Minimally Invasive Mitral Valve Surgery

  • Mateo Marin-Cuartas
  • Piroze M. DavierwalaEmail author


Minimally invasive mitral valve procedures have been performed with increasing frequency for almost two decades. These alternatives offer similar efficacy to that achieved via standard median sternotomy, particularly in large volume centers, along with low perioperative morbidity and mortality rates. Additionally, less postoperative pain, shorter recovery times, as well as superior cosmetic results make these procedures more attractive for patients. However, these techniques are technically complex and associated with a significant learning curve. Although these techniques are well established in referral centers, future innovations should concentrate on decreasing complexity and improving reproducibility of these procedures. This chapter offers an overview of the most relevant aspects related to minimally invasive mitral valve surgery.


Chordal repair Minimally invasive mitral valve surgery Mitral valve repair Mitral valve surgery Right minithoracotomy 


  1. 1.
    Marin Cuartas M, Javadikasgari H, Pfannmueller B, Seeburger J, Gillinov AM, Suri RM, Borger MA. Mitral valve repair: robotic and other minimally invasive approaches. Prog Cardiovasc Dis. 2017;60:394–404.PubMedCrossRefGoogle Scholar
  2. 2.
    Carpentier A. Cardiac valve surgery—the “French correction”. J Thorac Cardiovasc Surg. 1983;86:323–37.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Carpentier A, Loulmet D, et al. Open heart operation under video surgery and minithoracotomy. First case (mitral valvuloplasty) operated with sucess. C R Acad Sci III. 1996;319:219–23.PubMedGoogle Scholar
  4. 4.
    Carpentier A, Loulmet D, Aupecle B, et al. Computer assisted open heart surgery. First case operated on with success. C R Acad Sci III. 1998;321:437–42.PubMedCrossRefGoogle Scholar
  5. 5.
    Falk V, Walther T, Autschbach R, et al. Robot-assisted minimally invasive solo mitral valve operation. J Thorac Cardiovasc Surg. 1998;115(2):470–1.PubMedCrossRefGoogle Scholar
  6. 6.
    Rosengart TK, Feldman T, Borger MA, et al. Percutaneous and minimally invasive valve procedures. A scientific statement from the American Heart Association Council on Cardiovascular Surgery and Anesthesia. Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcome Research Interdisciplinary Working group. Circulation. 2008;117:1750–67.Google Scholar
  7. 7.
    Holzhey DM, Seeburger J, Misfeld M, et al. Learning minimally invasivemitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation. 2013;128:483–91.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Folkmann S, Seeburger J, Garbade J, et al. Minimally invasive mitral valve surgery for mitral valve infective endocarditis. Thorac Cardiovasc Surg. 2018;66:525–9.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    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
  10. 10.
    Davierwala PM, Seeburger J, Pfannmueller B, Garbade J, Misfeld M, Borger MA, Mohr FW. Minimally-invasive mitral valve surgery: “The Leipzig experience”. Ann Cardiothorac Surg. 2013;2:744–50.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Cohn LH, Adams DH, Couper GS, 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.S.421–428.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2010;90:1401–8. 1410.e1CrossRefGoogle Scholar
  13. 13.
    Iribarne A, Easterwood R, Russo MJ, 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.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review. Innovations (Phila). 2011;6:84–103.CrossRefGoogle Scholar
  15. 15.
    Cao C, Gupta S, Chandrakumar D. A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease. Ann Cardiothorac Surg. 2013;2:693–703.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Casselman F, Aramendi J, Bentala M, et al. Endoaortic clamping does not increase the risk of stroke in minimal access mitral valve surgery: a multicenter experience. Ann Thorac Surg. 2015;100:1334–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Krapf C, Wohlrab P, Häußinger S, et al. Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate? Eur J Cardiothorac Surg. 2013;44:898–904.PubMedCrossRefGoogle Scholar
  18. 18.
    Tutschka MP, Bainbridge D, Chu MW, et al. Unilateral postoperative pulmonary edema after minimally invasive cardiac surgical procedures: a case-control study. Ann Thorac Surg. 2015;99:115–22.PubMedCrossRefGoogle Scholar
  19. 19.
    Chitwood WR, Rodriguez E. Minimally invasive and robotic mitral valve surgery. In: Cohn LH, editor. Cardiac surgery in the adult. 4th ed. New York: McGraw-Hill; 2008. p. 1080–100.Google Scholar
  20. 20.
    Loulmet DF, Carpentier A, Cho PW, et al. Less invasive techniques for mitral valve surgery. J Thorac Cardiovasc Surg. 1998;115:772–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Casselman FP, Van Slycke S, Wellens F, et al. Mitral valve surgery can now routinely be performed endoscopically. Circulation. 2003;108(Suppl 1):II48–54.PubMedGoogle Scholar
  22. 22.
    Felger JE, Chitwood WR, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach. Ann Thorac Surg. 2001;72:1203–8.PubMedCrossRefGoogle Scholar
  23. 23.
    McClure RS, Athanasopoulos LV, McGurk S, et al. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up. J Thorac Cardiovasc Surg. 2013;145:1199–206.PubMedCrossRefGoogle Scholar
  24. 24.
    Javadikasgari H, Suri RM, Tappuni B, et al. Robotic mitral valve repair for degenerative posterior leaflet prolapse. Ann Cardiothorac Surg. 2017;6:27–32.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early results of robotically assisted mitral valve surgery: analysis of the first 1000 cases. J Thorac Cardiovasc Surg. 2018;155:82–91.e2.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Poffo R, Pope RB, Toschi AP, Mokross CA. Video-assisted minimally invasive mitral valve repair: periareolar approach. Rev Bras Cir Cardiovasc. 2009;24:425–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Galloway AC, Schwartz CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg. 2009;88:1180–4.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Goldstone AB, Atluri P, Szeto WY, 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.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Glauber M, Miceli A, Canarutto D, et al. Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients. J Cardiothorac Surg. 2015;10:181.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Lamelas J, Williams RF, Mawad M, LaPietra A. Complications associated with femoral cannulation during minimally invasive cardiac surgery. Ann Thorac Surg. 2017;103:1927–32.PubMedCrossRefGoogle Scholar
