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Eur J Cardiothorac Surg 1999;15:233-239
© 1999 Elsevier Science NL

The evolution of minimally invasive mitral valve surgery – 2 year experience1

F.W. Mohr, J.F. Onnasch, V. Falk, T. Walther, A. Diegeler, R. Krakor, F. Schneider, R. Autschbach

Department of Cardiac Surgery, Heartcenter, University of Leipzig, Leipzig, Germany

Received 22 September 1998; received in revised form 21 December 1998; accepted 8 January 1999.

Corresponding author. Tel.: +49-341-865-1421; fax: +49-341-865-1452.


   Abstract
Top
 Abstract
Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 
Objectives: The aim of the study was to evaluate the evolution of Port-Access minimally invasive mitral valve surgery to a robot assisted video assisted solo surgery approach. Methods: One hundred and twenty-nine patients with non-ischemic mitral valve disease underwent 3D-video assisted mitral valve surgery via a 4 cm right lateral minithoracotomy using femoro-femoral bypass and endoaortic clamping. Transcranial Doppler and continuous transesophageal echocardiography were used to monitor placement and positional stability of the endoclamp. After the initial series (group I, n=62), a simplified solo surgical technique using voice controlled robotic assistance for videoscope guidance was used in the last 67 patients (group II). Results: After an initial learning curve and modifications of catheter design, the procedure could be steadily redefined and simplified. In the last 67 patients, the procedure was completed without the need for an additional assistant as `solo surgery'. The mitral valve was repaired in 72 and replaced in all other patients. Duration of bypass and clamp time steadily improved during our study and in the most recent 67 patients average 107±34 and 48±16 min, respectively. The voice controlled robotic arm (AESOP 3000, Automated Endoscope System for Optimal Positioning) provided a stable and precise video image with excellent exposure of all valvular and subvalvular structures. Hospital mortality was high in the early series (mean survival 88.7% at 804±35 days; 95% CI: 735–873) and partially procedure related (aortic dissection in two patients). In group II, hospital mortality has declined to 3.0% (mean survival 97.0% at 568±12 days; 95% CI: 553–600). Conclusion: Port-Access minimally invasive mitral valve surgery has evolved to be a reliable video assisted technique with reproducible results. Surgery can now be performed almost in the same time as with conventional techniques. Robotic assistance has enabled a solo surgery approach.

Key Words: Mitral valve • Minimally invasive surgery • Tele-surgery • Robotics


   Introduction
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 
There has been a fast evolution of new surgical techniques for mitral valve repair and replacement procedures [1] [2] [3] [4] [5] [6]. The different approaches vary mainly in the access route. Although only a small thoracotomy is necessary when applying the methods developed by Chitwood or Carpentier, a true minimal access is only possible with the Port-Access system, allowing for closed chest cardiopulmonary bypass and endoscopic surgery. The initial results using this method, however, were somewhat disappointing. The peripheral vascular access and the use of retrograde perfusion have led to some severe complications and limited the widespread use of this technique. Furthermore, additional costs were not counterbalanced by shorter recoveries. In our early experience, a number of complications were encountered and bypass times exceeded those for conventional surgery. In an effort to enhance these results, numerous modifications to simplify the surgical approach were made and a robot assisted solo surgical approach with video assistance was developed. This article describes the evolution of the Port Access method including robotic driven video assistance and updates the results of our previously published series [7].


   Materials and methods
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 
One hundred and twenty-nine consecutive patients with non-ischemic mitral valve diseases were included in the study from June 1996 (group I, n=62). From June 1997 to December 1998, a robot assisted solo surgical approach was used (group II, n=67). The demographic data are shown in Table 1.


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  		Table 1. Demographic data

 
The technique of Port-Access cardiopulmonary bypass has been described to detail by others and our group elsewhere [7] [8] [9]. After initial problems with single lung ventilation, double lumen intubation was abandoned. Instead, cardiopulmonary bypass is now routinely begun and both lungs are deflated before entering the chest. The use of an endovascular pulmonary vent was abandoned because significant drainage of pulmonary venous return was not obtained. A custom made rib-retractor with integrated housing for a left atrial vent, not only enhanced exposure of the mitral valve but also proved more effective in eliminating blood from the left atrium.

