Experimental Transapical Endoscopic Ventricular Visualization and Mitral Repair

Abstract

Background An increasing number of experimental beating heart animal studies describe simple transapical mitral valve repairs based on the direct endoscopic visualization of the left ventricle. The aim of our human cadaveric study was to develop a method for more complex transapical endoscopic procedures by on-pump heart operations.

Materials and Methods After preparation of 20 human fresh cadavers, a standard left anterolateral minithoracotomy was performed in the fifth intercostal space and the pericardium was entered. A rigid 0 degree endoscope and the instruments were introduced through a silicon apical port. To restore the natural form of the left heart, CO₂ was insufflated. To test the mitral valve competence, the left ventricle was pressure-injected with saline after each step. After transecting the chords of the A2 segment of the anterior mitral leaflet before the experimental mitral valve repair, the tendinous chord was replaced using an especially designed clip chord. The second part of the experiment consisted of a segmental excision of the P2 segment of the posterior mitral leaflet followed by a standard valvuloplasty and suture annuloplasty.

Results With the help of the described transapical endoscopic mitral valve repair technique, we gained direct visual information of the coaptation line of the mitral leaflets as well as the anatomy and function of the subvalvular apparatus. Using intracardiac imaging, we could perform successful transapical complex mitral repair in each case.

Conclusion The minimally invasive transapical endoscopic method has the potential to offer advantages for on-pump mitral valve repair procedures even in complex mitral valve repair cases.

Keywords

anatomy - minimally invasive surgery - mitral valve surgery

Note

The work was presented at the 25th Annual Meeting of the European Association for Cardio-Thoracic Surgery in Lisbon 2011 (25th EACTS Meeting Techno-College/Acquired Cardiac Disease/Session 4: Mitral valve/Zoltan Galajda, Debrecen: Transapical endoscopic mitral repair/October 1, 2011, 15:00–18:00, Lisbon).

• References

• 1 Mihaljevic T, Ootaki Y, Robertson JO , et al. Beating heart cardioscopy: a platform for real-time, intracardiac imaging. Ann Thorac Surg 2008; 85 (3) 1061-1065
• 2 Horai T, Fukamachi K, Fumoto H , et al. Direct endoscopy-guided mitral valve repair in the beating heart: an acute animal study. Innovations (Phila) 2011; 6 (2) 122-125
• 3 Shiose A, Takaseya T, Fumoto H , et al. Cardioscopy-guided surgery: intracardiac mitral and tricuspid valve repair under direct visualization in the beating heart. J Thorac Cardiovasc Surg 2011; 142 (1) 199-202
• 4 Padala M, Jimenez JH, Yoganathan AP, Chin A, Thourani VH. Transapical beating heart cardioscopy technique for off-pump visualization of heart valves. J Thorac Cardiovasc Surg 2012; 144 (1) 231-234
• 5 Lutter G, Pokorny S, Frank D, Cremer J, Lozonschi L. Transapical mitral valve implantation: the Lutter valve. Heart Lung Vessel 2013; 5 (4) 201-206
• 6 Ruttkay T, Baksa G, Götte J , et al. Comparative Endoscopic Anatomic Description of the Mitral Valvular Complex: a Cadaveric Study. Thorac Cardiovasc Surg 2014; [published online ahead of print January 13, 2014]
• 7 Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparoscopy in colorectal surgery. Colorectal Dis 2008; 10 (8) 823-826
• 8 Walther T, Dewey T, Borger MA , et al. Transapical aortic valve implantation: step by step. Ann Thorac Surg 2009; 87 (1) 276-283
• 9 Seeburger J, Leontjev S, Neumuth M , et al. Trans-apical beating-heart implantation of neo-chordae to mitral valve leaflets: results of an acute animal study. Eur J Cardiothorac Surg 2012; 41 (1) 173-176 , discussion 176
• 10 Fann JI, Pompili MF, Stevens JH , et al. Port-access cardiac operations with cardioplegic arrest. Ann Thorac Surg 1997; 63 (6, Suppl): S35-S39