All herein-described procedural steps were performed in accordance with the Institutional Review Board of the University Heart and Vascular Center Hamburg guidelines and after written informed consent was obtained.
1. Fully endoscopic MIS MV repair
<ol>
	<li>Ensure the patient is under general anesthesia, in a supine position, scrubbed with iodine disinfectant, and draped with a sterile drape.</li>
	<li>Gain thoracic access along the peri-mammillary margin through the fourth...

<ol>
	<li>David, T. E., Ivanov, J., Armstrong, S., Rakowski, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Late+outcomes+of+mitral+valve+repair+for+floppy+valves:+Implications+for+asymptomatic+patients.">Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients.</a> The Journal of Thoracic and Cardiovascular Surgery. 125 (5), 1143-1152 (2003).</li><li>David, T. E., David, C. M., Lafreniere-Roula, M., Manlhiot, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+outcomes+of+chordal+replacement+with+expanded+polytetrafluoroethylene+sutures+to+repair+mitral+leaflet+prolapse.">Long-term outcomes of chordal replacement with expanded polytetrafluoroethylene sutures to repair mitral leaflet prolapse.</a> The Journal of Thoracic and Cardiovascular Surgery. 160 (2), 385-394 (2020).</li><li>Beckmann, A., Meyer, R., Lewandowski, J., Markewitz, A., Harringer, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=German+heart+surgery+report+2018:+the+annual+updated+registry+of+the+German+Society+for+Thoracic+and+Cardiovascular+Surgery.">German heart surgery report 2018: the annual updated registry of the German Society for Thoracic and Cardiovascular Surgery.</a> The Thoracic and Cardiovascular Surgeon. 67 (5), 331-344 (2019).</li><li>Abdelbar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+tricuspid+valve+surgery+is+a+safe+and+effective+option.">Endoscopic tricuspid valve surgery is a safe and effective option.</a> Innovations. 15 (1), 66-73 (2020).</li><li>Pfannmueller, B., Misfeld, M., Davierwala, P., Weiss, S., Borger, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Concomitant+tricuspid+valve+repair+during+minimally+invasive+mitral+valve+repair.">Concomitant tricuspid valve repair during minimally invasive mitral valve repair.</a> The Thoracic and Cardiovascular Surgeon. 68 (6), 486-491 (2020).</li><li>Ko, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+mitral+valve+surgery:+a+systematic+safety+analysis.">Minimally invasive mitral valve surgery: a systematic safety analysis.</a> Open Heart. 7 (2), e001393 (2020).</li><li>Pozzi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+percutaneous+femoral+vessels+cannulation+for+minimally+invasive+mitral+valve+surgery.">Total percutaneous femoral vessels cannulation for minimally invasive mitral valve surgery.</a> Annals of Cardiothoracic Surgery. 2 (6), 739-743 (2013).</li><li>Kim, J., Yoo, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+mitral+valve+repair+using+a+three-dimensional+endoscope+system:+initial+clinical+experience+in+Korea.">Totally endoscopic mitral valve repair using a three-dimensional endoscope system: initial clinical experience in Korea.</a> Journal of Thoracic Disease. 12 (3), 705-711 (2020).</li><li>Kroon, H. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dedicated+plug+based+closure+for+large+bore+access-The+MARVEL+prospective+registry.">Dedicated plug based closure for large bore access-The MARVEL prospective registry.</a> Catheterization and Cardiovascular Interventions. 97 (6), 1270-1278 (2021).