In the first 20 patients, a centrifugal pump was used to enhance venous return. Although very effective, vacuum assisted venous drainage by applying negative pressure up to 50 mmHg to the venous reservoir is equally effective and helped to reduce costs. Fluoroscopy is no longer used to monitor the endoclamp since we could demonstrate that transesophageal echocardiography is as effective for this purpose [10]. The implementation of continuous transcranial Doppler flow measurements of the middle cerebral arteries added an important safety measure, as we found that right radial artery pressure measurements alone are not sensitive enough to immediately detect impairment of cerebral perfusion caused by balloon migration to the aortic arch [11] ( Fig. 1 ).



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  		Fig. 1. Principle of robot assisted solo surgery (right) to conventional port-access approach (left). No additional assistant other than the scrub nurse is required.

 
By introducing passive articulating arms to hold both the left atrial retractor and the videoscope, the potential for a solo surgical approach became obvious. Although providing well centered and steady camera support, the need for frequent adjustments of these `prerobotic' holding devices still distracted the surgeon and interrupted the conduct of surgery. Therefore, a voice controlled robotic arm (AESOP 3000, Automated Endoscope System for Optimal Positioning; Computer Motion, Santa Barbara, CA) was used to guide the videoscope in the last 67 patients. Motion of the robotic device was verbally activated by simple voice commands using a headset microphone ( Fig. 2 ). The technique of robot assisted Port-Access mitral valve surgery is described in detail elsewhere [12].



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  		Fig. 2. Transcranial Doppler signal from the right middle cerebral artery. Note the disappearance of the signal with migration of the endoaortic clamp in front of the brachiocephalic trunk.

 
In the early series, transesophageal echocardiography (TEE) revealed frequent air emboli during reperfusion. To avoid this, the surgical field is now constantly flushed with CO2 (5 l/min) before the left atrium is opened. Initially, only mechanical valves were implanted and repairs performed. Recently, we began to also implant stentless mitral valves (QMV, Glycar, Bronxville, NY) that require attachment to both papillary muscles (n=3) [13].


   Statistics
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 
Results are given as mean±standard deviation and mean±standard error for survival rates. For comparison of group mean values, the t-test was applied. Survival rates and event free survival rates were calculated using the Kaplan–Meier method. Ninety-five percent confidence intervals are given. Events were defined as death, reoperation, thromboembolic or bleeding complications leading to readmission.


   Results
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 
In all patients the mitral valve was accessible through the right lateral minithoracotomy, with the last 67 patients having incisions averaging 4.4±1.0 cm. Intraoperative data are shown in Table 2. As expected, the total time of surgery was significantly reduced in group II as was the clamp time. The time of cardiopulmonary bypass did not differ significantly, mainly because CPB was begun earlier (before entering the chest) in group II. In group II, the AESOP 2000 provided a steady field of view, thus enabling the surgeon to focus on tissue manipulation rather than to share concentration to compensate for moving images known from manually videoscope guidance. Lens cleaning frequently needed when performing hand-held endoscopy were rarely necessary. Repair procedures were greatly enhanced by the ability to store and return to different positions automatically as well as by precise zooming. Verbal control of the device enabled continuous surgery with no need to change instruments for adjustments of the scope. No technical mishaps occurred during the procedures. However, the robot, initially developed for laparoscopic surgery, sometimes worked itself to its `elbow limit' restricting further movement mechanically. This required repositioning of the arm and reset of the zero level. With the new version (AESOP 3000) that is now placed opposite to the surgeon, this problem did not occur anymore.


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  		Table 2. Intraoperative results

 
Intraoperative transesophageal echocardiogram showed regular valve function after mitral valve repair in all except three patients of the first series, who were subsequently converted to valve replacement after failed repair (stenosis or residual regurgitation). In two of the patients, an enlarged thoracotomy incision was necessary. All patients with mitral valve replacement had a good functional result intraoperatively.

