From classical sternotomy to truly endoscopic mitral valve surgery: a step by step procedure

There is an increasing tendency towards minimally invasive valve surgery and various surgical techniques have been proposed to realise this goal. The aim of the present study was to describe our current surgical technique and clinical experience with respect to an endoscopic technique that allows the surgeon to perform an operation through a series of small intercostal ports.

After a learning experience with thoracoscopic left internal mammary to left anterior descending coronary artery bypass surgery, we adopted the endocardiopulmonary bypass technique to perform mitral valve surgery. The technique requires exclusive use of video-assisted surgery and control by transoesophageal echocardiography (TEE). Surgery requires long instruments and extra-corporeal knot tying. Between February 1997 and November 2001, 259 patients were operated on. Mitral valve repair was performed in 190 of them. One patient had a redo procedure using this approach to correct a paravalvular leak, but all other procedures were primary interventions.

In all patients, surgery was performed using a 2 inch working port and two additional half-inch trocar-ports. Five patients required a conversion to median sternotomy: three because of inadequate size of the femoral vessels and two because of intraoperative aortic dissection. Hospital mortality included two patients, and seven patients required late reoperation (four of these were as a result of endocarditis).

Endoscopic mitral valve surgery is demanding, but feasible. Once the appropriate skills are acquired, both patient and surgeon can enjoy the benefits of this exciting new technique.