Minimally invasive cardiac surgery for complex procedures: extensive septal myectomy and double valve replacement

In this video tutorial, we demonstrate that minimally invasive cardiac surgery and all its benefits can be applied even to complex, multiple cardiac procedures. We present a 71-year-old patient with severely obstructive hypertrophic cardiomyopathy, moderate mitral regurgitation for systolic anterior motion of the mitral valve, moderate aortic stenosis and regurgitation and atrial fibrillation. We performed a mitroaortic valve replacement, transmitral and transaortic septal myectomy and left atrial appendage closure through a minimally invasive approach (right anterolateral minithoracotomy). After establishing peripheric cardiopulmonary bypass, aortic cross-clamping and a left atrium opening, the anterior mitral leaflet was incised circumferentially at its insertion on the annulus to allow an optimal transmitral myectomy. Subsequently, mitral valve removal was completed, and a bioprosthesis was implanted. After closure of the left atrium, the left atrial appendage was closed using a 40-mm device (Atriclip). The aorta was then opened, the aortic valve was excised and a transaortic septal myectomy was completed. Finally, a sutureless aortic bioprosthesis was implanted. Postoperative transoesophageal and transthoracic surgery demonstrated a residual left ventricular outflow tract gradient of 14 mmHg and the correct performance of both biological prostheses. Minimally invasive heart surgery can be offered even to patients requiring complex and multiple procedures, including septal myectomy. Combining the benefits of the operation with those of a minimally invasive approach may optimize postoperative and long-term surgical outcomes.