In the total series, four patients had to be converted to conventional sternotomy because of acute retrograde aortic dissection (n=2, group I; n=1 group II) or injury of the left ventricular posterior wall (n=1, group I). In two patients (group I) positional instability of the endoclamp required an additional ministernotomy for placement of a clamp and cardioplegia delivery.

Postoperative results are shown in Table 3. Primary intubation time could be reduced significantly in group II. Six patients required re-exploration for bleeding. A number of neurological complications were encountered in the first series [7] (Table 4). In the recent series, transient hemiparesis was encountered in three patients. Since the implementation of transcranial Doppler, balloon migrations towards the brachiocephalic trunc were immediately detected and corrected, which further reduced the risk for neurologic problems. The hospital mortality that was high in our initial series (for detailed analysis see Ref. [7]) but constantly declined and is 3.0% in the last 67 patients. There was one intraoperative retrograde aortic dissection in the late series. Despite emergency sternotomy and prompt replacement of the aortic valve and ascending aorta and arch repair, the patient died on the 29th postoperative day because of severe brain damage. In one patient (group II) with a heavily calcified mitral valve annulus and subsequent decalcification and valve replacement, the posterior left ventricular wall (AV junction) ruptured 4 h after surgery. Emergent median sternotomy was subsequently performed and the ventricular wall reconstructed, but the patient died on the 1st postoperative day from irreversible low cardiac output. Median stay on the ICU as well as the total time of hospitalization could be decreased markedly in the second series.


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  		Table 3. Postoperative results

 

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  		Table 4. Complications

 
By November 30, 1998, follow-up was complete in all patients. Three patients of group I developed paravalvular leakage after mitral valve replacement and required conventional reoperation which was uneventful. In one patient (group I) emergency reoperation was performed due to a ring dehiscence following mitral valve repair after 6 weeks postoperatively. One patient of the second series had to be reoperated 1 month postoperatevely because of recurrence of mitral regurgitation III° after primary reconstruction. All other valves including the stentless quadruspid valves were functioning normally. In all except six patients (four in group I) undergoing mitral valve repair, there was no or only trivial residual mitral regurgitation. Grade II mitral regurgitation was found in six patients but treated medically as all six patients had improved clinically. Mean survival rate for group I is 88.7% at a mean follow-up of 804±35 days (95% CI: 735–873). In group II survival is 97.0% at a mean follow-up of 568±12 days (95% CI: 553–600; Fig. 3 ). Event-free survival is 83.8% at a mean of 793±35 days (95% CI: 724–862) for group I and 95.4% at a mean follow-up of 546±17 days (95% CI: 531–597) for group II, respectively.



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  		Fig. 3. Survival curve.

 

   Discussion
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 
In the last 2 years, minimally invasive surgical techniques have developed from experimental methods to widespread clinical application. Although numerous methods for less invasive mitral valve surgery have been described, there is still no clear definition of the term less or minimally invasive, and certainly no agreement in terms of the importance of smaller incisions for the reduction of overall surgical trauma [14]. The situation is further complicated by the fact, that despite most studies include only small numbers of patients and incomplete data, uniform statements are made as to the reduction of pain, shorter recovery and improved results. In most studies stating that patients who underwent minimally invasive surgery had less pain, pain was not measured at all [4] [5] [14] [15]. So far, no randomized studies comparing any of these new techniques with a conventional approach have been published making definite statements concerning the benefit for the patient other than a better cosmetic result rather speculative. After initial enthusiasm, some of the approaches were readily modified or abandoned due to thoracal instability [5] or an increased frequency of wound complications. Some techniques introduced for minimally or less invasive mitral valve surgery were in fact only modifications of the formerly used lateral thoracotomy approach.

