Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels
May 26th, 2023
This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.
This protocol demonstrates in detail how to perform fully-endoscopic mitral valve surgery with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step for a successful procedure. Then access along the pericardial margin to the fourth intercostal space.
Achieve distention of the intercostal space using a soft tissue retractor. Perform the puncture of the femoral artery using a standard puncture needle, and insert the guide wire under TE guidance. Determine the depth of the initial puncture using a puncture locating dilator, which is inserted over the wire.
This detects puncture depth by outflow, backflow, stop of backflow. Define the depths at skin level, which is defined by the visible stop of backflow of the measuring tool. For delayed release of the vascular closure device to prolong this is defined as puncture depth at skin level plus one centimeter.
Place the arterial cannula over the wire. And connect it to cardiopulmonary bypass. Puncture the femoral vein medial to the artery in the same manner.
And after the insertion of the venous cannula, connect to the cardiopulmonary bypass. Insert the 3D high definition camera over the thoracic incision. Then, open the pericardium above the right side phrenic nerve.
This is achieved by using a diathermy. Place a thoracic clip, or clamp, through a small incision for cross-clamping the aorta. This happens under induced ventricular fibrillation.
Arrest the heart with antegrade cardioplegia and moderate hypothermia of 32 degrees, which is established and maintained by the heart-lung machine. The effectiveness of cardioplegia is documented by an electrocardiogram. The left atrium is opened with a scissor.
After opening the left atrium, the left atrial roof is lift with a dynamic retractor. Then, the mitral valve is exposed. And the pathology is inspected.
In this case, we can see a prolapse of the posterior mitral leaflet. After detecting the pathology, size for correct annuloplasty ring, which is achieved by annuloplasty measuring tool. Size for correct neochordae via a caliper for the length of native chordae.
Re-suspend the posterior mitral leaflet, and implant the angioplasty ring by implanting the neochordae at the respective papillary muscle. And afterwards, placing circumferential annular sutures. To perform so, first the neochordae are secured to the papillary muscle.
And then passed twice through the free margin of the posterior leaflet, and knotted down. Then annuloplasty is performed in order to regain normal annular shape and prevent further dilation, as well as increased coaptation of the leaflets. Circumferential sutures are placed around the annulus.
And then sutures are put through the annuloplasty ring, which is taken down on to the annulus via the sutures. After knotting down the annuloplasty ring, a water test is performed to confirm the sufficiency of mitral valve repair. Close the left atrium with polypropylene non-absorbable for all suture, in a running suture technique.
After achievement of left atrial closure, remove the aortic cross clamp. Then, close thoracic access, and perform cardiopulmonary bypass weaning. Remove the venous cannula by suture technique.
Puncture the arterial cannula, and insert the wire under TE guidance. After retracting the cannula, insert the closure system sheath fully over the wire, and remove the dilator. Insert and close the device over the integrated insertion tool.
Then slowly remove the whole system, at a steady 45 degree angle, and a constant retraction force of the measured depth. Observe markings on the sheath. Adjust the deployment test, and protect the lever of the toggle release.
Retract the system further from the femoral artery. And the tension appears, an indicator field shows yellow green. Advance the lock tool until the click is heard.
When hemostasis is obtained, remove the guide wire. Cut the lead suture. And close the skin with a single suture.
In our study group of 35 patients, no death or stroke was noticed. No major or life-threatening bleeding occurred. And access site complications did not occur.
Would it not have any access site related transfusions in this study group? Fully-endoscopic mitral valve repair can be performed with a high degree of safety, efficacy, and excellent results up to 20 years. Percutaneous implementation of cardiopulmonary bypass can facilitate the procedure.
The percutaneous plug based closure device simplifies the procedure as well as achieves immediate hemostasis.
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Overview
This protocol demonstrates in detail how to perform fully-endoscopic mitral valve surgery with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described for a successful procedure.
Key Study Components
Area of Science
- Cardiovascular surgery
- Endoscopic techniques
- Vascular closure methods
Background
- Mitral valve surgery is critical for patients with valve dysfunction.
- Endoscopic techniques minimize patient recovery time and complications.
- Percutaneous access reduces the need for large incisions.
- Vascular closure devices are essential for safe access and closure.
Purpose of Study
- To provide a detailed protocol for performing EMS.
- To enhance the understanding of percutaneous cannulation techniques.
- To improve surgical outcomes through standardized procedures.
Methods Used
- Access along the pericardial margin to the fourth intercostal space.
- Distention of the intercostal space using a soft tissue retractor.
- Puncture of the femoral artery using a standard puncture needle.
- Insertion of a guide wire under TE guidance.
Main Results
- Successful access to the femoral artery was achieved.
- Guide wire insertion was performed accurately.
- Closure of the vascular access site was effectively demonstrated.
- Instructions provided ensure reproducibility of the procedure.
Conclusions
- The protocol offers a comprehensive guide for EMS.
- Utilizing percutaneous techniques enhances patient safety.
- Standardized methods can lead to improved surgical outcomes.
Frequently Asked Questions
Executive Industry Relevance
Fully endoscopic mitral valve repair with percutaneous groin vessel cannulation exemplifies the evolution of minimally invasive cardiovascular interventions, reducing procedural trauma and access-site complications. The integration of plug-based vascular closure devices streamlines cardiopulmonary bypass (CPB) establishment and closure, supporting safer, more reproducible workflows in advanced surgical centers. This approach enhances procedural predictability and operational efficiency at critical inflection points in device-enabled cardiac surgery portfolios.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise evaluation of vascular closure device performance in complex surgical settings.
- Supports mechanistic de-risking of percutaneous access and closure technologies.
- Facilitates functional validation of device-tissue interactions under clinically relevant conditions.
Screening & Assay Development
- Provides a standardized surgical model for assessing closure device efficacy and safety.
- Enables reproducible measurement of hemostasis and access-site complication rates.
- Supports quantitative comparison of device performance across patient cohorts.
Translational & Preclinical Research
- Aligns with translational goals by minimizing surgical trauma and improving patient recovery profiles.
- Demonstrates continuity from device feasibility to clinical workflow integration.
- Informs risk-adjusted advancement of vascular closure technologies for broader cardiovascular applications.
Pipeline & Workflow Integration
This method positions percutaneous vascular closure devices as integral to the continuum from device discovery through clinical implementation in minimally invasive cardiac surgery.
- Discovery Biology: Supports hypothesis testing on device-tissue compatibility and closure reliability.
- Screening: Enables standardized, reproducible assessment of closure success and complication rates.
- Analytics: Provides quantitative outputs such as hemostasis achievement and absence of access-site complications.
- Translational Research: Bridges device feasibility with clinical workflow adoption in endoscopic cardiac procedures.
- Enterprise Reuse: Establishes a reusable procedural platform for evaluating next-generation vascular closure devices.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in device safety and efficacy for minimally invasive CPB access.
- Operational Value: Standardizes percutaneous access and closure, reducing variability and procedural risk.
- Strategic Value: Enables more efficient go/no-go decisions for device advancement and portfolio prioritization.
- Portfolio Impact: Reduces late-stage risk by validating closure device performance in clinically relevant workflows.
Implementation Considerations
- Requires expertise in endoscopic cardiac surgery and percutaneous vascular access.
- Demands access to high-definition imaging and specialized closure device instrumentation.
- Necessitates cross-team standardization of procedural steps and complication monitoring.
- May require adaptation for different patient anatomies or surgical indications.
- Dependent on robust quantitative endpoints for closure success and complication rates.
