Minimally Invasive Mitral Valve Surgery via Mini-Thoracotomy: Current Update

  • Serguei I. Melnitchouk
  • Jacob P. Dal-Bianco
  • Michael A. Borger
Valvular Heart Disease (J Passeri, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Valvular Heart Disease

Opinion statement

In recent years, minimally invasive mitral valve surgery (MIMVS) has established itself as an alternative and increasingly used option for patients with mitral valve (MV) pathology. MIMVS is associated with a very low perioperative morbidity and mortality rate in appropriately selected patients, comparable to a full sternotomy approach. Besides superior cosmetic results, patients after MIMVS enjoy shorter recovery times and earlier returns to full activity. A number of approaches are branded as minimally invasive, but the most widely used one entails peripheral cardiopulmonary bypass and a small right anterolateral mini-thoracotomy. The operative technique and outcomes of this approach are summarized in the current update.


Minimally invasive Mitral valve repair Mini-thoracotomy Endoscopic 


Compliance with Ethics Guidelines

Conflict of Interest

Serguei I. Melnitchouk, Jacob P. Dal-Bianco, and Michael A. Borger each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Funkat A, Beckmann A, Lewandowski J, Frie M, Ernst M, Schiller W, et al. Cardiac surgery in Germany during 2013: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2014;62:380–92.CrossRefPubMedGoogle Scholar
  2. 2.
    Luca F, van Garsse L, Rao CM, Parise O, La Meir M, Puntrello C, et al. Minimally invasive mitral valve surgery: a systematic review. Minim Invasive Surg. 2013;2013:179569.PubMedCentralPubMedGoogle Scholar
  3. 3.
    Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation. 2013;128:483–91.CrossRefPubMedGoogle Scholar
  4. 4.
    Seeburger J, Borger MA, Falk V, Kuntze T, Czesla M, Walther T, et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothoracic Surg : Off J Eur Assoc Cardiothoracic Surg. 2008;34:760–5.CrossRefGoogle Scholar
  5. 5.
    Goldstone AB, Atluri P, Szeto WY, Trubelja A, Howard JL, MacArthur Jr JW, et al. Minimally invasive approach provides at least equivalent results for surgical correction of mitral regurgitation: a propensity-matched comparison. J Thorac Cardiovasc Surg. 2013;145:748–56.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Kuntze T, Borger MA, Falk V, Seeburger J, Girdauskas E, Doll N, et al. Early and mid-term results of mitral valve repair using premeasured Gore-Tex loops (‘loop technique’). Eur J Cardiothorac Surg : Off J Eur Assoc Cardiothorac Surg. 2008;33:566–72.CrossRefGoogle Scholar
  7. 7.
    McClure RS, Cohn LH, Wiegerinck E, Couper GS, Aranki SF, Bolman 3rd RM, et al. Early and late outcomes in minimally invasive mitral valve repair: an eleven-year experience in 707 patients. J Thorac Cardiovasc Surg. 2009;137:70–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Rodriguez E, Nifong LW, Chu MW, Wood W, Vos PW, Chitwood WR. Robotic mitral valve repair for anterior leaflet and bileaflet prolapse. Ann Thorac Surg. 2008;85:438–44. discussion 444.CrossRefPubMedGoogle Scholar
  9. 9.
    Casselman FP, Van Slycke S, Dom H, Lambrechts DL, Vermeulen Y, Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable. J Thorac Cardiovasc Surg. 2003;125:273–82.CrossRefPubMedGoogle Scholar
  10. 10.•
    Petracek MR, Leacche M, Solenkova N, Umakanthan R, Ahmad RM, Ball SK, et al. Minimally invasive mitral valve surgery expands the surgical options for high-risks patients. Ann Surg. 2011;254:606–11. This paper describes minimally invasive mitral valve surgery approach by use of fibrillatory arrest in order to avoid aortic cross-clamping and cardioplegic myocardial arrest in patients with prior sternotomy. Authors report low mortality and morbidity on 504 consecutive patients who underwent mitral valve surgery via this approach. They conclude that this approach expands the surgical options for high-risk patients and yields to superior results than the conventional median sternotomy approach.CrossRefPubMedGoogle Scholar
  11. 11.
    Lamelas J, Sarria A, Santana O, Pineda AM, Lamas GA. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg. 2011;91:79–84.CrossRefPubMedGoogle Scholar
  12. 12.
    Navia JL, Cosgrove 3rd DM. Minimally invasive mitral valve operations. Ann Thorac Surg. 1996;62:1542–4.CrossRefPubMedGoogle Scholar
