Live Webcast of Minimally Invasive Mitral Valve Repair

New York City, March 9, 2005: New York University Medical Center's Department of Cardiothoracic Surgery conducted a live surgical webcast of a minimally invasive mitral valve repair procedure. One of the more than 1,800 adult and pediatric open-heart operations performed there each year. Dr. Stephen B. Colvin, Chairman of Cardiothoracic Surgery, stated, "Minimally invasive cardiac surgery has become the standard of care for virtually all patients requiring valve surgery and most patients requiring coronary artery revascularization or bypass (CABG). We are excited with the opportunity to conduct a case and discuss our technique and outcomes through this Internet broadcast. NYU is a training center for cardiac surgeons from around the world and this educational program expands the opportunity for our colleagues to learn and comment about this important procedure." Dr. Aubrey C. Galloway, Vice Chairman of Cardiothoracic Surgery serves as moderator.

Minimally invasive cardiac surgery also dramatically reduces the possibility of infection and improves cosmetic results. Traditional open procedures require a 10-inch chest scar, whereas this minimally invasive approach results in a substantially smaller, less visible "keyhole" incision on the right side of the chest. For many women, the scar is almost unnoticeable as it lies underneath the breast.

In 2001, Drs. Colvin, Galloway and Grossi, working with engineers from Medtronic, Inc. (Minneapolis, Minnesota), designed the CG Future Band for use in mitral valve repair surgery to help restore or "remodel" the leaking mitral valve opening to a more-normal shape. "The CG Future band restores proper valve coaptation and improves valve function after repair," according to Galloway, "The design of The Future Band allows the surgeon to achieve more predictable remodeling of the valve annulus while maintaining normal physiology and flexibility. This should lead to more predictable long-term results after valve repair surgery."

"The design of this valve repair system is truly futuristic," says Colvin, "The low profile band is designed for improved ease of implantation, which is advantageous in all cases, but especially valuable as minimally invasive techniques become more common."

Colvin wears a head-mount camera to display the procedure as he sees it. An approximately 4 inch long thoracotomy incision is made into the 4th intercostal space. A small rib spreader retractor enlarges the operating window to a 6 inch circle. The aorta is exposed and cannulated for the heart lung machine. Venous flow for the pump is into the superior vena cava. A catheter is placed into the coronary sinus to provide myocardial protective solution while the heart is stopped. The aorta is cross-clamped with a flexible clamp that is then folded out of the field of view. The patient’s temperature is cooled slightly. The atrium is opened and the mitral valve is exposed to view.

Colvin uses 10-12 inch long special purpose circular instruments for this surgical technique (Arizona Surgical Technology and Education Center, ASTEC, Phoenix, Arizona). First he exposes the posterior leaflet of the valve. He then resects it down to the annulus—about 2 cm of the leaflet is removed.

The annulus is then plicated and a “foldingplasty” is done to minimize the height of the annulus and to prevent kinking of the arteries feeding the heart. 6-0 Prolene (Ethicon, division of Johnson & Johnson, Summerville, New Jersey) sutures are used. A sizer for the Future Band flexible annuloplasty band is then brought into the field, a size is chosen and the appropriate band is anchored to the anterior and posterior trigones of the annulus and sutured into place. The band is made of a polyester covered metal alloy and is able to flex gently with the opening and closing of the mitral valve. Colvin applies sutures to the annulus and the band, ties them outside the chest and places them with a knot pusher. Once the band is in place the valve is seen to be “reframed.”

The band covers only about 2/3s of the annulus, allowing the anterior valve leaflet free natural movement. The completed valve repair results in a larger blood outflow orifice. After the band is securely seated, a transesophageal echocardiogram demonstrates the greatly improved function of the repaired valve. Colvin then removes the rib spreaders, closes the atrium, and floods with heart with CO2 to reduce the possibility of air embolism. The patient is brought up to normal temperature and off the pump. The heart is restarted and full function is returned. The wound is closed traditionally.

Galloway notes, “We used the Heartport (now CardioVations, a division of Ethicon, Somerville, New Jersey) technique for 5 or 6 years and found a 5.4% mortality rate. That approach to heart surgery required occlusion of the aorta with a balloon catheter and femoral perfusion. It was too expensive and too complicated for most surgeons. This technique is much simpler and much cheaper while employing techniques all heart surgeons use every day. Our mortality rate now averages 1.4%.”

Approximately, 60,000 patients require some form of mitral valve repair each year. The minimally invasive approach for mitral valve surgery provides several important benefits to patients. "We reduce the trauma and pain associated with open-chest surgery and improve quality of life for patients," stated Galloway, "Eliminating the larger incision greatly reduces post-operative discomfort and enables patients to quickly begin a much shorter recovery process." Currently, NYU patients are comfortably managed on a four-day care map versus the traditional 7-10 days required with most open-heart procedures. In as little as two weeks, patients have resumed day-to-day activities and even returned to their jobs.