Minimally Invasive Valve Surgery

Overview

The tricuspid valve, pulmonary valve, mitral valve, and aortic valve are among the four valves in your heart that control blood flow. Regurgitation, in which blood leaks back through the valve in the wrong direction, can be caused by a damaged heart valve. It could also have stenosis, which causes the valve to not open as well as it should and obstruct blood flow. Additionally, the mitral valve doesn't shut tightly when it prolapses.

Your cardiologist might advise heart valve replacement or repair if you have a damaged heart valve. Your heart is medically stopped during valve surgery, and a heart-lung machine is used to oxygenate and circulate your blood. The damaged valve is removed by your surgeon, who then sews a replacement valve into place. Although a mechanical valve composed of plastic and metal is more frequently employed, the replacement valve may be taken from an organ donor.

Diseased valves can occasionally be repaired; for instance, if calcium deposits on the valve can be surgically removed, the valve may be reshaped to close more forcefully. Sometimes, if the valve hole is too large, sutures might be used to close it.

Many institutions provide both minimally invasive surgery, which only needs minor incisions in the chest, and open-chest valve surgery, which necessitates a significant breastbone incision.

 

What is Minimally Invasive Valve Surgery?

Minimally invasive heart valve surgery (MIVS) is performed via parasternal incision, which is next to the sternum, a hemi-sternotomy, or a right mini-thoracotomy (the most common access points). The evidence that is now available demonstrates equivalent or superior outcomes compared to the standard surgical method, which calls for a full median sternotomy. When practicable, antegrade ascending aorta cannulation is used (usually for aortic valve surgery).

Femoral artery cannulation with retrograde arterial perfusion is another frequently utilized method. Retrograde arterial perfusion is frequently used despite there being some disagreement over whether it increases the risk of stroke and other vascular problems. This is because it is thought that the benefits outweigh the dangers.

For bicaval access, venous cannulation can be done through the right atrial appendage or the internal jugular and femoral veins. After establishing Cardiopulmonary Bypass (CPB), the aortic cross-clamp is applied to the ascending aorta either externally in aortic valve surgery or endoluminally in mitral and tricuspid valve surgery using the endoballoon.

Transesophageal echocardiography is important to MIVS for the diagnosis and treatment of valve pathology, the implantation of the cannula, and the de-airing of the heart after the valve procedure.

 

Minimally Invasive Valve Surgery Types

There are three distinct types of minimally invasive valve surgery:

Minimally Invasive Aortic Valve Surgery

The right upper chest is used to access the aortic valve during surgery, and an incision is made between the second and third ribs close to the breastbone (sternum). The surgeon performs the procedure similar to how they would through a much larger cut through the breastbone using specialized surgical instruments and cameras.

Your heart is medically stopped during valve surgery, and a heart-lung machine is used to oxygenate and circulate your blood. Depending on the type of valve illness you have, your doctor may repair the valve or replace it. Your aortic valve is removed during an aortic valve replacement procedure, and a mechanical valve or a valve from a cow or pig is used in its stead.

 

Minimally Invasive Mitral Valve Surgery

Between the left atrium and the left ventricle of the heart lies a valve known as the mitral valve. It permits blood to move in one direction (from the left atrium into the left ventricle) but not the other. The mitral valve has two flaps. The bicuspid valve is yet another name for it. Due to two different types of mitral valve disease, mitral valve operations can replace or repair damaged mitral valves:

• Mitral valve stenosis. This happens when the mitral valve flaps harden, thicken, or congregate. As a result, less blood may pass from the left atrium to the left ventricle through the valve opening.
• Mitral valve regurgitation. This happens when the mitral valve flaps are unable to firmly and completely seal. Blood from the left ventricle flows back into the left atrium when this occurs. Your heart muscle may become harmed by this leakage or regurgitation over time.