  13. 13.
    Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997;226:421–6. discussion 427–8.PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Pompili MF, Stevens JH, Burdon TA, Siegel LC, Peters WS, Ribakove GH, et al. Port-access mitral valve replacement in dogs. J Thorac Cardiovasc Surg. 1996;112:1268–74.CrossRefPubMedGoogle Scholar
  15. 15.
    Mohr FW, Falk V, Diegeler A, Walther T, van Son JA, Autschbach R. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg. 1998;115:567–74. discussion 574–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Schwartz DS, Ribakove GH, Grossi EA, Stevens JH, Siegel LC, St Goar FG, et al. Minimally invasive cardiopulmonary bypass with cardioplegic arrest: a closed chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg. 1996;111:556–66.CrossRefPubMedGoogle Scholar
  17. 17.
    Chitwood Jr WR, Elbeery JR, Moran JF. Minimally invasive mitral valve repair using transthoracic aortic occlusion. Ann Thorac Surg. 1997;63:1477–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Falk V, Walther T, Diegeler A, Wendler R, Autschbach R, van Son JA, et al. Echocardiographic monitoring of minimally invasive mitral valve surgery using an endoaortic clamp. J Heart Valve Dis. 1996;5:630–7.PubMedGoogle Scholar
  19. 19.
    Chitwood Jr WR, Elbeery JR, Chapman WH, Moran JM, Lust RL, Wooden WA, et al. Video-assisted minimally invasive mitral valve surgery: the “micro-mitral” operation. J Thorac Cardiovasc Surg. 1997;113:413–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Mohr FW, Onnasch JF, Falk V, Walther T, Diegeler A, Krakor R, et al. The evolution of minimally invasive valve surgery--2 year experience. Eur J Cardiothorac Surg : Off J Eur Assoc Cardiothorac Surg. 1999;15:233–8. discussion 238–9.CrossRefGoogle Scholar
  21. 21.
    Grossi EA, Galloway AC, LaPietra A, Ribakove GH, Ursomanno P, Delianides J, et al. Minimally invasive mitral valve surgery: a 6-year experience with 714 patients. Ann Thorac Surg. 2002;74:660–3. discussion 663–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Chitwood Jr WR, Rodriguez E, Chu MW, Hassan A, Ferguson TB, Vos PW, et al. Robotic mitral valve repairs in 300 patients: a single-center experience. J Thorac Cardiovasc Surg. 2008;136:436–41.CrossRefPubMedGoogle Scholar
  23. 23.
    Mihaljevic T, Jarrett CM, Gillinov AM, Williams SJ, DeVilliers PA, Stewart WJ, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized. J Thorac Cardiovasc Surg. 2011;141:72–80 e1-4.CrossRefPubMedGoogle Scholar
  24. 24.
    Suri RM, Burkhart HM, Daly RC, Dearani JA, Park SJ, Sundt 3rd TM, et al. Robotic mitral valve repair for all prolapse subsets using techniques identical to open valvuloplasty: establishing the benchmark against which percutaneous interventions should be judged. J Thorac Cardiovasc Surg. 2011;142:970–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Carpentier A. Reconstructive valvuloplasty. A new technique of mitral valvuloplasty. Presse Med. 1969;77:251–3.PubMedGoogle Scholar
  26. 26.
    Maisano F, Schreuder JJ, Oppizzi M, Fiorani B, Fino C, Alfieri O. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg : Off J Eur Assoc Cardiothorac Surg. 2000;17:201–5.CrossRefGoogle Scholar
  27. 27.
    Carpentier A, Chauvaud S, Fabiani JN, Deloche A, Relland J, Lessana A, et al. Reconstructive surgery of mitral valve incompetence: ten-year appraisal. J Thorac Cardiovasc Surg. 1980;79:338–48.PubMedGoogle Scholar
  28. 28.
    Frater RW. 10th Goretex chorda anniversary. J Heart Valve Dis. 1996;5:348–51.PubMedGoogle Scholar
  29. 29.
    David TE. Replacement of chordae tendineae with expanded polytetrafluoroethylene sutures. J Card Surg. 1989;4:286–90.CrossRefPubMedGoogle Scholar
  30. 30.
    Perier P, Hohenberger W, Lakew F, Batz G, Urbanski P, Zacher M, et al. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach. Ann Thorac Surg. 2008;86:718–25. discussion 718–25.CrossRefPubMedGoogle Scholar
  31. 31.
    von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg. 2000;70:2166–8.CrossRefGoogle Scholar
  32. 32.•
    Davierwala PM, Seeburger J, Pfannmueller B, Garbade J, Misfeld M, Borger MA, et al. Minimally invasive mitral valve surgery: “The Leipzig experience”. Ann Cardiothorac Surg. 2013;2:744–50. This is a report on a total of 3438 patients who underwent minimally invasive mitral valve surgery at the Leipzig Heart Center where it became a routine procedure. Authors report excellent results of the procedure that can be performed safely and effectively with very few perioperative complications.PubMedCentralPubMedGoogle Scholar