The most innovative surgical approach in terms of miniturization of access is the Port-Access approach developed by the Stanford group [8] [9]. It is the only approach that enables mitral valve surgery through an incision as small as 4 cm through the fourth intercostal space. In the attempt to develop a fully endoscopic procedure for mitral valve surgery, we focused on the improvement of the Port-Access technique. Our initial results with this technique reflected both a learning curve from the surgical and the technical side. The relatively high number of complications as well as a high mortality rate have raised heavy criticism and led us to rethink our strategy. The modifications of the surgical technique described in this article and changes in the design of the endoclamp and the femoral canula have clearly helped to improve results. As a consequence, both operating times, morbidity and mortality rates are now equal or even better than those achieved with a conventional approach via a mid-line sternotomy. Although some groups report admirable early discharge rates of a mean of only 4 days after a mitral valve procedure [6] [16], this is still not our experience with the typical patient with long-standing mitral valve disease. Young patients with isolated mitral insufficiency and no co-morbidity may be early extubated and discharged, but this is true for a conventional approach as well. Concerning postoperative pain, a large prospective study at our center using a daily questionnaires demonstrated a significant advantage for the minimally invasive group [17]. Since the thorax is intact, no restrictions for mobilization apply and full return to daily life activities can be reached earlier.

The use of transcranial Doppler has helped to detect migration of the endoclamp, a problem that has been reported by other groups as well [18], and are most likely responsible for some of the observed neurological complications ( Fig. 4 ). The use of CO2 insufflation has markedly reduced both the amount of air in cardiac chambers as documented by TEE and the number of air-emboli that can be detected with transcranial Doppler even after meticulous deairing. There is no difference in comparison with conventional mitral valve surgery.



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  		Fig. 4. Event-free survival curve.

 
Careful patient selection is crucial to avoid vascular complications from femoral artery cannulation and retrograde perfusion. Aortic insufficiency and the presence of any atheromatous debris in the ascending and descending aorta must be ruled out preoperatively. Patients with severe calcification of the mitral valve annulus requiring aggressive decalicification should be excluded because of the limited strength of endoscopic instruments.

The use of a voice controlled robotic arm to guide the videoscope has not only enhanced visualization by providing a stable, tremor-free image but also obviated the need for assisting personnel except for the scrub nurse. Removal of the scope for cleaning purposes was rarely ever necessary when using the robot [12]. The voice activation proved to be a convenient way of controlling the arm because speech is the most natural communication pattern and does not require interruptions, as is the case with manual adjustments.

In conclusion, despite some unfavorable early results, Port Access minimally invasive mitral valve surgery has become a reliable technique with comparable results with conventional techniques [19]. In our hands it has been developed from an experimental stage to a routine endoscopic solo surgery procedure. We can now state that there is a benefit for the patient.

Computer enhanced telemanipulators may further improve the results of less invasive approaches for the mitral valve [20]. By coupling two master consoles, this technology may also be very helpful to improve training for this complex endoscopic surgery, which at our institution is currently performed by only one experienced surgeon.


   Footnotes
 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998. Back


   Appendix A. Conference discussion
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
References
 
Dr R. Chitwood (Greenville, NC, USA): I think it is very important that you have emphasized that there is a learning curve with video-assisted surgery. We have done 75 cases using video assistance with what we consider good results. We presented some of the early data at the American Association for Thoracic Surgery in 1997. Also, we have done 15 mitral valve patients using the robotic video assistance. So I clearly think that this operation is very possible. I think the work that you have shown with the IntuitiveTM robotic device is absolutely fantastic.

I really have one question. Where do you think this technology is going for the average surgeon? Can the average surgeon use these techniques to do minimally invasive cardiac surgery in a safe, efficient way, and is this method going to lead cardiac surgeons into the next century?

Dr Mohr: I think you address the point. Right now this kind of surgery should be reserved to some special surgeons who are fully trained. It has to be the task of our society to develop a training course before you perform the operation and the surgery on patients. I think the learning curve I had, shouldn't happen to anybody else. We also have to come up with some training centers, and I think, especially these computer-enhanced systems will allow for a control through the computer with a super master. If you allow me, I will show such an example in my last slide.

