Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Podsumowanie

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.

Streszczenie

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.

Wprowadzenie

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 is....

Protokół

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

1. Ensure the patient is under general anesthesia, in a supine position, scrubbed with iodine disinfectant, and draped with a sterile drape.
2. Gain thoracic access along the peri-mammillary margin through the fourth intercostal space.
3. Achieve distension of the intercostal space using a soft-tissue retractor.

2. P....

Wyniki

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.......

Dyskusje

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 devices^7,12. In a series of 3.......

Materiały

Name	Company	Catalog Number	Comments
30° camera head	Aesculap Einstein Vision	PV 632
3D-HD camera	Aesculap Einstein Vision	PV 630
Annuloplasty ring	Edwards	93381
Aortic clamp	Cardio Vision	CV 195.10
Aterial Cannula	Medtronic	96570-121
Femoral Cannula	Metronic	96670-125
Full HD 3D Monitor	Aesculap Einstein Vision	PV 646
Giude wire	Merit Medica	6678-71
Heart valve retractor set	Cardio Vision	CV 100.00
LED light source	Aesculap Einstein Vision	OP 950
Manta	Teleflex Medical Inc.	2115
Neo chordae	Serag Wiesner	MCL14A
Soft Tissue Retractor	Cardio Vision	Cv100/80
Stative table arm for endoscopes	Cardio Vision	CV 281.73
Stative table arm for instruments	Cardio Vision	CV 281.72
Suture for fixing Loops	Gore-Tex Suture	4N02