Name: fully endoscopic mitral valve repair with percutaneous cannulation of groin vessels
Uploaded: 2023-05-26T12:00:00
Description: Watch this Scientific Journal Video about Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels at JoVE.com

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. 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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 ...

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