</li><li>Van Praet, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+MANTA+vascular+closure+device+for+percutaneous+femoral+vessel+cannulation+in+minimally+invasive+surgical+mitral+valve+repair.">The MANTA vascular closure device for percutaneous femoral vessel cannulation in minimally invasive surgical mitral valve repair.</a> Innovations. 15 (6), 568-571 (2020).</li><li>Otto, C. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ACC/AHA+guideline+for+the+management+of+patients+with+valvular+heart+disease:+a+report+of+the+American+College+of+Cardiology/American+Heart+Association+Joint+Committee+on+Clinical+Practice+Guidelines.">ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.</a> Journal of the American College of Cardiology. 77 (4), 450-500 (2020).</li><li>Vergnat, M., Finet, G., Rioufol, G., Obadia, J. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+femoral+artery+access+with+Prostar+device+for+innovative+mitral+and+aortic+interventions.">Percutaneous femoral artery access with Prostar device for innovative mitral and aortic interventions.</a> European Journal of Cardiothoracic Surgery. 39 (4), 600-602 (2011).</li><li>Ramponi, F., Yan, T. D., Vallely, M. P., Wilson, M. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+percutaneous+cardiopulmonary+bypass+with+Perclose+ProGlide.">Total percutaneous cardiopulmonary bypass with Perclose ProGlide.</a> Interactive Cardiovascular and Thoracic Surgery. 13 (1), 86-88 (2011).</li><li>Sahin, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+PeRcutanEous+and+surgical+femoral+aCcess+for+endovascuLar+aOrtic+repair+in+patientS+with+typE+III+aortic+Dissection+(PRECLOSE+Trial).">Comparison between PeRcutanEous and surgical femoral aCcess for endovascuLar aOrtic repair in patientS with typE III aortic Dissection (PRECLOSE Trial).</a> Vascular. 29 (4), 616-623 (2020).</li><li>Malkawi, A. H., Hinchliffe, R. J., Holt, P. J., Loftus, I. M., Thompson, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+access+for+endovascular+aneurysm+repair:+a+systematic+review.">Percutaneous access for endovascular aneurysm repair: a systematic review.</a> European Journal of Vascular and Endovascular Surgery. 39 (6), 676-682 (2010).</li><li>Kastengren, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+vascular+closure+device+in+minimally+invasive+mitral+valve+surgery.">Percutaneous vascular closure device in minimally invasive mitral valve surgery.</a> The Annals of Thoracic Surgery. 110 (1), 85-91 (2020).</li><li>Ahmad, A. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+experiences+with+MANTA+vascular+closure+device+in+minimally+invasive+valve+surgery.">First experiences with MANTA vascular closure device in minimally invasive valve surgery.</a> The Thoracic and Cardiovascular Surgeon. 69 (5), 455-460 (2021).</li><li>Wood, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pivotal+clinical+study+to+evaluate+the+safety+and+effectiveness+of+the+MANTA+percutaneous+vascular+closure+device.">Pivotal clinical study to evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device.</a> Circulation. Cardiovascular Interventions. 12 (7), e007258 (2019).</li><li>De Palma, R., Settergren, M., R&#252;ck, A., Linder, R., Saleh, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+percutaneous+femoral+arteriotomy+closure+using+the+MANTATM+device+on+vascular+and+bleeding+complications+after+transcatheter+aortic+valve+replacement.">Impact of percutaneous femoral arteriotomy closure using the MANTATM device on vascular and bleeding complications after transcatheter aortic valve replacement.</a> Catheterization and Cardiovascular Interventions. 92 (5), 954-961 (2018).</li></ol>