  33. 33.
    Seeburger J, Falk V, Borger MA, Passage J, Walther T, Doll N, et al. Chordae replacement versus resection for repair of isolated posterior mitral leaflet prolapse: a egalite. Ann Thorac Surg. 2009;87:1715–20.CrossRefPubMedGoogle Scholar
  34. 34.
    Perier P, Hohenberger W, Lakew F, Batz G, Diegeler A. Rate of repair in minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2:751–7.PubMedCentralPubMedGoogle Scholar
  35. 35.
    Reser D, van Hemelrijck M, Pavicevic J, Platzmann A, Caliskan E, Falk V, et al. Repair rate and durability of video assisted minimally invasive mitral valve surgery. J Card Surg. 2014;29:766–71.CrossRefPubMedGoogle Scholar
  36. 36.
    Gammie JS, Bartlett ST, Griffith BP. Small-incision mitral valve repair: safe, durable, and approaching perfection. Ann Surg. 2009;250:409–15.PubMedGoogle Scholar
  37. 37.
    Borger MA, Kaeding AF, Seeburger J, Melnitchouk S, Hoebartner M, Winkfein M, et al. Minimally invasive mitral valve repair in Barlow’s disease: early and long-term results. J Thorac Cardiovasc Surg. 2014;148:1379–85.CrossRefPubMedGoogle Scholar
  38. 38.
    Murzi M, Miceli A, Di Stefano G, Cerillo AG, Farneti P, Solinas M, et al. Minimally invasive right thoracotomy approach for mitral valve surgery in patients with previous sternotomy: a single institution experience with 173 patients. J Thorac Cardiovasc Surg. 2014;148:2763–8.CrossRefPubMedGoogle Scholar
  39. 39.•
    Arcidi Jr JM, Rodriguez E, Elbeery JR, Nifong LW, Efird JT, Chitwood Jr WR. Fifteen-year experience with minimally invasive approach for reoperations involving the mitral valve. J Thorac Cardiovasc Surg. 2012;143:1062–8. This systematic review and meta-analysis of comparative studies was performed to update the current evidence on mitral valve surgery through a lateral mini-thoracotomy versus median sternotomy. More than 20,000 patients from 45 studies were included in this study, allowing the authors to conclude that MIMVS and conventional mitral valve surgery have a similar perioperative outcome. Mitral valve surgery via a right lateral mini-thoracotomy seems to be favorable with regard to resource-related outcome.CrossRefPubMedGoogle Scholar
  40. 40.
    Santana O, Reyna J, Pineda AM, Mihos CG, Elkayam LU, Lamas GA, et al. Outcomes of minimally invasive mitral valve surgery in patients with an ejection fraction of 35% or less. Innovations. 2013;8:1–5.PubMedGoogle Scholar
  41. 41.
    Seeburger J, Raschpichler M, Garbade J, Davierwala P, Pfannmueller B, Borger MA, et al. Minimally invasive mitral valve surgery in octogenarians-a brief report. Ann Cardiothorac surg. 2013;2:765–7.PubMedCentralPubMedGoogle Scholar
  42. 42.
    Vollroth M, Seeburger J, Garbade J, Borger MA, Misfeld M, Mohr FW. Conversion rate and contraindications for minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2:853–4.PubMedCentralPubMedGoogle Scholar
  43. 43.
    Sundermann SH, Sromicki J, Rodriguez Cetina Biefer H, Seifert B, Holubec T, Falk V, et al. Mitral valve surgery: right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2014;148:1989–1995.e4.CrossRefPubMedGoogle Scholar
  44. 44.
    Iribarne A, Easterwood R, Russo MJ, Wang YC, Yang J, Hong KN, et al. A minimally invasive approach is more cost-effective than a traditional sternotomy approach for mitral valve surgery. J Thorac Cardiovasc Surg. 2011;142:1507–14.PubMedCentralCrossRefPubMedGoogle Scholar
  45. 45.
    Cao C, Gupta S, Chandrakumar D, Nienaber TA, Indraratna P, Ang SC, et al. A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease. Ann Cardiothorac Surg. 2013;2:693–703.PubMedCentralPubMedGoogle Scholar
  46. 46.
    Modi P, Rodriguez E, Hargrove 3rd WC, Hassan A, Szeto WY, Chitwood Jr WR. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg. 2009;137:1481–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Serguei I. Melnitchouk
    • 1
  • Jacob P. Dal-Bianco
    • 2
  • Michael A. Borger
    • 3
  1. 1.Division of Cardiac SurgeryMassachusetts General HospitalBostonUSA
  2. 2.Division of CardiologyMassachusetts General HospitalBostonUSA
  3. 3.Division of Cardiac SurgeryColumbia University Medical CenterNew YorkUSA

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