A new way forward from London Bridge Hospital
In the last decade surgeons have begun to make innovative changes in cardiac surgery.
This is epitomised by the new approaches to operations on the mitral valve.
Traditionally, mitral valve surgery involves a median sternotomy. With this approach,
there is a long scar and there is a small chance of sternal dehiscence which has
Cosgrove and colleagues, Cohn and colleagues, and Navia and Cosgrove first showed
mitral and aortic operations could be performed safely and efficiently after modifying
the conventional sternotomy. Subsequently, a variety of instruments were developed;
alternative perfusion techniques came up; video-assisted devices and robots helped in
evolving even less invasive cardiac procedures.
Because of excellent long-term results after sternotomy, most surgeons still regard
minimally invasive valve procedures as unnecessary and unsafe due to limited exposure
and increased technical demands.The other criticism is that these technological
advances are being driven by the high-tech industry, leading to increased costs without
demonstrated positive clinical outcomes.
These criticisms have forced minimally invasive valve operations to evolve slowly.The
challenge now is to develop minimally invasive valve approaches with gold standard
results that are reproducible among centres.
Patients are intubated for single left-sided ventilation to facilitate exposure before
commencing cardiopulmonary bypass. A transesophageal echocardiographic probe is
used for evaluation of ventricular function and mitral valve evaluation. Femoral vessel
cannulation for cardiopulmonary bypass is performed using the Seldinger technique.
Most cases need assisted-suction venous drainage.
A transthoracic aortic cross clamp is positioned under close video-assisted control and
cardioplegia is administered. For valve exposure, a chest retractor is placed across the
chest wall through the anterior fourth interspace near the right sternal border. A 5mm,
thoracoscope is inserted through the fourth or fifth intercostal space. An assistant,
directed by the surgeon, manipulates the camera. In each operation, the majority of the
valve procedure is performed using assisted vision through the thoracoscope. Long-
shafted instruments, passed through the incision, allow operation on the mitral valve
through this small incision. After the operation, the patient is monitored in ITU for a day
or two. He is mobilised in the wards and sent home 3-4 days after the operation.
The major advantages would be avoiding a median sternotomy with its risks of infection,
as well as sternal dehiscence which causes major morbidity as well as increased risks of
mortality.The risks include need for a median sternotomy in case of problems during
the operation or postoperative complications, like bleeding, which might not be able to
be tackled by minimally invasive incisions.
As technology improves and surgeons are more well versed with these novel
approaches to heart operations, the future lies with these kind of minimally invasive
Mitral Valve Surgery
The benefits of minimally invasive heart
• A smaller incision
• A smaller scar
Other possible benefits:
• Reduced risk of infection
• Less bleeding with minimally invasive heart
• Less pain and trauma
• Decreased length of stay in hospital after
the procedure: the average stay is 3-4 days
after minimally invasive surgery, while the
average stay after traditional heart surgery
is 7-10 days
• Decreased recovery time:
the average recovery time after minimally
invasive heart surgery is 2-4 weeks, while
the average recovery time after traditional
heart surgery is 6-8 weeks
UCLHThe Heart Hospital
and London Bridge Hospital
Contact Mr Kolvekar’s secretary,
Tel: +44 (0) 20 7504 8946