1. Current Surgical Standards for Mitral Leaflet and Chordal Repair: Patient Selection,Techniques and Clinical Outcomes CRT February 2011
Niv Ad, MD
Chief, Cardiac Surgery
Professor of Surgery, VCU
Inova Heart and Vascular Institute
Washington DC Metropolitan Area

2. Disclosures Medtronic Speaker Trainer Estech Consultant SJD Medical
Advisory Board

3. Mitral Valve Anatomy Segments of mitral valve leaflets:
anterior, posterior
Annulus contacts
and relaxes (dynamic)
Relationship
to aortic valve
‘Bean’ shape 3

4. Degenerative MR
Adams et al. Ann ThoracSurg 2006;82: 4

5. Mitral Valve Repair Triangular Resection
Less tension on posterior annulus than quadrangular resection
Applied for a large unsupported, prolapsing posterior leaflet
Use two layers of continuous 4-0 Prolene suture
For a large unsupported prolapsing posterior leaflet, Dr Carpentier described his technique of triangular resection of posterior leaflet in his paper. 5

6. Mitral Valve Repair Quadrangular Resection6

7. Mitral Valve Repair Gortex Chord Reconstruction7

8. Current Annuloplasty Choices
Complete Ring
Complete Flexible Ring
Flexible Band
Rigid Bands
Composite/Variations of the above 8

11. Minimally Invasive Valve Surgery
Same Indications
Myxomatous or Degenerative Disease
Ischemic
Rheumatic
Same Techniques
Leaflet Resection
Gortex Cord Reconstruction
Annuloplasty Band
Flexible or Rigid

12. Minimally Invasive Valve Surgery
Same Operation as with Sternotomy
Same durability
Same results
Different Technologies
Thoracoscopic
Robotic
Direct Vision
Same Operation Different Tools

13. Evolution of Technology 2001-2010
The Evolution of minimally Invasive Mitral Valve Repair: From Heartport Through da Vinci to Fibrillation without Crossclamping

14. An intraoperative picture which reveals femoral venous and arterial canulas, the 4cm long 4th intercostal space thoracotomy and the video camera system.

15. Robotic Mitral Valve Surgery15

18. Patients Should Have a Minimally Invasive Valve Surgery Unless…
All valve patients are potential candidates
Relative contra-indications
Other cardiac pathology e.g. CAD
Advanced age

20. Patients Should Have a Minimally Invasive Valve Surgery Unless…
All valve patients are potential candidates
Relative contra-indications
Other cardiac pathology e.g. CAD
Advanced age
Peripheral vascular disease
Body habitus
Extreme obesity
Severe pectus excavatum
Previous thoracic surgery
Projected volume for 2011 – 200 cases

21. Benefits of Minimally Invasive Surgery
Less Trauma = Less Pain
Shorter Length of Stay
Quicker Overall Recovery
Dramatically Improved Patient Satisfaction

22. Why do Few Surgeons Perform Minimally Invasive Surgery?
Steep Learning Curve
It’s Harder
Takes Longer
Low Valve Volumes at Most Institutions – Little Room for Innovation

24. Early and Late Results Robotic N=35 Direct Approach P value
Cardioplegia
N=51
No Cardioplegia
N=93
Perioperative MI -
Mediastinitis
Permanent Stroke
TIA
Prolonged Ventilator
2(2%)
0.27
Atrial Fibrillation
1(3%)
3(6%)
4(4%)
0.09
Renal Failure
Renal Failure, Dialysis
Tamponade
1(2%)
0.28
Reoperation Bleeding
0.11
Operative Death
Readmit <30 Days
9(18%)*
1(1%)
0.001
Reoperation Mitral Valve
0.52
*This group is significantly different

25. Summary Surgical repair of the MV Less resection NeoChordes
Edge to Edge not common
Larger Rings
Excellent immediate outcome
Predicted durability

26. Thank You