This is my vision of what we are aiming for next year. That is, a slave control unit with the robotic system at the patient site, a master control for the surgeon, and a second control for the super master who controls the surgeon in a digital fashion. He can take over the instruments and show the assistant what he should do, just taking his own joysticks like the pilot and the co-pilot. This is just our vision and we are just moving in this direction. Actually, we are dedicating two experimental operating rooms for this purpose and I believe that is the way we have to evaluate it in the future.

Dr R. Przybylski (Zabrze, Poland): Did you have any complication after femoral cannulation?

Dr Mohr: As you know, I have shown the severe complications, altogether there are three aortic dissections. The first two aortic dissections occurred in the first series and we had one retrograde aortic dissection in patient No. 80. This was a major concern at the very beginning, and it still is. At the beginning the catheter design was just too rigid, it injured the intima, and obviously retrograde flow is always a danger of retrograde dissection. We learned to more carefully select the patients, excluding patients who have kinked iliac arteries, etc. Besides one patient who had a stenosis at the site of the femoral artery postoperatively, we didn't have a problem at the groin.

Dr N. Devega (Malaga, Spain): You have compared the conventional surgery with your surgery in many points but you haven't made any comparison about the neurological complications. You have something like 4%, and what are the neurological complications?

Dr Mohr: There is also an incidence of 3% neurological complications in our conventional group. Some patients have psychologic disorders for 2 or 3 days. We also had in this group, one patient who had a transient hemiplegia. I don't know the reason for that, but this is true.

Dr Devega: This is probably not the experience of people around here. I mean, I don't know if everybody admits having 4% of neurological complications in mitral surgery.

Dr Mohr: It just depends what kind of patients you operate on, if you have a lot of patients with stage III and IV like we have. I think the patient selection in the former East Germany is still very special. You see many patients who should have been operated on 10 years ago, and that might be one of the reasons for that also.

Dr H. Rodriguez (Caracas, Venezuela): I am concerned about the cost of this procedure, because one of the most important points now in the whole world is the cost of procedures. Can you tell me if you have any relation between the people that you operate on in a normal way and this way?

Dr Mohr: You know, it is very clear right now, this is a clinical trial. The normal port-access procedure adds $3000 to the conventional cost, and I think this is much too much. We have to have some competition in this field, which can lower the price. The only thing you really need is the endoaortic clamp if you want to go with this technique – I am not saying this is the future. We are just following this way because we wanted to aim for total endoscopic surgery and for the least invasive access. As such we had to pay the price. Don't ask me about the cost of the intuitive system. We just purchased the system. I don't tell you how much it is.


   References
Top
 Abstract
 Introduction
Materials and methods
Statistics
Results
Discussion
Appendix A. Conference...
 References
 

