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The Minithoracotomy Approach: A Safe and Effective Alternative for Heart Valve Surgery

2013; Elsevier BV; Volume: 97; Issue: 1 Linguagem: Inglês

10.1016/j.athoracsur.2013.09.090

1552-6259

Giovanni Mariscalco, Francesco Musumeci,

Aortic Disease and Treatment Approaches

Despite criticisms over the last decade, heart valve surgery through right anterior minithoracotomy (MT) proved excellent short-term and long-term-term results, becoming a feasible and popular alternative to the sternotomy approach. The rapid development and refinements of techniques have led to MT valve surgery being considered safe, effective, and durable. Minithoracotomy has been demonstrated to be a valid cost-effective and cost-saving strategy for valve surgery, being associated with reduced morbidity and mortality. Tangible benefits include less pain, faster postoperative recovery, and better cosmetic results. As a result, MT has been increasingly used as a routine approach in many centers for both aortic and mitral valve surgery. Despite criticisms over the last decade, heart valve surgery through right anterior minithoracotomy (MT) proved excellent short-term and long-term-term results, becoming a feasible and popular alternative to the sternotomy approach. The rapid development and refinements of techniques have led to MT valve surgery being considered safe, effective, and durable. Minithoracotomy has been demonstrated to be a valid cost-effective and cost-saving strategy for valve surgery, being associated with reduced morbidity and mortality. Tangible benefits include less pain, faster postoperative recovery, and better cosmetic results. As a result, MT has been increasingly used as a routine approach in many centers for both aortic and mitral valve surgery. With the advent of cardiopulmonary bypass (CPB) in 1954, complex surgical valve procedures became available, with a progressive improvement in experience with various prosthetic devices [1Gibbon J.H. Application of a mechanical heart and lung apparatus to cardiac surgery.Minn Med. 1954; 37: 171-185PubMed Google Scholar]. Although the first valvular approach through right thoracotomy under CPB was reported by Lillehei and colleagues [2Lillehei C.W. Gott V.L. Dewall R.A. Varco R.L. Surgical correction of pure mitral insufficiency by annuloplasty under direct vision.Lancet. 1957; 77: 446-449Google Scholar] in 1957, valve surgery through full sternotomy (ST) became subsequently popular, because of the complete exposure of the heart, the adequate myocardial protection, and the reduced operative time. That conventional approach proved to have outstanding outcomes and long-term success in both aortic and mitral valve (MV) surgery [3Gammie J.S. Zhao Y. Peterson E.D. O'Brien S.M. Rankin J.S. Griffith B.P. Less-invasive mitral valve operations: trends and outcomes from The Society of Thoracic Surgeons Adult Cardiac Surgery Database.Ann Thorac Surg. 2010; 90: 1401-1410Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 4McClure R.S. Athanasopoulos L.V. McGurk S. Davidson M.J. Couper G.S. Cohn L.H. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up.J Thorac Cardiovasc Surg. 2013; 145: 1199-1206Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 5Svensson L.G. Atik F.A. Cosgrove D.M. et al.Minimally invasive versus conventional mitral valve surgery: a propensity matched comparison.J Thorac Cardiovasc Surg. 2010; 139: 926-932Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar, 6Glower D.D. Siegel L.C. Frishmeyer K.J. et al.Predictors of outcome in a multicenter port-access valve registry.Ann Thorac Surg. 2000; 70: 1054-1059Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. During the past 10 years, however, minimally invasive valve surgery gained popularity minimizing patient trauma, improving recovery, and reducing hospital expenditures (Fig 1) [3Gammie J.S. Zhao Y. Peterson E.D. O'Brien S.M. Rankin J.S. Griffith B.P. Less-invasive mitral valve operations: trends and outcomes from The Society of Thoracic Surgeons Adult Cardiac Surgery Database.Ann Thorac Surg. 2010; 90: 1401-1410Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 4McClure R.S. Athanasopoulos L.V. McGurk S. Davidson M.J. Couper G.S. Cohn L.H. