Most complex mitral valve repair surgery can be performed through an incision smaller than 4 inches long.
Mitral valve repair is the gold standard procedure for patients who require surgery for mitral valve disease1. This is particularly important in the setting of degenerative disease where repair rates of close to 100% are achievable2. Minimally invasive mitral valve repair surgery should ensure procedural safety and the ability of the surgeon to perform a durable mitral valve repair3.
The approach we typically use is a limited, 7-8 cm, lower midline skin incision, using standard cardiopulmonary bypass techniques with central cannulation. This limited incision also provides sufficient exposure for tricuspid and aortic valve repair or replacement if needed.
Limited skin incisions offer minimal scarring and very high patient satisfaction with less need for pain medications.
Median sternotomy has unquestionably evolved over recent decades. In experienced centers, a limited skin incision sternotomy may achieve all the goals of minimally invasive surgery:
Excellent cosmesis and very high patient satisfaction (the scars are smaller and less visible).
Minimizing trauma with excellent post-operative pain control (most of our patients do not utilize narcotics after leaving the hospital).
Low rates of bleeding and transfusion (our re-exploration rate for bleeding is <1%).
The ability to perform any reconstructive technique that would be used in a standard sternotomy, with very high repair rates (our most recent series documented a repair rate exceeding 99% in an all-comers population of degenerative disease regardless of complexity).
Limited skin incision are often concealed by clothing.
When fully healed the limited skin incision sternotomy scar is concealed by clothing, even when the patient wears low-necked clothing. In some women the scar is well concealed by their brassiere. For all these reasons, we feel the limited lower midline skin incision is the most flexible approach to the heart, and it is the approach we use in most patients.
Not all patients are suitable for minimally invasive surgery. Operating through small incisions is more technically demanding and in some cases could reduce the safety of the procedure. Patients who require additional cardiac procedures like coronary artery bypass surgery, elderly patients, patients with very diseased arteries, and patients with a very weakly contracting heart will not be suitable for this approach. Our paramount objective is to ensure a good valve repair, with no residual leakage, at a low operative risk. Our surgeons will only perform a repair through a small incision when they believe they can do a good quality valve repair at a low risk to the patient; if the valve disease is complicated (as assessed by the echocardiogram) then we recommend a full incision as we believe a larger scar is preferable to an imperfect repair.
(*)Castillo JG, Milla F, Anyanwu AC, Adams DH. Video-atlas on minimally invasive mitral valve surgery—The David Adams technique. Ann Cardiothorac Surg 2013;2(6):828-832.
(1) David TE, Armstrong S, McCrindle BW, et al. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation 2013;127:1485-92. [PubMed]
(2) Castillo JG, Anyanwu AC, Fuster V, et al. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg 2012;144:308-12. [PubMed]
(3) Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA 2013;310:609-16. [PubMed]
Page Created: Tuesday, 13 December 2005
Last Updated: Wednesday, 29 January 2014
Department of Cardiothoracic Surgery | The Mount Sinai Hospital | 1190 Fifth Avenue, Box 1028 | New York, NY 10029 | 866-MITRAL5 (648-7255)