a

Minimally Invasive Mitral Valve Repair Surgery

good morning hey I'm doctor Tim Williams

of st. Francis cardiovascular and

thoracic welcome to room four we're here

this morning going to perform a

minimally invasive mitral valve surgery

this is a very healthy 59 year old

gentleman basically asymptomatic who

presented to his primary care doctor

with a new heart murmur that led to an

echo echo showed he had severe mitral

regurgitation that led to a cardiology

consult where he was evaluated by our

colleagues at Upstate cardiology he

underwent a trance a faggio echo which

confirmed severe mitral regurgitation he

underwent a left heart cath which showed

basically clean core news so because he

he only has mitral valve disease and not

concomitant coronary artery disease he's

a candidate for this minimally invasive

approach the old standard way of doing

mitral valve surgery is through a

sternotomy where you have an incision

down your chest but in a case like this

where he doesn't need coronary surgery

were able to do a minimally invasive

incision on the side of his chest not

having to divide his sternum spread his

ribs and do his operation that way

the whole key to doing this operation is

getting in the right interspace the

first time so we spend a lot of time

making sure that we're going to get in

the right interspace between the ribs

where we'll have good access to the

heart okay so we've got to make this

incision down to the chest wall now not

everybody is a candidate for this

operation you got to have the right

anatomy that's suitable for it

so now what I'm doing is I'm counting

ribs to make sure that I go into the

right inner space so that it have good

visualization of the valve all right I

think I've identified the correct inner

space to go in

so to be able to see to do this

operation we have to do what's called

one lung ventilation and here in just a

minute I'm gonna ask Michael who's our

nurse anesthetist today to drop a lung

all right Coco let's see let me see it

again

there we go alright Michael once you

drop his right lung for me

yeah I'm in the chest this is the

retractor we use to spread the ribs with

and it comes with various blades we just

have to pick out the right size blade

for the body habitus of the particular

patient we're working with and you can

see there's the patient's right lung got

a pair pickups I go this is his right

lung right here the heart is going to be

deep to that alright so this is looking

inside his chest we have now deflated

his right lung the object you see

beating in there which is this right

here is the right atrium this white

ribbon right here is the phrenic nerve

and you have to be very careful to avoid

damaging the phrenic nerve because that

controls his right hemidiaphragm and he

would not do well if that got damaged so

the next step we're going to do is we're

going to open this pericardium which is

the tough sac that surrounds the heart

and start putting retraction sutures in

and what that will actually bring the

heart towards us and it will give us a

better idea of what we're able to do so

there's the right atrium access to the

left atrium is going to be right below

that we have good vision

all right so we're in the pericardium

and pericardium is is a kind of a

lubricating sac that carries a fluid

that we have to get out of our way but

it keeps the heart lubricated as it

beats all right let's see if I can stick

that through his mammary artery

all right let me see a pair of pickups

so now we just kind of get in the heart

position to where we want it to get this

operation done and it just requires a

little bit of a little bit of dissection

here a little dissection there making

sure that we can proceed safely with

this approach of course if I if I felt

like that we could not proceed safely

then what I would do is just close this

up go to a sternotomy and do it the

traditional way but I feel pretty

confident that we have good

visualization so what we'll do now is go

ahead and give the patient heparin you

can start you can ventilate the right

lung and now the next step is we'll go

to the patient's groin where we family

cannulate we there are several ways to

cannulate a patient to put them on

bypass but we the guys in our group we

kind of feel like femoral is the best

route to go

we are now identifying and surrounding

his femoral artery and femoral vein they

will be used for access to put the

patient on cardiopulmonary bypass which

is what we have to use to do is a mitral

valve so we'll we'll put cannulas in

these two blood vessels one will drain

blood from the patient where it will go

back to our heart-lung machine back

there and Michael our perfusion is today

we'll we'll filter it and oxygenate it

and then pump it back to the patient

it's basically what keeps the patient

alive while we're doing the operation

this is the patient's right groin this

white structure is the femoral artery

this blue structure right beside it's

the femoral vein so we're going to we're

going to cannulate through these two

structures to put him on cardiopulmonary

bypass this cannula is in his femoral

artery and this cannula right here is in

the femoral vein and if you can see it's

kind of hard to tell but the blood and

the vein cannula is a lot darker it's

deoxygenated blood the blood and the

arterial cannula is bright red so it's

oxygenated blood well through this

cannula right here we drain the blood

out of the patient's body it goes back

to the heart-lung machine where it gets

oxygenated and then it's pumped back to

the patient through this cannula right

here and this is what's going to keep

him alive while we stop his heart from

beating while we fix this mitral valve

so we've got the patient heparinized

we're cannulated we are about to go on

bypass and what will happen is the heart

will decompress and we take all the

blood out of it then we'll

then we'll have access to his right

atrium so what we're doing now is we're

preparing the patient to stop his heart

from beating while we do this operation

put a clamp across the aorta which will

isolate the heart from the circulation

and we'll give it a substance called

cardioplegia which preserves it and and

stops it while we open his heart so