The application of vascular closure devices for arterial CPB cannulation is a transcatheter technique that has the potential to improve outcomes in cardiac surgery is. Application of this technique in cardiac surgery procedures, and especially EMS valve surgery, has been adopted in specialized centers over recent years to avoid surgical cutdown and the exposure of groin vessels. ProStar and ProGlide systems are the most commonly used devices7,12. In a series of 3...

The gold standard for the treatment of primary, degenerative mitral regurgitation (MR) is surgical mitral valve (MV) repair. The efficacy of this approach has been proven in large clinical studies with conclusive long-term data1. Due to a large armamentarium of surgical techniques for MV repair, such as annuloplasty or the insertion of Gore-Tex neochordae, almost all pathologies of the MV are treatable. This includes complex circumstances like Morbus Barlow with prolapse of both MV leaflets, with proven safety and efficacy as well as excellent results up to 20 years2. Furthermore, the majority of isolated MV surgery in Germany is performed via minimally invasive approaches, like a right anterolateral minithoracotomy3. Also, concomitant tricuspid valve (TV) surgery is amenable by minimally invasive access, even in a beating heart fashion4,5.
Surgical cutdown to access groin vessels has traditionally been a routine procedure for the implementation of cardiopulmonary bypass (CPB). However, this approach inherits a certain risk of postoperative wound healing disorders or seroma formation6. The adaption of transcatheter techniques for fully percutaneous insertion of a cannula for the establishment of CPB has been described7,8, and this may reduce possible groin complications. Already used devices for percutaneous vessel closure in endoscopic mitral valve surgery (EMS) include suture-based systems7,8. Recently, a collagen plug-based vascular closure device was introduced for transcatheter heart valve procedures. This large bore closure device can be used for the closure of arterial access sites of up to 25 French (Fr.). Safety and efficacy of the system have previously been demonstrated in a real-world transcatheter aortic valve implantation (TAVI) patient cohort9. The first data of minimally invasive surgery (MIS) of the MV or TV utilizing this system for the closure of the femoral artery showed promising results regarding postoperative groin complications10.
We herein describe the fundamental steps of fully endoscopic mitral valve surgery, including percutaneous groin cannulation and decannulation using a novel vascular closure device. The fully endoscopic approach differs from the MIS non-endoscopic technique in terms of a very small thoracic incision (3-5 cm), avoidance of rib-spreading, and visualization of cardiac structures with an endoscope with no direct view of the heart.
This surgery can be performed on patients with significant heart valve regurgitation or stenosis of atrioventricular heart valves, who are suitable for cardiac surgery. Preoperative diagnostics include transthoracic/transesophageal echocardiography and computed tomography of the chest and iliac vessels in elderly patients or patients with a history of peripheral artery disease.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>30&#176; camera head</td>
			<td>Aesculap Einstein Vision</td>
			<td>PV 632</td>
			<td></td>
		</tr>
		<tr>
			<td>3D-HD camera&#160;</td>
			<td>Aesculap Einstein Vision</td>
			<td>PV 630</td>
			<td></td>
		</tr>
		<tr>
			<td>Annuloplasty ring&#160;</td>
			<td>Edwards</td>
			<td>93381</td>
			<td></td>
		</tr>
		<tr>
			<td>Aortic clamp</td>
			<td>Cardio Vision</td>
			<td>CV 195.10</td>
			<td></td>
		</tr>
		<tr>
			<td>Aterial Cannula</td>
			<td>Medtronic</td>
			<td>96570-121</td>
			<td></td>
		</tr>
		<tr>
			<td>Femoral Cannula</td>
			<td>Metronic</td>
			<td>96670-125</td>
			<td></td>
		</tr>
		<tr>
			<td>Full HD 3D Monitor</td>
			<td>Aesculap Einstein Vision</td>
			<td>PV 646</td>
			<td></td>
		</tr>
		<tr>
			<td>Giude wire</td>
			<td>Merit Medica</td>
			<td>6678-71</td>
			<td></td>
		</tr>
		<tr>
			<td>Heart valve retractor set</td>
			<td>Cardio Vision</td>
			<td>CV 100.00</td>
			<td></td>
		</tr>
		<tr>
			<td>LED light source</td>
			<td>Aesculap Einstein Vision</td>
			<td>OP 950</td>
			<td></td>
		</tr>
		<tr>
			<td>Manta</td>
			<td>Teleflex Medical Inc.</td>
			<td>2115</td>
			<td></td>
		</tr>
		<tr>
			<td>Neo chordae</td>
			<td>Serag Wiesner</td>
			<td>MCL14A</td>
			<td></td>
		</tr>
		<tr>
			<td>Soft Tissue Retractor</td>
			<td>Cardio Vision</td>
			<td>Cv100/80</td>
			<td></td>
		</tr>
		<tr>
			<td>Stative table arm for endoscopes</td>
			<td>Cardio Vision</td>
			<td>CV 281.73</td>
			<td></td>
		</tr>
		<tr>
			<td>Stative table arm for instruments</td>
			<td>Cardio Vision</td>
			<td>CV 281.72</td>
			<td></td>
		</tr>
		<tr>
			<td>Suture for fixing Loops</td>
			<td>Gore-Tex Suture</td>
			<td>4N02</td>
			<td></td>
		</tr>
	</tbody>
</table>

fully endoscopic mitral valve repair with percutaneous cannulation of groin vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

In a preliminary patient cohort undergoing EMS and using this novel vascular closure device at our center, promising results were documented11. This cohort included 35 patients, with the most common accompanying diseases being arterial hypertension (10/35, 28.6%) and atrial fibrillation (9/35, 25.7%). Valve failure mechanisms included primary, degenerative MR (30/35, 85.7%), secondary, functional MR (3/35, 8.6%), and endocarditis (2/35, 5.7%). Concomitant procedures in MV MIS MV were tricuspid val...