 

Transcatheter Aortic Valve Replacement (TAVR)

Surgery to repair or replace your aortic valve may help to alleviate symptoms and minimize your risk of developing potentially deadly problems when your aortic valve isn't functioning properly due to aortic stenosis. You have the chance to feel better and live longer with aortic valve replacement, which can be completed either by an open chest operation or with minimally invasive surgery. However, TAVR is now the least invasive kind of treatment.

In TAVR, your doctors replace your damaged valve by inserting a new one into your aortic valve. The new valve is wedged into position, and TAVR is less invasive than other repair or replacement operations. As a result, TAVR has many benefits, such as a quicker recovery and a reduction in the symptoms of aortic stenosis.

 

Minimally Invasive Valve Repair Surgery

Repair or reconstruction is the first line of management when treating a diseased or damaged heart valve since it protects the native valve and may help to long-term maintain overall heart function. To strengthen and tighten the valve and its leaflets/cusps, a variety of state-of-the-art instruments may be used during valve repair. Valve reconstruction comes in a variety of forms, including:

• Annuloplasty. A customized ring-like device is inserted around the valve to tighten or strengthen the valve's opening (annulus).
• Reshaping. Excess tissue is eliminated from the valve's leaflets and cusps so that they securely close, ensuring that the valve can open and close effectively.
• Reconnecting. To enable the valve to open and close effectively in the event of gaps or tears in the valve leaflets or cusps, they are repaired.
• Structural cord repair. Each valve's leaflets or cusps are held in place by tiny cords and muscles that cooperate to open and close the valve. The cords can be changed or cut shorter to enable the valve to function properly.
• Commissurotomy. The valve's leaflets and cusps may thicken and become trapped as a consequence of valve stenosis, preventing the valve from operating as it should. The leaflets can fully open and close by removing extra tissue.

A valve replacement may be the safest and best solution when disease or damage is severe. A mechanical valve or a biological tissue valve, both of which offer significant benefits, may be employed as the most recent valve replacement choices.

 

Minimally Invasive Valve Surgery vs Open Valve Surgery

To give the surgeon direct and unhindered access to the chest and heart valve during this operation, a sternotomy (entry to the chest through a cut along the sternum/breastbone) is used. Cardiopulmonary bypass, or using a heart-lung machine to oxygenate and circulate blood while the heart is stopped, is how valve surgery is typically carried out. Any of the four heart valves (aortic, mitral, tricuspid, or pulmonary) can be repaired or replaced by open surgery.

In contrast to open surgery, which requires a sternotomy, minimally invasive valve surgery accesses the chest and heart by two tiny cuts or ports (each several inches long). A specialized video scope is placed through one cut to provide a clear, detailed image of the affected valve. The surgeon will repair the valve using specialized tools through the other small opening, which is only a few inches in diameter, keeping the heart as near to its native structure as possible.

 

Minimally Invasive Valve Surgery Benefits

For decades, many heart-circulatory issues have been successfully treated surgically using open-chest valve surgery. However, many patients now prefer a minimally invasive surgical procedure. These operations are carried out using a combination of hybrid techniques, tiny cameras, and advanced thin instruments.

Adults undergoing minimally invasive valve procedures do so in operating rooms with state-of-the-art diagnostic tools, cutting-edge technology, and cutting-edge imaging capabilities. The capabilities of a cardiac catheterization laboratory and an operating room are combined in this setting. Comparing minimally invasive valve surgery methods to open-chest procedures, there are several benefits. They include:

• Shorter hospital stay. It is possible to reduce the length of hospital stays by up to 50%.
• Fewer complications. The risk of infection and postoperative problems is reduced during minimally invasive valve surgery since the breastbone (sternum) is not cut.
• Less pain. Compared to open-heart surgery, less tissue and muscle trauma leads to less pain.
• Less bleeding. Patients lose less blood and are less likely to need a transfusion as a result of smaller incisions.
• Less scarring. After a minimally invasive valve operation, there are only a few small scars and/or a two-inch scar left.

