1. Minimally Invasive Mitral Valve Repair
Paul S. Massimiano MD
Inova Heart and Vascular Institute
Adventist Healthcare

2. I have no real or apparent conflicts of interest to report.
Paul S. Massimiano, MD
I have no real or apparent conflicts of interest to report.

3. Goals of Mitral Valve Repair
Repair Rates of % for degenerative disease.
Excellent Mortality = 0%
Excellence in all quality measures
*Decreased Complications
*Decreased A-Fib
*Decreased Blood Transfusions
*Decreased Length of Stay
*Decreased Cost
*Increased Patient Satisfaction

4. Start with the Basics Broad consensus in the literature that
repair is preferable to replacement for
degenerative disease
2. Principles of Repair in Degenerative
Mitral Valve Disease
Establish Leaflet Coaptation
Resection
Neochord Construction
Alfieri Maneuvers
Restore Annular Geometry
Rigid/Flexible Band or Ring

5. Overview of the current state of Mitral Valve Repair
2005 to 2007
28,507 patients undergoing mitral valve surgery
Among surgeons performing mitral valve repair,
mean rate of repair - 41%
Median number of mitral valve operations per surgeon per year = 5
Probability of repair increased from 36.5%
to 73.6% with increasing mitral case volume
Bolling, S, et al
Ann Thor Surg
2010; 90:

6. Current State of Mitral Valve Repair
2000 to 2007 – 47,126 patients
Repair rate for isolated mitral regurgitation ranged from 51% to 69%
-Gammie, JS et al,
Ann Thor Surg 2009
87:
“…Ongoing ‘gap’ in best practice surgical care of patients with significant degenerative disease of at least 20%, which translates into a significant incidence of unnecessary mitral valve replacement”
-Adams, DH, EUR Heart J
(2010) 31,

7. Current State of Mitral Valve Repair
Since most of the cases(80-90%) in these studies were performed with median sternotomy, how well are we really doing with that approach?

8. Minimally Invasive Mitral Valve Repair Hypothesis 1997
-Using the same principles of repair we can achieve at least the same repair rates and outcomes with a less invasive approach than with median sternotomy
-Minimally invasive surgery has distinct advantages over sternotomy
Less trauma = less pain
Shorter length of stay
Faster overall recovery
Dramatically improved patient satisfaction

9. What is Minimally Invasive Mitral Valve Repair?
Small right lateral thoracic incision
(< 2 inches) with minimal or no rib-spreading
Femoral arterial & venous cannulation
Can be accomplished with a variety of techniques – all with excellent results
Direct vision
Robotic
Thoracoscopic
*Identical principles of repair as sternotomy

10. Evolution of Practice at the INOVA Heart & Vascular Institute
Direct Vision  Robotic & Thoracoscopic  Direct Vision

11. Video

12. Minimally Invasive Incision
1 Week Post-Op

13. All Mitral Valve Repair and/or Cox-Maze III Surgical Ablation
Results: Inova Heart and Vascular Institute
All Mitral Valve Repair and/or Cox-Maze III Surgical Ablation

14. “Minimally Invasive Mitral Valve Surgery” and/or Cox-Maze III
2007 – 2011 continued:
239 patients
75 Stand Alone Maze
164 MV Repairs Overall Repair Rate 98.7% *
-Repair Rate for Degenerative Disease 100%
*(2 patients with Rheumatic MS/MR)

15. Results - Minimally Invasive Mitral Valve surgery and/or Cox-Maze III
Variables-Postoperative Data
Patients (N=239)
Postoperative low cardiac output
1 (0.4%)
Patients w packed rbc transfusion Intra-op
5 (2.0 %)
Patients w packed rbc transfusion post-op
6 (2.5%)
Patients requiring no transfusion
228 (95.3%)
Any Infection
2 (<1%)
Myocardial Infarction
Stroke
TIA

16. Results - Minimally Invasive Mitral Valve surgery and/or Cox-Maze III
Acute Renal Failure
Hemodialysis
Prolonged Ventilator > 24 hours
9 (4%)
Atrial Fibrillation
6 (2.5%)
Reop for Bleeding
1 (0.4%)
Reoperation for Mitral Valve
Readmit ICU
4 (2%)
ICU Hrs (mean/median)
33.6/19.6
Operative Mortality
Days Length of Stay (mean/median)
4.1/3.0
Readmit < 30 days
17 (7%)

17. “Minimally Invasive Mitral Valve Surgery” and/or Cox-Maze III

18. Conclusions
Minimally invasive Mitral Valve Repair is a safe & effective approach to Mitral Valve Disease
Repair rates are comparable to median sternotomy in experienced hands
Mitral Valve repair may offer a significant advantage in decreasing post-operative complications, length of stay, cost, and patient satisfaction

19. Conclusions
The real issue is not the surgical approach, rather it is the fact that to achieve excellence in repair rates and quality measures, with either a sternotomy or mini approach, extensive training and on-going experience with a significant volume of repairs per surgeon per year is required.

20. But… Who will ultimately decide this debate?