Minimally Invasive Mitral Valve Surgery: A Critical Component of Comprehensive Cardiac Care

This Clinician’s View is written by cardiothoracic surgeon Lawrence Lee, MD, MBA, Executive Medical Director, Heart, Lung & Vascular Institute, AdventHealth Orlando.

Throughout my career as a cardiothoracic surgeon, one tenet has guided my work: personalized care is essential to achieving the best possible outcome.

At AdventHealth, I work in a comprehensive, high-volume cardiac center that performs more than 130 mitral valve surgeries alone each year, and yet, no two patients are exactly the same. Therefore, we must customize and determine the best approach for each person. This includes offering minimally invasive mitral valve surgery to appropriately selected patients, which provides tangible benefits, including reduced surgical trauma and quicker recovery and healing, with long-term outcomes comparable to traditional sternotomy approaches.

A Patient-Centered Surgical Approach to Address a Growing Need

Mitral valve disease, especially mitral regurgitation, is highly prevalent in the United States, affecting an estimated 5 million people. It is among the most common types of valvular heart disease, with prevalence increasing with age -- it affects more than 11% of individuals older than 75.

For degenerative mitral valve disease (primary mitral regurgitation), the gold standard of care is mitral valve repair; in fact, in national and international guidelines from cardiology and cardiac surgical societies, mitral valve repair is the only Class I recommended treatment for this pathology. The key challenge, however, is to provide patients with a durable, long-lasting repair. Minimally invasive surgery is not simply about a smaller incision. It represents a deeper technical capability that supports a repair-first philosophy while reducing recovery burden for appropriately selected patients. That goal is a critical part of evolving into a comprehensive mitral program.

In appropriate patients, mitral valve repair can be achieved in a minimally invasive manner through a right mini-thoracotomy. This approach requires a 4-6 cm incision between the ribs on the right side of the chest instead of opening the sternum, sparing trauma to the chest bones and eliminating the activity restrictions associated with a traditional sternotomy incision. The surgeon then operates between the ribs to access the mitral valve within the left atrium. Cardiopulmonary bypass is achieved through peripheral cannulation, most commonly via the femoral artery and vein in the groin rather than directly in the chest.

This same minimally invasive approach can also be used to perform mitral valve replacement when repair is not suitable. Additionally, this incision can be used to perform tricuspid valve surgery, arial septal defect (ASD) closures, and some atrial fibrillation ablations.

Achieving Comparable Outcomes with Additional Advantages

Minimally invasive mitral valve surgery provides several well-established clinical advantages over conventional median sternotomy, while delivering comparable repair or replacement outcomes in appropriately selected patients. Benefits include the following:

• Quicker recovery – includes shorter hospital length of stay (typically 3-5 days), earlier ambulation, and faster return to work and daily activities. By contrast, sternotomy precautions limit any strenuous upper body activity while the bone heals, which can be several months.
• Reduced surgical trauma, pain and blood loss – preserves chest wall integrity, reducing postoperative pain and surgical blood loss, lessening the need for blood transfusions and decreasing reliance on opioids.
• Lower infection risk – reduced incidence of deep sternal wound infections and mediastinitis, which is particularly beneficial for high-risk patients, including those with diabetes, obesity or osteoporosis.
• Improved cosmetic results – results in smaller, less visible incisions.

Patient Selection Essential to Optimizing Outcomes

While the benefits of minimally invasive mitral valve surgery are evident, results are highly dependent on surgical expertise and institutional volume. In addition, patient selection is critical to achieving a successful surgical outcome.

A fundamental philosophy of minimally invasive cardiac surgery is that the quality of the valve operation cannot be compromised for the sake of a smaller incision. As such, every decision to take the minimally invasive approach needs to be made on a case-by-case basis and only after thorough evaluation and consultation with the patient on the pros and cons of all their treatment options. Comprehensive preoperative imaging, including echocardiography and computed tomography (CT) angiography, is essential to assess a patient’s coronary status, valve anatomy, and vascular access prior to determining their surgical options.

Typically, the best candidates for minimally invasive mitral valve surgery have isolated mitral valve disease without extensive aortic valve pathology, coronary artery disease, severe peripheral vascular disease, or complex multivalve disease.

Developing a Comprehensive Cardiac Evaluation Program and Surgical Center

At AdventHealth, we aim to offer a global, cohesive structural heart program which includes all available surgical and non-surgical treatment options. Our center currently offers multidisciplinary evaluation of mitral valve patients in order to better advise on treatment approaches. Our institutional philosophy is that care is best provided when there is shared decision making amongst the patient, primary cardiologist, and any subspeciality physicians, including interventional cardiologists and cardiac surgeons.

Offering both traditional and minimally invasive mitral valve surgery in this context of a comprehensive multidisciplinary valve program are just some examples of how AdventHealth continues to provide patients with whole-person care.