Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

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.