Watch this Scientific Journal Video about Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels at JoVE.com

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

This protocol demonstrates in detail how to perform fully-endoscopic mitral valve surgery with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step for a successful procedure. Then access along the pericardial margin to the fourth intercostal space.Achieve distention of the intercostal space using a soft tissue retractor. Perform the puncture of the femoral artery using a standard puncture needle, and insert the guide wire under TE guidance. Determine the depth of the initial puncture using a puncture locating dilator, which is inserted over the wire.This detects puncture depth by outflow, backflow, stop of backflow. Define the depths at skin level, which is defined by the visible stop of backflow of the measuring tool. For delayed release of the vascular closure device to prolong this is defined as puncture depth at skin level plus one centimeter.Place the arterial cannula over the wire. And connect it to cardiopulmonary bypass. Puncture the femoral vein medial to the artery in the same manner.And after the insertion of the venous cannula, connect to the cardiopulmonary bypass. Insert the 3D high definition camera over the thoracic incision. Then, open the pericardium above the right side phrenic nerve.This is achieved by using a diathermy. Place a thoracic clip, or clamp, through a small incision for cross-clamping the aorta. This happens under induced ventricular fibrillation.Arrest the heart with antegrade cardioplegia and moderate hypothermia of 32 degrees, which is established and maintained by the heart-lung machine. The effectiveness of cardioplegia is documented by an electrocardiogram. The left atrium is opened with a scissor.After opening the left atrium, the left atrial roof is lift with a dynamic retractor. Then, the mitral valve is exposed. And the pathology is inspected.In this case, we can see a prolapse of the posterior mitral leaflet. After detecting the pathology, size for correct annuloplasty ring, which is achieved by annuloplasty measuring tool. Size for correct neochordae via a caliper for the length of native chordae.Re-suspend the posterior mitral leaflet, and implant the angioplasty ring by implanting the neochordae at the respective papillary muscle. And afterwards, placing circumferential annular sutures. To perform so, first the neochordae are secured to the papillary muscle.And then passed twice through the free margin of the posterior leaflet, and knotted down. Then annuloplasty is performed in order to regain normal annular shape and prevent further dilation, as well as increased coaptation of the leaflets. Circumferential sutures are placed around the annulus.And then sutures are put through the annuloplasty ring, which is taken down on to the annulus via the sutures. After knotting down the annuloplasty ring, a water test is performed to confirm the sufficiency of mitral valve repair. Close the left atrium with polypropylene non-absorbable for all suture, in a running suture technique.After achievement of left atrial closure, remove the aortic cross clamp. Then, close thoracic access, and perform cardiopulmonary bypass weaning. Remove the venous cannula by suture technique.Puncture the arterial cannula, and insert the wire under TE guidance. After retracting the cannula, insert the closure system sheath fully over the wire, and remove the dilator. Insert and close the device over the integrated insertion tool.Then slowly remove the whole system, at a steady 45 degree angle, and a constant retraction force of the measured depth. Observe markings on the sheath. Adjust the deployment test, and protect the lever of the toggle release.Retract the system further from the femoral artery. And the tension appears, an indicator field shows yellow green. Advance the lock tool until the click is heard.When hemostasis is obtained, remove the guide wire. Cut the lead suture. And close the skin with a single suture.In our study group of 35 patients, no death or stroke was noticed. No major or life-threatening bleeding occurred. And access site complications did not occur.Would it not have any access site related transfusions in this study group? Fully-endoscopic mitral valve repair can be performed with a high degree of safety, efficacy, and excellent results up to 20 years. Percutaneous implementation of cardiopulmonary bypass can facilitate the procedure.The percutaneous plug based closure device simplifies the procedure as well as achieves immediate hemostasis.

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1.4K vistas.  University Heart and Vascular Center Hamburg. Este protocolo demuestra en detalle cómo realizar una cirugía de válvula mitral totalmente endoscópica con canulación percutánea de los vasos inguinales, utilizando un dispositivo de cierre vascular percutáneo basado en tapón. Los pasos fundamentales y las instrucciones útiles se describen en detalle para cada paso para un procedimiento exitoso. Luego acceda a lo largo del margen pericárdico hasta el cuarto espacio intercostal.Lograr la distensión del espacio intercostal uti...