  31. 31.
    Reser D, van Hemelrijck M, Pavicevic J, et al. Repair rate and durability of video assisted minimally invasive mitral valve surgery. J Card Surg. 2014;29:766–71.PubMedCrossRefGoogle Scholar
  32. 32.
    Heuts S, Maessen JG, Sardari Nia P. Preoperative planning of left-sided valve surgery with 3D computed tomography reconstruction models: sternotomy or a minimally invasive approach? Interact Cardiovasc Thorac Surg. 2016;22:587–93.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Akowuah E, Burdett C, Khan K, et al. Early and late outcomes after minimally invasive mitral valve repair surgery. J Heart Valve Dis. 2015;24:470–7.PubMedGoogle Scholar
  34. 34.
    Reser D, Walser R, van Hemelrijk M, et al. Long-term outcomes after minimally invasive aortic valve surgery through right anterior minithoracotomy. Thorac Cardiovasc Surg. 2017;65:191–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Aybek T, Dogan S, Risteski PS, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg. 2006;81:1618–24.PubMedCrossRefGoogle Scholar
  36. 36.
    Ricci D, Pellegrini C, Aiello M, et al. Port-access surgery as elective approach for mitral valve operation in re-do procedures. Eur J Cardiothorac Surg. 2010;37:920–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Murzi M, Miceli A, Di Stefano G, 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.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Ghoneim A, Bouhout I, Mazine A, et al. Beating heart minimally invasive mitral valve surgery in patients with patent coronary bypass grafts. Can J Cardiol. 2016;32:987.e981–6.Google Scholar
  39. 39.
    Reser D, Sündermann S, Grünenfelder J, et al. Obesity should not deter a surgeon from selecting a minimally invasive approach for mitral valve surgery. Innovations (Phila). 2013;8:225–9.CrossRefGoogle Scholar
  40. 40.
    Lamelas J, Sarria A, Santana O, et al. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg. 2011;91:79–84.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Lange R, Voss B, Kehl V, et al. Right minithoracotomy versus full sternotomy for mitral valve repair: a propensity matched comparison. Ann Thorac Surg. 2017;103:573–9.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Mohr FW, Falk V, Diegeler A, et al. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg. 1998;115:567–74.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Moscarelli M, Fattouch K, Casula R, et al. What Is the role of minimally invasive mitral valve surgery in high-risk patients? A meta-analysis of observational studies. Ann Thorac Surg. 2016;101:981–9.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Santana O, Reyna J, Grana R, et al. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011;91:406–10.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Poffo R, Pope RB, Selbach RA, et al. Video-assisted cardiac surgery: results from a pioneer project in Brazil. Rev Bras Cir Cardiovasc. 2009;24:318–26.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Yamada T, Ochiai R, Takeda J, et al. Comparison of early postoperative quality of life in minimally invasive versus conventional valve surgery. J Anesth. 2003;17:171–6.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Vollroth M, Seeburger J, Garbade J, et al. Conversion rate and contraindications for minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2:853–4.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothorac Surg. 2008;34:760–5.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Glower DD, Landolfo KP, Clements F, et al. Mitral valve operation via Port Access versus median sternotomy. Eur J Cardiothorac Surg. 1998;14(Suppl 1):S143–7.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;70:252–89.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.CrossRefPubMedGoogle Scholar
  52. 52.
    Gammie JS, Sehng S, Griffith BP, et al. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2009;87:1431–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Chatterjee S, Rankin JS, Gammie JS, et al. Isolated mitral valve surgery risk in 77,836 patients from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2013;96:1587–94.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    German Heart Surgery Report 2015. The annual updated regsitry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2016;64:462–74.CrossRefGoogle Scholar
  55. 55.
    Pompili MF, Stevens JH, Burdon TA, et al. Port-acces mitral valve replacement in dogs. J Thorac Cardiovasc Surg. 1996;112:1268–74.PubMedCrossRefGoogle Scholar
  56. 56.
    Fann JI, Pompili MF, Burdon TA, et al. Minimally invasive mitral valve surgery. Semin Thorac Surg. 1997;9:320–30.Google Scholar
  57. 57.
    Navia JL, Cosgrove DM 3rd. Minimally invasive mitral valve operations. Ann Thorac Surg. 1996;62:1542–4.PubMedCrossRefGoogle Scholar
  58. 58.
    Aklog L, Adams DH, Couper GS, Gobezie R, Sears S, Cohn LH. Techniques and results of direct-acces minimally invasive mitral valve surgery: a paradigm for the future. J Thorac Cardiovas Surg. 1998;116:705–15.CrossRefGoogle Scholar
  59. 59.
    Mohr FW, Onnasch JF, Falk V, et al. The evolution of minimally invasive mitral valve surgery-2 year experience. Eur J Cardiothorac Surg. 1999;15:233–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Poffo R, Montanhesi PK, Toschi AP, Pope RB, Mokross CA. Periareolar access for minimally invasive cardiac surgery: the Brazilian technique. Innovations (Phila). 2018;13:65–9.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.University Department of Cardiac SurgeryLeipzig Heart CenterLeipzigGermany

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