent results without increasing morbidity or mortality, including sophisticated valve reconstructions using either of the described techniques. Thus, MIC-MVS has become a standard approach for isolated mitral valve operations at our institution. The transthoracic clamp technique tends to shorten the time of surgery and aortic cross-clamping, to reduce perioperative complication rates by simplifying the operative procedure, and significantly saves operative costs. Thus, our group recommends the use of the transthoracic clamp over the balloon occluder. However, the Port Access technique is still indicated in redo-minimally invasive mitral valve surgery. A careful patient selection for minimally invasive procedures remains crucial in order to obtain excellent results.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Sardari FF, Schlunt ML, Applegate II RL, Gundry SR. The use of transesophageal echocardiography to guide sternal division for cardiac operations via mini-sternotomy J Card Surg 1997;12:67-70.[Medline]
  2. Navia JL, Cosgrove III DM. Minimally invasive mitral valve operations Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
  3. Chitwood Jr WR, Wixon CL, Elbeery JR, Moran JF, Chapman WH, Lust RM. Video-assisted minimally invasive mitral valve surgery J Thorac Cardiovasc Surg 1997;114:773-782.[Abstract/Free Full Text]
  4. Stevens JH, Burdon TA, Peters WS, et al. Port-Access coronary artery bypass grafting: a proposed surgical method J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
  5. Reichenspurner H, Gulielmos V, Wunderlich J, et al. Port-Access coronary artery bypass grafting with the use of cardiopulmonary bypass and cardioplegic arrest Ann Thorac Surg 1998;65:413-419.[Abstract/Free Full Text]
  6. Reichenspurner H, Boehm DH, Gulbins H, et al. Three-dimensional video and robot-assisted Port-Access mitral valve operation Ann Thorac Surg 2000;69:1176-1181.[Abstract/Free Full Text]
  7. Walther T, Falk V, Metz S, et al. Pain and quality of life after minimally invasive versus conventional cardiac surgery Ann Thorac Surg 1999;67:1643-1647.[Abstract/Free Full Text]
  8. Schroeyers P, Wellens F, De Geest R, et al. Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience Ann Thorac Surg 2001;72:S1050-4.[Abstract/Free Full Text]
  9. Gulielmos V, Tugtekin SM, Kappert U, et al. Three-year follow-up after Port-Access mitral valve surgery J Card Surg 2000;15:43-50.[Medline]
  10. Vanermen H, Farhat F, Wellens F, et al. Minimally invasive video-assisted mitral valve surgery: from Port-Access towards a totally endoscopic procedure J Card Surg 2000;15:51-60.[Medline]
  11. Mohr FW, Onnasch JF, Falk V, et al. The evolution of minimally invasive valve surgery—2 year experience Eur J Cardiothorac Surg 1999;15:233-238.[Abstract/Free Full Text]
  12. Onnasch JF, Schneider F, Falk V, Mierzwa M, Bucerius J, Mohr FW. Five years of less invasive mitral valve surgery: from experimental to routine approach Heart Surg Forum 2002;5:132-135.[Medline]
  13. Casselman FP, Van Slycke S, Wellens F, et al. Mitral valve surgery can now routinely be performed endoscopically Circulation 2003;108(suppl 1):II48-54.



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