Minimally invasive mitral valve repair in patients with pectus excavatum and complex mitral pathology−the usefulness of the sternal lifting technique and the modified tourniquet technique.

MO006 

Case Video Submission 

Mikiko Senzai (1), Kazunori Yoshida (1), Yoshihisa Nakao (1), Atsutoshi Hatada (1), Taichi Sakaguchi (2)

(1) Nishinomiya Watanabe Cardiovascular Center, Nishinomiya, Hyogo, Japan, (2) Hyogo College of Medicine, Nishinomiya City, Hyogo, Japan

Mikiko Senzai    -  Contact Me
Nishinomiya Watanabe Cardiovascular Center

Kazunori Yoshida    -  Contact Me
Nishinomiya Watanabe Cardiovascular Center

Yoshihisa Nakao    -  Contact Me
Nishinomiya Watanabe Cardiovascular Center

Atsutoshi Hatada    -  Contact Me
Nishinomiya Watanabe Cardiovascular Center

Taichi Sakaguchi    -  Contact Me
Hyogo College of Medicine

Mikiko Senzai    -  Contact Me
Osaka University

Objectives
The patient with chest deformity is generally not a good candidate for minimally invasive mitral valve repair (MIMVR) because poor visualization of the mitral valve (MV) is concerned. We report a successful case of MIMVR in a patient with pectus excavatum and a complex mitral regurgitation (MR). Our simple sternal lifting technique and modified tourniquet technique were helpful in improving the visualization of the MV and facilitating complex neochordal repair.

Case Video Summary:
A fifty-year-old woman with severe MR was referred to us for MIMVR. Physical examination showed that she had pectus excavatum. Preoperative computed tomography showed the heart was displaced to the left side with a narrowing thoracic anterior-posterior distance (5.8 cm). The preoperative trans-esophageal echocardiography (TEE) showed anterior mitral leaflet (AML) prolapse and posterior mitral leaflet with restricted motion and mitral annular disjunction.
We performed MIMVR through a right lateral minithoracotomy. To enhance the visual field of the heart, the sternum was lifted by a right angle retractor inserted into the medial border of the thoracotomy. This maneuver significantly improved the visualization of the MV, even with a direct vision. The MV showed A2-A3 prolapse with markedly degenerated leaflets and subvalvular apparatus, which had an abnormal attachment to the leaflet. P3 segment was tethered with restricted leaflet motion. First, several ink dots were made to mark the expected leaflet coaptation line. Then, a short CV4 ePTFE loop was fixed to the anterior head of the posteromedial papillary muscle. Three ePTFE sutures were passed to the short loop, and each end was passed onto the prolapsing leaflet segment and temporally fixed using a small tourniquet. After seating an annuloplasty band, the neochordal length was adjusted with the left ventricle filled with saline until the valve was fully competent and the previously marked ink dots were well aligned on the coaptation line. Post-bypass TEE showed no MR.

Conclusions:
Our simple sternum lifting technique and modified tourniquet technique may be useful in patients with thoracic deformity and complex mitral pathology.

Minimally Invasive & Robotic Mitral Valve Repair