 

Disadvantages of Minimally Invasive Heart Surgery 

• Patient selection. Patient selection may be more difficult for extremely large patients who have Pectus Excavatum (the heart may be moved deeper into the left thorax) and have had thoracic surgery in the past. To sufficiently expose the operative field, adhesions from prior thoracic surgery must be removed.
• Clinical expertise. demands the integration of video signals into visual feedback and hand-eye coordination, which calls for a particular skill level. It takes skill to use longer instruments and lost tactile sensation during robot-assisted surgery. All of the above point to a steeper learning curve to becoming comfortable with the procedures.
• Vascular complications. Following cannulation of the femoral vessels, vascular problems may develop. This kind of complication has been considerably decreased by careful preoperative assessment of the iliac artery, femoral artery, and aorta performed by additional imaging (angiogram/MRI/CT scan) techniques. Retrograde arterial perfusion and perioperative risk of stroke are still being reported.
• Injury. Phrenic nerve traction injury should be prevented during the lateral pericardial incision for mitral valve surgery.

 

Minimally Invasive Valve Surgery Candidates

Several factors may be taken into account when deciding if valve surgery is the best course of action for a damaged or diseased valve. In addition to the patient's general health and medical background, the surgeon will carefully consider important aspects of their situation, such as:

• Symptoms that interfere with or decrease quality of life.
• The degree of the valve's condition or damage.
• The presence of further cardiothoracic disease or damage.
• Whether the patient has had cardiothoracic surgeries in the past.

The optimum course of treatment for a patient may depend on a variety of factors, including minimally invasive valve surgery. The patient's age and medical history, in addition to the exact type and extent of the valvular disease, are crucial factors. The best candidates are those who have:

• Severely damaged valve.
• Several damaged valves.
• Severe arterial blockages (coronary artery disease or peripheral artery disease).
• Obesity.
• Had previous cardiothoracic surgeries.

 

How is Minimally Invasive Valve Surgery Performed

If a patient has isolated valve disease and neither clinically significant aortic valve disease nor coronary artery disease, they may be candidates for minimally invasive valve surgery. Instead of the massive midline incision and sternum division utilized in conventional open surgery, only a tiny 4-6 cm incision is made on the right side of the chest to complete the procedure.

The tiny space between the ribs is used for the procedure. The heart can be stopped while the valve is being repaired by inserting the heart-lung machine through a tiny incision in the groin. To introduce the specialized least invasive devices, a soft retractor is placed, gently widening the small area between the ribs. An endoscope (ideally one with a 3D camera) is inserted to obtain a high-resolution view of the valve.

The stability of the chest is completely retained while using this approach, patients heal faster, and the minor scar will be barely seen once the patient is fully recovered.

 

Minimally Invasive Valve Surgery Risks

Minimally invasive surgery does include some risk, as do any surgical procedures. They actively take action to prevent and avoid hazards during and after surgery with the help of a cardiothoracic surgeon and a cooperative team of professionals who thoroughly grasp the potential issues and dangers associated with the procedure. In contrast to conventional surgery, minimally invasive surgery has a decreased risk of excessive bleeding (requiring transfusions), lower risk of infection, and no dangers related to a sternotomy. Similar to open heart surgery, minimally invasive valve surgery carries some risks, such as:

• Bleeding or blood clots (heart attack or stroke).
• Infection.
• Pneumonia.
• Pancreatitis.
• Renal failure.
• Irregularities in the heart's rhythm.

 

Conclusion

The development of sutureless valves should make minimally invasive valve replacements simpler and quicker with lower stroke risks thanks to less invasive techniques. Sutureless valves are becoming more prevalent in clinical settings all around the world. This procedure involves the removal of all diseased leaflets and annular valve calcification, in contrast to transcatheter valve replacement, which makes it possible to implant a larger expandable prosthesis. After the aortic annulus has been cleaned up, a sutureless bovine valve is constructed on a self-expanding stent that may be inserted and released to suit the annulus.