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up.J Thorac Cardiovasc Surg. 2013; 145: 1199-1206Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 5Svensson L.G. Atik F.A. Cosgrove D.M. et al.Minimally invasive versus conventional mitral valve surgery: a propensity matched comparison.J Thorac Cardiovasc Surg. 2010; 139: 926-932Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar, 6Glower D.D. Siegel L.C. Frishmeyer K.J. et al.Predictors of outcome in a multicenter port-access valve registry.Ann Thorac Surg. 2000; 70: 1054-1059Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 7Galloway A.C. Schwartz C.F. Ribakove G.H. et al.A decade of minimally invasive mitral repair: long-term outcomes.Ann Thorac Surg. 2009; 88: 1180-1184Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Modi P. Rodriguez E. Hargrove W.C. Hassan A. Szeto W.Y. Chitwood W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 9Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients.Eur J Cardiothorac Surg. 2008; 34: 760-765Crossref PubMed Scopus (229) Google Scholar, 10Murzi M. Cerillo A.G. Miceli A. et al.Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.Eur J Cardiothorac Surg. 2013; 43: e167-e172Crossref PubMed Scopus (87) Google Scholar, 11Grossi E.A. Galloway A.C. Ribakove G.H. et al.Impact of minimally invasive valvular heart surgery: a case-control study.Ann Thorac Surg. 2001; 71: 807-810Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 12Grossi E.A. Galloway A.C. LaPietra A. et al.Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.Ann Thorac Surg. 2002; 74: 660-664Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 13Casselman F.P. Valn Slycke S. Dom H. Lambrechts D.L. Vermeulen Y. Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable.J Thorac Cardiovasc Surg. 2003; 125: 273-282Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar, 14Suri R.M. Schaff H.V. Meyer S.R. Hargrove W.C. Thoracoscopic versus open mitral valve repair: a propensity score analysis of early outcomes.Ann Thorac Surg. 2009; 88: 1185-1190Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 15Raanani E. Spiegelstein D. Sternik L. et al.Quality of mitral valve repair: median sternotomy versus port-access approach.J Thorac Cardiovasc Surg. 2010; 140: 86-90Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 16Iribarne A. Russo M.J. Easterwood R. et al.Minimally invasive versus sternotomy approach for mitral valve surgery: a propensity analysis.Ann Thorac Surg. 2010; 90: 1471-1478Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 17Sharony R. Grossi E.A. Sanders P.C. et al.Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement.J Heart Valve Dis. 2004; 13: 887-893PubMed Google Scholar, 18Plass A. Scheffel H. Alkadhi H. et al.Aortic valve replacement through minimally invasive approach: preoperative planning, surgical technique, and outcome.Ann Thorac Surg. 2009; 88: 1851-1856Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 19Glower D.D. Lee T. Desai B. Aortic valve replacement through right minithoracotomy in 306 consecutive patients.Innovations. 2010; 5: 326-330PubMed Google Scholar, 20Brinkman W.T. Hoffman W. Dewey T.M. et al.Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups.Ann Thorac Surg. 2010; 90: 131-135Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 21Ruttman E. Gilhofer T.S. Ulmer H. et al.Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy.J Heart Valve Dis. 2010; 19: 606-614PubMed Google Scholar, 22Murzi M. Cerillo A.G. Bevilacqua S. Gilmanov D. Farneti P. Glauber M. Traversing the learning curve in minimally invasive heart valve surgery: a cumulative analysis o fan individual surgeon's experience with a right minithoracotomy approach for aortic valve replacement.Eur J Cardiothorac Surg. 2012; 41: 1242-1246Crossref PubMed Scopus (60) Google Scholar, 23Glauber M. Miceli A. Gilmanov D. et al.Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score analysis.J Thorac Cardiovasc Surg. 2013; 145: 1222-1226Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar]. Alternative approaches to conventional ST include partial sternotomy and minithoracotomy (MT) [3Gammie J.S. Zhao Y. Peterson E.D. O'Brien S.M. Rankin J.S. Griffith B.P. Less-invasive mitral valve operations: trends and outcomes from The Society of Thoracic Surgeons Adult Cardiac Surgery Database.Ann Thorac Surg. 2010; 90: 1401-1410Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 4McClure R.S. Athanasopoulos L.V. McGurk S. Davidson M.J. Couper G.S. Cohn L.H. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up.J Thorac Cardiovasc Surg. 2013; 145: 1199-1206Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 5Svensson L.G. Atik F.A. Cosgrove D.M. et al.Minimally invasive versus conventional mitral valve surgery: a propensity matched comparison.J Thorac Cardiovasc Surg. 2010; 139: 926-932Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar]. Mitral and aortic valve procedures through right MT have been proved to be safe and efficient options with excellent early and late outcomes [6Glower D.D. Siegel L.C. Frishmeyer K.J. et al.Predictors of outcome in a multicenter port-access valve registry.Ann Thorac Surg. 2000; 70: 1054-1059Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 7Galloway A.C. Schwartz C.F. Ribakove G.H. et al.A decade of minimally invasive mitral repair: long-term outcomes.Ann Thorac Surg. 2009; 88: 1180-1184Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Modi P. Rodriguez E. Hargrove W.C. Hassan A. Szeto W.Y. Chitwood W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 9Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients.Eur J Cardiothorac Surg. 2008; 34: 760-765Crossref PubMed Scopus (229) Google Scholar, 10Murzi M. Cerillo A.G. Miceli A. et al.Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.Eur J Cardiothorac Surg. 2013; 43: e167-e172Crossref PubMed Scopus (87) Google Scholar, 11Grossi E.A. Galloway A.C. Ribakove G.H. et al.Impact of minimally invasive valvular heart surgery: a case-control study.Ann Thorac Surg. 2001; 71: 807-810Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 12Grossi E.A. Galloway A.C. LaPietra A. et al.Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.Ann Thorac Surg. 2002; 74: 660-664Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 13Casselman F.P. Valn Slycke S. Dom H. Lambrechts D.L. Vermeulen Y. Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable.J Thorac Cardiovasc Surg. 2003; 125: 273-282Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar, 14Suri R.M. Schaff H.V. Meyer S.R. Hargrove W.C. Thoracoscopic versus open mitral valve repair: a propensity score analysis of early outcomes.Ann Thorac Surg. 2009; 88: 1185-1190Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 15Raanani E. Spiegelstein D. Sternik L. et al.Quality of mitral valve repair: median sternotomy versus port-access approach.J Thorac Cardiovasc Surg. 2010; 140: 86-90Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 16Iribarne A. Russo M.J. Easterwood R. et al.Minimally invasive versus sternotomy approach for mitral valve surgery: a propensity analysis.Ann Thorac Surg. 2010; 90: 1471-1478Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 17Sharony R. Grossi E.A. Sanders P.C. et al.Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement.J Heart Valve Dis. 2004; 13: 887-893PubMed Google Scholar, 18Plass A. Scheffel H. Alkadhi H. et al.Aortic valve replacement through minimally invasive approach: preoperative planning, surgical technique, and outcome.Ann Thorac Surg. 2009; 88: 1851-1856Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 19Glower D.D. Lee T. Desai B. Aortic valve replacement through right minithoracotomy in 306 consecutive patients.Innovations. 2010; 5: 326-330PubMed Google Scholar, 20Brinkman W.T. Hoffman W. Dewey T.M. et al.Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups.Ann Thorac Surg. 2010; 90: 131-135Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 21Ruttman E. Gilhofer T.S. Ulmer H. et al.Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy.J Heart Valve Dis. 2010; 19: 606-614PubMed Google Scholar, 22Murzi M. Cerillo A.G. Bevilacqua S. Gilmanov D. Farneti P. Glauber M. Traversing the learning curve in minimally invasive heart valve surgery: a cumulative analysis o fan individual surgeon's experience with a right minithoracotomy approach for aortic valve replacement.Eur J Cardiothorac Surg. 2012; 41: 1242-1246Crossref PubMed Scopus (60) Google Scholar, 23Glauber M. Miceli A. Gilmanov D. et al.Right anterior minithoracotomy versus conventional aortic valve replacement: a propensity score analysis.J Thorac Cardiovasc Surg. 2013; 145: 1222-1226Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar]. Based on these results, the consensus statement of the International Society of Minimally Invasive Coronary Surgery (ISMICS) has recently defined MV surgery through MT as an alternative to conventional ST [24Falk V. Cheng D.C. Martin J. et al.Minimally invasive versus open mitral valve surgery: a consensus statement of the International Society of Minimally Invasive Coronary Surgery (ISMICS) 2010.Innovations (Phila). 