we're looking inside this patient's left

atrium no can let me have the other

nerve hook Thanks and this structure

right here that I'm tugging on is the

anterior leaflet of the mitral valve

we'll tuck that back in there you're

looking down into the left ventricle

right there and here is the posterior

leaflet of the mitral valve and this

little thing right here is the ruptured

chordae tendineae and that's why his

valve is leaking so so we're going to

resect this portion of his posterior

leaflet put it back together put a ring

in here to support the valve that we

have taken out that's part of the

posterior leaflet of the mitral valve

then we're going to sew the other

leaflet back together let me see a nerve

hook or yeah so it's kind of hard to

tell but right here is where we just cut

out that big chunky piece of Val

and then we're going to bring this back

together

okay

all right now I think that's got the

posterior leaflet back together so we're

going to tie it and then we're going to

test it so we've put the posterior

leaflet back together and I'm fairly

comfortable with the way it looks now

we're going to put a ring around the

annulus of the mitral valve which

supports it structurally and that should

help with with finishing up our repair

just three yep so this is the sizer that

we use to size the ring that we're going

to place around the annulus of the

mitral valve and we try to match it up

as best to fit the size of the anterior

leaflet this is shaped just like the

anterior leaflet all right here's the

ring and it's mounted on a delivery

device which is this the white cuff

portion is the actual ring itself that's

what will stay in the patient and the

mic and the flow of blood will go

through the center of this it's just a

an empty muscular bag and so the

geometry changes dramatically from a

empty heart to a full heart and one of

the challenging things of doing this

surgery is that we're used to seeing a

full heart and yet you try to work on a

heart that's collapsed and looks nothing

like it does in the textbooks we're

using right now is called a knot pusher

because my fingers aren't long enough to

reach down in here and secure the knot

scissors yeah those are region all right

now there's often a misconception that

patients have about these minimally

invasive approaches being less painful

and that's just not the case we we do we

have a lot of tricks we use to minimize

the pain but it there's still some

tolerable pain associated with this

approach

so after we get the left atrium closed

we're going to get it what we call a hot

shot dose of cardioplegia then we're

going to get all the air out of the

heart and it's critical to get all the

air out because it can cause a stroke

and then we'll wean him off a bypass and

check our repair now if our repair is

inadequate you have two options one is

you can try to re repair it or you just

have to replace it with a prosthetic

valve but I thought our our test looked

pretty good although you never know

until you come off bypass yeah so we're

now we're given the heart a dose of

cardioplegia kind of rejuvenates it

warms it up gets it ready to to come off

bypass

so now we're looking by echo to see how

much air is in the heart so we got a

group we have a device in here to get it

out clamps off so now the heart is

getting is back open to the circulation

yeah this starting to be

suit your line looks good so we're

pacing the heart now still getting rid

of all the air before we take this VIN

out and try to come off bypass so you

can see the heart is beating

of course we're being paced right now

because the rates a little slow which is

not unusual and the suture line for the

repair was right underneath my pickups

that's where we entered the left atrium

and then there's the heart beating away

so we just wait until we get to thirty

six point five degrees centigrade then

we'll come on off pump check our repair

so this is the lung wery inflated his

right lung see it right there nice and

pink

yep see it right here this is this is

the patients right long it's now

inflated full of air so now we have to

come off bypass and we have to get these

cannulas out of his groin now I'm going

to cover this up just to keep it from

drying out

okay

so he's no longer having to be paced

we're in a normal sinus rhythm at about

63 beats a minute so once we get the

protamine in we have to make sure that

all the bleeding is controlled before we

close him up that's what we're doing

down anytime we operate on somebody here

we strive not to have to give them any

blood or blood products and a

post-operative hemoglobin 210 means he

won't have to have any blood or blood

products so that's very good we're

always happy with that so this is a

little catheter that goes right into

this right under the skin right where

the muscle is and it'll slowly drip pain

medicine in the incision over the next

48 hours and that too is helps minimize

the pain

so there's our incision alright so we

had a successful mitral valve repair

today when we got in there and gotten

looking at his mitral valve it was it

confirmed exactly what we saw an echo

he had a prolapse of p2 which is the

posterior segment of the mitral valve

with a ruptured cord we were able to

resect that bring it back together then

put a ring in there to support it and of

course on the echo he had virtually no

mite regurgitation at the end of the

operation so we're done we came off

bypass we closed him up you can see

three tubes coming out of his side right

now but the most the smallest one the

most superior is a pain tube where he

will get a dose of pain medicine slowly

dripped in over there over the next 48

hours that will help dramatically with

his pain the next two tubes are drainage

tubes and it's it's it's the norm for

any heart surgery patient to have a

little bit of drainage postoperatively

and we don't like that fluid to collect

inside the chest so we like to drain it

off and he so he has these two tubes

ones what the big one is is laying back

behind his lung the smaller one is

wrapped around his heart and those will

come out tomorrow everything went

textbook today this guy will probably be

going home in three days would be my

guess