Totally Endoscopic Triple Valve Surgery: AVR, MVr, TVr

In this CTSNet series, Dr. Mario Castillo-Sang presents innovative, totally endoscopic cardiac procedures for a variety of conditions. Stay tuned for more series videos in the coming weeks.     

This case included aortic valve replacement (AVR), mitral valve repair (MVr), and tricuspid valve repair (TVr) during triple valve surgery (TVS). The patient was a 68-year-old male with a flail posterior leaflet with an anteriorly directed jet observed on the echocardiogram, along with preserved ventricular function. The patient also had moderate to severe aortic insufficiency and moderate tricuspid regurgitation, with a dilated annulus measuring 40 mm. 

The surgical approach was through a 2.5 cm incision in the fourth intercostal space for the working port, and a 10 mm camera trocar was inserted through the third intercostal space. Cannulation was performed through an incision on the left groin. 

In cases with significant pericardial fat pad like this one, the surgeons took down the pad over the pericardium and delineated the phrenic nerve to avoid injury. The pericardium was opened using an energy jaw device, and pericardial stitches were applied as shown in the video, typically four to the posterior pericardium and one to the anterior pericardium. 

A 5 mm trocar was passed through the interior chest wall, and through it, the surgeons passed the ventricular pacing wire, the atrial holder, and the anterior pericardial stitch. A root vent cannula was applied and cross-clamped, delivering antegrade del Nido cardioplegia while the patient was cooled to 32 degrees Celsius. 

The left atrium appendage was closed with a barbed suture in a running fashion, and then the mitral valve was exposed. In cases of multisegment disease, annuloplasty sutures are applied to create better exposure. The valve was analyzed and a flail segment to the medial P2 and a slight prolapse of the P1 area were found. The authors decided to apply a neochord to the P2 segment using the premeasured ChordX system, which is analogous to the Leipzig technique. To do this, the length of the posterior leaflet neochord was measured to be applied from the edge of the flattened prolapse to the site of the papillary muscle to which it would be anchored on the posteromedial muscle. 

Valve analysis for the rest of the valve showed that there was no significant prolapse except for a slight one at P1. It is important to perform this careful analysis to avoid missing lesions in the valve. The neochords were anchored and placed close to the edge of the leaflet to medial P2 and P3. A lateral commissuroplasty stitch was performed for the P1 area that was slightly prolapsed, using the anchoring suture of the neochord system as a hand sewn-adjustable neochord to central P2. Final static testing with del Nido cardioplegia showed a competent valve, with an ink test showing a deep coaptation zone. The left atrium was closed in one layer, and then the AVR was performed.  

The aorta was opened, and direct ostial del Nido cardioplegia was administered (not shown). Aortic valve exposure was achieved through reflecting stitches from the aortic wall to the pericardium. The authors typically place ventricular-to-aorta stitches without pledgets for these operations, and they use a bovine pericardial valve. The aorta was closed in a single layer with 4-0 polypropylene running blanket (RB) sutures, and then the clamp was removed. As the heart reperfused, attention was turned to the tricuspid valve, where annuloplasty sutures were placed, and a downsizing annuloplasty with a 28 mm band final was placed. Static testing with saline yielded satisfactory results, and the right atrium was closed in one layer. The final echocardiogram showed no residual mitral regurgitation with a low mean gradient, the aortic valve functioned without regurgitation, and the tricuspid valve was also functioning well, with preserved ventricular contractility. The patient was extubated in the operating room, as is the authors’ practice for elective endoscopic surgery. The patient was discharged on postoperative day three, and during follow-up at one, three, and 12 months, was found to be doing well in New York Heart Association (NYHA) class 1, with stable echocardiographic findings at one year. 

Minimally invasive aortic valve and mitral surgery can be performed safely with del Nido cardioplegia (1, 2). TVS has been performed before using other forms of long acting cardioplegia (3). In the authors’ experience, TVS performed endoscopically can be performed safely with long acting cardioplegia such as del Nido solution. The antegrade arrest is obtained by delivering del Nido solution in aliquots of 400 to 600 ml into the root and then turning on the root vent once the heart distends. The authors have found that at 400 ml, most hearts have either arrested or fibrillated. The surgeons will typically administer a two-liter dose in this fashion.  

The aorta is not opened, and arrest with direct antegrade ostial cardioplegia is avoided, as this would lead to the inability to static test the mitral valve, which is important in cases of multisegment mitral disease. Cooling the patient to 32 degrees Celsius also contributes to myocardial protection. Performing the aortic valve replacement prior to the mitral valve creates difficulties in exposing the mitral valve and introduces the risk of potential root injury as the left atrium is pulled up with the retractor. Endoscopic cardiac surgery is an effective tool for performing multivalve operations. 

References

1. Luo H, Qi X, Shi H, Zhao H, Liu C, Chen H, Peng R, Yu Z, Hu K, Wang C, Li X. Single-dose del Nido cardioplegia used in adult minimally invasive valve surgery. Journal of Thoracic Disease. 2019 Jun;11(6):2373.
2. Malvindi PG, Bifulco O, Berretta P, Silvano R, Alfonsi J, Cefarelli M, Zingaro C, Di Eusanio M. del Nido and Histidine-Tryptophan-Ketoglutarate cardioplegia in minimally invasive mitral valve surgery: A propensity-Match study. Perfusion. 2024 May;39(4):823-32
3. Moront MG, Kuehne M, Redfern RE. Minimally invasive triple valve surgery: A single center experience. Journal of Cardiac Surgery. 2020 Oct;35(10):2567-73.

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