2011; 6: 66-76Crossref PubMed Scopus (142) Google Scholar]. Therefore, MT has now reached recognition worldwide, becoming widely adopted for both MV and aortic valve (AV) surgery. A systematic search was performed using the PubMed database to identify all studies reporting results and outcomes of MT heart valve surgery. Search strategy combined "mitral valve," "aortic valve," "tricuspid valve," "minimally invasive," and "minithoracotomy." Published original articles, case series, and individual reports were analyzed. All studies were identified from the existing literature until April 2013. In addition, the "related articles" function in PubMed was used as a further check of rigor. When multiple studies had been published by a single institution, the largest, most recent, or most informative study was considered. In 1996, Carpentier and colleagues [25Carpentier A. Loulmet D. Carpentier A. et al.[Chirurgie à coeur ouvert par vidéo-chirurgie et mini-thoracotomie: premier cas (valvuloplastie mitrale) opéré avec succès.].C R Acad Sci Paris Life. 1996; 319: 219-223PubMed Google Scholar] performed the first video-assisted MV repair through a right anterolateral MT using peripheral extracorporeal circulation with ventricular fibrillation. A video-assisted controlled by a voice-activated camera arm and by robotic telemanipulation and three-dimensional endoscopy was subsequently introduced [26Chitwood W.R. Elbeery J.R. Chapman W.H.H. et al.Video-assisted minimally invasive mitral valve surgery: the "micro-mitral" operation.J Thorac Cardiovasc Surg. 1997; 113: 413-414Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 27Chitwood W.R. Wixon C.I. Elbeery J.R. Moran J.F. Chapman W.H.H. Lust R.M. Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovasc Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar, 28Schwartz D.S. Ribakove G.H. Grossi E.A. et al.Minimally invasive mitral valve replacement: port-access technique, feasibility, and myocardial functional preservation.J Thorac Cardiovasc Surg. 1997; 113: 1022-1030Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 29Glower D.D. Landolfo K.P. Clements F. et al.Mitral valve operation through port access versus median sternotomy.Eur J Cardiothorac Surg. 1998; 14: 143-147Crossref Google Scholar, 30Falk V. Walther T. Autschbach R. et al.Robot-assisted minimally invasive solo mitral valve operation.J Thorac Cardiovasc Surg. 1998; 115 (470–11)Abstract Full Text Full Text PDF Scopus (155) Google Scholar]. In the same years, feasibility and myocardial functional preservation were reached through right MT with the port-access technique [28Schwartz D.S. Ribakove G.H. Grossi E.A. et al.Minimally invasive mitral valve replacement: port-access technique, feasibility, and myocardial functional preservation.J Thorac Cardiovasc Surg. 1997; 113: 1022-1030Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. In 1998 Carpentier's group performed the first completely robotic MV repair [32Carpentier A. Loulmet D. Aupècle B. et al.Computer assisted open heart surgery. First case operated on with success.C R Acad Sci III. 1998; 321: 437-442Crossref PubMed Scopus (215) Google Scholar]. A variety of surgical approaches and techniques for MV surgery through right MT have been proposed. A dual-lumen endotracheal tube or bronchial blocker are generally required [6Glower D.D. Siegel L.C. Frishmeyer K.J. et al.Predictors of outcome in a multicenter port-access valve registry.Ann Thorac Surg. 2000; 70: 1054-1059Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 7Galloway A.C. Schwartz C.F. Ribakove G.H. et al.A decade of minimally invasive mitral repair: long-term outcomes.Ann Thorac Surg. 2009; 88: 1180-1184Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Modi P. Rodriguez E. Hargrove W.C. Hassan A. Szeto W.Y. Chitwood W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 9Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients.Eur J Cardiothorac Surg. 2008; 34: 760-765Crossref PubMed Scopus (229) Google Scholar, 10Murzi M. Cerillo A.G. Miceli A. et al.Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.Eur J Cardiothorac Surg. 2013; 43: e167-e172Crossref PubMed Scopus (87) Google Scholar, 11Grossi E.A. Galloway A.C. Ribakove G.H. et al.Impact of minimally invasive valvular heart surgery: a case-control study.Ann Thorac Surg. 2001; 71: 807-810Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 12Grossi E.A. Galloway A.C. LaPietra A. et al.Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.Ann Thorac Surg. 2002; 74: 660-664Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 13Casselman F.P. Valn Slycke S. Dom H. Lambrechts D.L. Vermeulen Y. Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable.J Thorac Cardiovasc Surg. 2003; 125: 273-282Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar, 14Suri R.M. Schaff H.V. Meyer S.R. Hargrove W.C. Thoracoscopic versus open mitral valve repair: a propensity score analysis of early outcomes.Ann Thorac Surg. 2009; 88: 1185-1190Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 15Raanani E. Spiegelstein D. Sternik L. et al.Quality of mitral valve repair: median sternotomy versus port-access approach.J Thorac Cardiovasc Surg. 2010; 140: 86-90Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 16Iribarne A. Russo M.J. Easterwood R. et al.Minimally invasive versus sternotomy approach for mitral valve surgery: a propensity analysis.Ann Thorac Surg. 2010; 90: 1471-1478Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 26Chitwood W.R. Elbeery J.R. Chapman W.H.H. et al.Video-assisted minimally invasive mitral valve surgery: the "micro-mitral" operation.J Thorac Cardiovasc Surg. 1997; 113: 413-414Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 27Chitwood W.R. Wixon C.I. Elbeery J.R. Moran J.F. Chapman W.H.H. Lust R.M. Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovasc Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar, 28Schwartz D.S. Ribakove G.H. Grossi E.A. et al.Minimally invasive mitral valve replacement: port-access technique, feasibility, and myocardial functional preservation.J Thorac Cardiovasc Surg. 1997; 113: 1022-1030Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 29Glower D.D. Landolfo K.P. Clements F. et al.Mitral valve operation through port access versus median sternotomy.Eur J Cardiothorac Surg. 1998; 14: 143-147Crossref Google Scholar, 30Falk V. Walther T. Autschbach R. et al.Robot-assisted minimally invasive solo mitral valve operation.J Thorac Cardiovasc Surg. 1998; 115 (470–11)Abstract Full Text Full Text PDF Scopus (155) Google Scholar, 31Mohr F.W. Falk V. Diegeler A. Whalter T. van Son J.A. Autschbach R. Minimally invasive port-access mitral valve surgery.J Thorac Cardiovasc Surg. 1998; 15: 567-574Abstract Full Text Full Text PDF Scopus (361) Google Scholar, 32Carpentier A. Loulmet D. Aupècle B. et al.Computer assisted open heart surgery. First case operated on with success.C R Acad Sci III. 1998; 321: 437-442Crossref PubMed Scopus (215) Google Scholar, 33Mohr F.W. Onnasch J.F. Falk V. et al.The evolution of minimally invasive mitral valve surgery—2 year experience.Eur J Cardiothorac Surg. 1999; 15: 233-239Crossref PubMed Scopus (138) Google Scholar, 34Casselman F.P. Van Slycke S. Wellens F. et al.Mitral valve surgery can now routinely be performed endoscopically.Circulation. 2003; 108: 48-54PubMed Google Scholar]. The entire procedures are performed through a 4 cm to 7 cm port located in the right inframammary groove, usually in the fourth intercostal space [6Glower D.D. Siegel L.C. Frishmeyer K.J. et al.Predictors of outcome in a multicenter port-access valve registry.Ann Thorac Surg. 2000; 70: 1054-1059Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 7Galloway A.C. Schwartz C.F. Ribakove G.H. et al.A decade of minimally invasive mitral repair: long-term outcomes.Ann Thorac Surg. 2009; 88: 1180-1184Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Modi P. Rodriguez E. Hargrove W.C. Hassan A. Szeto W.Y. Chitwood W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 9Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients.Eur J Cardiothorac Surg. 2008; 34: 760-765Crossref PubMed Scopus (229) Google Scholar, 10Murzi M. Cerillo A.G. Miceli A. et al.Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients.Eur J Cardiothorac Surg. 2013; 43: e167-e172Crossref PubMed Scopus (87) Google Scholar, 11Grossi E.A. Galloway A.C. Ribakove G.H. et al.Impact of minimally invasive valvular heart surgery: a case-control study.Ann Thorac Surg. 2001; 71: 807-810Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 12Grossi E.A. Galloway A.C. LaPietra A. et al.Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.Ann Thorac Surg. 2002; 74: 660-664Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar, 13Casselman F.P. Valn Slycke S. Dom H. Lambrechts D.L. Vermeulen Y. Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable.J Thorac Cardiovasc Surg. 2003; 125: 273-282Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar, 14Suri R.M. Schaff H.V. Meyer S.R. Hargrove W.C. Thoracoscopic versus open mitral valve repair: a propensity score analysis of early outcomes.Ann Thorac Surg. 2009; 88: 1185-1190Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 15Raanani E. Spiegelstein D. Sternik L. et al.Quality of mitral valve repair: median sternotomy versus port-access approach.J Thorac Cardiovasc Surg. 2010; 140: 86-90Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 16Iribarne A. Russo M.J. Easterwood R. et al.Minimally invasive versus sternotomy approach for mitral valve surgery: a propensity analysis.Ann Thorac Surg. 2010; 90: 1471-1478Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 26Chitwood W.R. Elbeery J.R. Chapman W.H.H. et al.Video-assisted minimally invasive mitral valve surgery: the "micro-mitral" operation.J Thorac Cardiovasc Surg. 1997; 113: 413-414Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 27Chitwood W.R. Wixon C.I. Elbeery J.R. Moran J.F. Chapman W.H.H. Lust R.M. Video-assisted minimally invasive mitral valve surgery.J Thorac Cardiovasc Surg. 1997; 114: 773-782Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar, 28Schwartz D.S. Ribakove G.H. Grossi E.A. et al.Minimally invasive mitral valve replacement: port-access technique, feasibility, and myocardial functional preservation.J Thorac Cardiovasc Surg. 1997; 113: 1022-1030Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 29Glower D.D. Landolfo K.P. Clements F. et al.Mitral valve operation through port access versus median sternotomy.Eur J Cardiothorac Surg. 1998; 14: 143-147Crossref Google Scholar, 30Falk V. Walther T. Autschbach R. et al.Robot-assisted minimally invasive solo mitral valve operation.J Thorac Cardiovasc Surg. 1998; 115 (470–11)Abstract Full Text Full Text PDF Scopus (155) Google Scholar, 31Mohr F.W. Falk V. Diegeler A. Whalter T. van Son J.A. Autschbach R. Minimally invasive port-access mitral valve surgery.J Thorac Cardiovasc Surg. 1998; 15: 567-574Abstract Full Text Full Text PDF Scopus (361) Google Scholar, 32Carpentier A. Loulmet D. Aupècle B. et al.Computer assisted open heart surgery. First case operated on with success.C R Acad Sci III. 1998; 321: 437-442Crossref PubMed Scopus (215) Google Scholar, 33Mohr F.W. Onnasch J.F. Falk V. et al.The evolution of minimally invasive mitral valve surgery—2 year experience.Eur J Cardiothorac Surg. 1999; 15: 233-239Crossref PubMed Scopus (138) Google Scholar, 34Casselman F.P. Van Slycke S. Wellens F. et al.Mitral valve surgery can now routinely be performed endoscopically.Circulation. 2003; 108: 48-54PubMed Google Scholar]. Arterial cannulation is accomplished with femoral artery or direct aortic cannulation, whereas venous drainage requires femoral vein with or without concomitant internal jugular cannulation, generally under transesophageal echocardiography guidance. Aortic occlusion is performed by either percutaneous endovascular intraluminal balloon (the port-access system) or transthoracic aortic clamp, inserted through a separate transthoracic incision [6Glower D.D. Siegel L.C. Frishmeyer K.J. et al.Predictors of outcome in a multicenter port-access valve registry.Ann Thorac Surg. 2000; 70: 1054-1059Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 7Galloway A.C. Schwartz C.F. Ribakove G.H. et al.A decade of minimally invasive mitral repair: long-term outcomes.Ann Thorac Surg. 2009; 88: 1180-1184Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 8Modi P. Rodriguez E. Hargrove W.C. Hassan A. Szeto W.Y. Chitwood W.R. Minimally invasive video-assisted mitral valve surgery: a 12-year, 2-center experience in 1178 patients.J Thorac Cardiovasc Surg. 2009; 137: 1481-1487Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 9Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients.Eur J Cardiothorac Surg. 2008; 34: 760-765Crossref PubMed Scopus (229) Google Scholar, 10Murzi M. Cerillo A.G. 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