Transapical cardioscopic mitral annuloplasty: a short-term survival study in a porcine model

The transapical approach provides concurrent surgical access to the mitral and the aortic valves, the root of the aorta and the left atrium. We previously showed the feasibility of transapical cardioscopic (TAC) surgery in a non-survival porcine model. However, reproducibility and feasibility of ring implantation using TAC have not been reported. Therefore, in this study, we hypothesized that implantation of a mitral annuloplasty ring can be feasibly and safely carried out endoscopically via the apex of the heart.

Using a porcine model in a short-term survival study, TAC mitral annuloplasty was performed in 6 pigs via an incision over the xyphoid, under cardiopulmonary bypass and cardiac arrest. A mitral annuloplasty ring was implanted via the apex to a normal mitral annulus, using a customized set of instruments and techniques. Haemodynamics, echocardiography, cardiac computed tomography, ventriculography, electrocardiography and histopathology studies were used to evaluate the function of the mitral valve and the left ventricle, coronary system and conduction system in the perioperative period and 4 weeks later.

All 6 animals survived and recovered from the TAC annuloplasty procedure. Postimplantation examination showed that the mitral valve was competent, left ventricular ejection fraction was 63 ± 4%, left ventricular length was 6.2 ± 0.5 cm and left ventricular end-diastolic volume was 80 ± 10 ml, which were comparable to preoperative values. Apart from a dense scar at the apex, no significant injury was noticed on the ventricle, the chordae and the mitral leaflets. The bypass, cross-clamp and implantation times were 181 ± 55 min, 130 ± 37 min and 47 ± 6 min, respectively.

Despite long surgical times due to the initial learning curve, successful execution of mitral ring annuloplasty could be safely achieved using the TAC approach, via a small incision without the involvement of sternum or the right pleural cavity, thereby potentially expanding the indication to patients with high-risk full sternotomy or right thoracotomy.