  1. Carpentier A., Loulmet D., Carpentier A., Le Bret E., Haugades B., Dassier P., Guibourt P. Chirurgie a coeur overt par video-chirurgie et mini-thoracotomie. premier cas (valvuloplastie mitrale) opere avec success. CR Acad Sci III 1996;319:219-223.
  2. Benetti F.J., Rizzardi J.L., Pre L., Polanco A. Mitral valve replacement under video assistance through a minithoracotomy. Ann Thorac Surg 1997;63:1150-1152.[Abstract/Free Full Text]
  3. Arom K.V., Emery R.W. Minimally invasive mitral operations. Ann Thorac Surg 1997;63:1219-1220.[Free Full Text]
  4. Loulmet DF, Carpentier A, Cho PW, Berrebi A, d'Attelis N, Austin CB, Couetil JP, Lajos P. Less invasive techniques for mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:772–779.
  5. Cosgrove D.M., Sabik J., Navia J.L. Minimally invasive valve operations. Ann Thorac Surg 1998;65:1535-1539.[Abstract/Free Full Text]
  6. Chitwood W.R. State of the art review: videoscopic minimally invasive mitral valve surgery. Trekking to a totally endoscopic operation. Heart Surg Forum 1998;1:13-16.[Medline]
  7. Mohr FW, Falk V, Diegeler A, Walther T, van Son JAM, Autschbach R. Minimally invasive Port-Access mitral valve surgery. J Thorac Cardiovasc Surg;115:567–576.
  8. Schwartz D.S., Ribakove G.H., Grossi E.A., Stevens J.H., Siegel L.C., St. Goar F.G., Peters W.S., McLoughlin D., Baumann F.G., Colvin S.B. Minimally invasive cardiopulmonary bypass with cardioplegic arrest: a closed chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg 1996;111:556-566.[Abstract/Free Full Text]
  9. Pompilli M.F., Stevens J.H., Burdon T.A., Siegel L.C., Peters W.S., Ribakove G.H., Reitz B.A. Port-Access Mitral valve replacement in dogs. J Thorac Cardiovasc Surg 1996;112:1268-1274.[Abstract/Free Full Text]
  10. Falk V., Walther T., Diegeler A., Autschbach R., Wendler R., van Son J.A.M., Siegel L.C., Pompili M.F., Mohr F.W. Echocardiographic monitoring of minimally invasive mitral valve surgery using an endoaortic clamp. J Heart Valve Dis 1996;5:630-637.[Medline]
  11. Schneider F., Falk V., Walther T., Mohr F.W. Control of endoaortic clamp position during Port-Access mitral valve operations using transcranial Doppler echography. Ann Thorac 1998;65:1481-1482.
  12. Falk V., Walther T., Autschbach R., Diegeler A., Battellini R., Mohr F.W. Robot assisted minimally invasive solo mitral valve operation. J Thorac Cardiovasc Surg 1998;115:470-471.[Free Full Text]
  13. Walther T., Weigl C., Falk V., Diegeler A., Schneider J., Autschbach R., Mohr F.W. Mitralklappenersatz mit einer gerüstfreien Bioprothese (QMV). Z f Kardiol 1998;87(Suppl. I):228.
  14. Lytle B.W. Minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 1996;111:554-555.
  15. Cooley D.A. Minimally invasive valve surgery versus conventional approach. Ann Thorac Surg 1998;66:1101-1105.[Abstract/Free Full Text]
  16. Spencer F.C., Galloway A.C., Grossi E.A., Ribakove G.H., Delianidis J., Baumann G.F., Colvin S.B. Recent developments and evolving techniques of mitral valve reconstruction. Ann Thorac Surg 1998;65:307-309.[Abstract/Free Full Text]
  17. Walther T., Falk V., Metz S., Diegeler A., Battelini R., Autschbach R., Mohr F.W. Schmerz und Lebensqualität nach minimal invasiver im Vergleich zu konventioneller Herzoperation. Thorac Cardiovasc Surg 1998;46(Suppl. I):62.
  18. Gulliamos V., Schüler S. Clinical experiences with minimally invasive mitral valve surgery using a simplified port access technique. Eur J Cardiothorac Surg 1998;14:141-147.[Abstract/Free Full Text]
  19. Glower DD, Landolfo KP, Clements F, Debruijn NP, Stafford-Smith M, Smith PK, Duhaylongsod F. Mitral valve operation via Port Access versus median sternotomy. Eur J Cardiothorac Surg 1998;14(Suppl. I):S143–S147.
  20. Falk V. Computer enhanced surgery. In: Yim AP, Hazelrigg SR, Izzat MB, Landrenaeau RJ, Mack MJ, Naunheim KS, editors. Minimal access cardiothoracic surgery. London: Saunders, 1999 in press.



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J. E. Felger, W. R. Chitwood Jr, L. W. Nifong, and D. Holbert
Evolution of mitral valve surgery: toward a totally endoscopic approach
Ann. Thorac. Surg., October 1, 2001; 72(4): 1203 - 1209.
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F. Schneider, J.-F. Onnasch, V. Falk, T. Walther, R. Autschbach, and F. W. Mohr
Cerebral microemboli during minimally invasive and conventional mitral valve operations
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