Minimally Invasive Mitral Valve Surgery (MIS MVS) is a modern approach to treating mitral valve problems, offering an alternative to traditional full sternotomy, or open-heart surgery. This technique accesses the heart through a much smaller incision, typically a mini-thoracotomy on the right side of the chest between the ribs, or via multiple small ports for a robotic-assisted procedure. Avoiding the need to cut through the breastbone, MIS MVS reduces patient trauma, minimizes blood loss, and lowers the risk of infection. The method promotes a faster recovery, shorter hospital stay, and a smaller scar while achieving outcomes comparable to conventional surgery. Candidacy requires a rigorous assessment of the patient’s overall health, the nature of their valve disease, and their unique anatomical features.
Mitral Valve Conditions Addressed by Minimally Invasive Surgery
The primary problem addressed by MIS MVS is severe mitral regurgitation, where the valve fails to close completely, causing blood to leak backward into the left atrium. This backward flow strains the heart and can lead to heart failure symptoms like shortness of breath and fatigue. The most common structural cause of regurgitation is mitral valve prolapse, where one or both valve leaflets bulge back into the atrium during contraction.
MIS MVS is also effective for repairing valves damaged by Barlow’s disease, a complex form of prolapse. While repair is the preferred goal, the minimally invasive approach can also be used for mitral valve replacement if the damage is too extensive. MIS MVS can also address mitral stenosis, a condition where the valve leaflets stiffen and fuse, narrowing the opening and restricting blood flow. Replacement is often necessary for stenosis, but the smaller access port remains advantageous for recovery.
Standard Patient Requirements for Eligibility
A patient’s overall physiological status is a primary consideration for MIS MVS candidacy. Surgeons prefer individuals with a low predicted surgical risk profile and a relative level of fitness to tolerate general anesthesia and cardiopulmonary bypass. Age is generally not the deciding factor; suitability is determined by the patient’s biological age and the condition of their other organ systems.
The structural characteristics of the valve disease are scrutinized because the valve must be amenable to repair through the limited access of the mini-thoracotomy. The best candidates have isolated mitral valve disease suitable for a durable repair, which is preferred over replacement. Surgeons also assess body habitus; excessive obesity, especially combined with a large chest size, can complicate access and impede instrument maneuverability.
Specific Factors That Prevent Minimally Invasive Surgery
Co-existing medical conditions or anatomical features can preclude a patient from MIS MVS, necessitating a full sternotomy for safety.
Need for Concurrent Procedures
One common reason for exclusion is the need for concurrent, complex procedures on other heart structures that are difficult to access through the small right-sided incision. This includes severe disease of the aortic or tricuspid valve requiring simultaneous replacement or extensive repair. Patients who require multi-vessel coronary artery bypass grafting (CABG) are also usually best served by a traditional approach that allows for full visualization and manipulation of the coronary arteries.
Prior Surgery and Calcification
Prior extensive thoracic surgery, especially a previous right-sided thoracotomy or major lung resection, can create dense scar tissue and adhesions, making safe surgical access difficult. Another major anatomical contraindication is severe calcification within the mitral valve annulus, known as Mitral Annular Calcification (MAC). Severe MAC makes repair impossible, and the extensive debridement required for secure valve seating during replacement cannot be safely performed through a small port.
Peripheral Vascular Disease
The condition of the peripheral vasculature is a factor because MIS MVS typically relies on cannulation of the femoral artery and vein to establish cardiopulmonary bypass. Severe aorto-iliac atherosclerosis, characterized by extensive plaque and calcification, poses a risk of stroke or aortic injury during cannulation. If peripheral access is too risky, surgeons may consider alternative cannulation sites, such as the axillary artery. However, severe peripheral vascular disease can still be an overriding contraindication.
Confirming Candidacy Through Preoperative Evaluation
Confirming candidacy begins with a comprehensive clinical assessment and specialized diagnostic tests. A transthoracic echocardiogram (Echo) and a transesophageal echocardiogram (TEE) are essential for precisely mapping the mitral valve anatomy. These tests assess the mechanism and severity of the disease, providing measurements of leaflet size, chordal integrity, and annular dimension to determine the feasibility of a durable repair.
To ensure safe establishment of cardiopulmonary bypass, a computed tomography (CT) scan of the chest, abdomen, and pelvis is routinely performed. This scan evaluates the entire arterial tree, mapping the ilio-femoral vessels to confirm adequate diameter and minimal calcification for peripheral cannulation. The CT also provides information on chest wall anatomy, helping determine the optimal incision site for the mini-thoracotomy. If concomitant coronary artery disease is suspected, a cardiac catheterization is performed to visualize the coronary arteries and rule out the need for a concurrent bypass procedure. The final decision involves a multidisciplinary discussion to confirm the patient’s anatomy and pathology align with the technical requirements for a safe and effective minimally invasive operation.