State of the Art
Minimally Invasive Surgical Treatment of Valvular Heart Disease

https://doi.org/10.1053/j.semtcvs.2014.02.001Get rights and content

Cardiac surgery is in the midst of a practice revolution. Traditionally, surgery for valvular heart disease consisted of valve replacement via conventional sternotomy using cardiopulmonary bypass. However, over the past 20 years, the increasing popularity of less-invasive procedures, accompanied by advancements in imaging, surgical instrumentation, and robotic technology, has motivated and enabled surgeons to develop and perform complex cardiac surgical procedures through small incisions, often eliminating the need for sternotomy or cardiopulmonary bypass. In addition to the benefits of improved cosmesis, minimally invasive mitral valve surgery was pioneered with the intent of reducing morbidity, postoperative pain, blood loss, hospital length of stay, and time to return to normal activity. This article reviews the current state-of-the-art of minimally invasive approaches to the surgical treatment of valvular heart disease.

Introduction

Over the past 20 years, the increasing popularity of less-invasive procedures has affected nearly every surgical specialty, including cardiac surgery. Consequently, patients requiring surgery frequently seek minimally invasive operations that promise smaller and ideally better tolerated incisions. With the recent approval of percutaneous valve replacement and repair technologies, it is clear that many patients prefer less-invasive therapies instead of proven traditional surgical approaches, despite an absence of mid- or long-term efficacy data. Thus, those who treat valvular heart disease are faced with a particular challenge that is revolutionizing current surgical practice—reform valve interventions to minimize the burden of surgery without compromising overall cardiovascular care. Advancements in imaging, surgical instrumentation, and robotic technology have enabled surgeons to perform complex cardiac surgical procedures through small incisions, often eliminating the need for sternotomy or cardiopulmonary bypass. The excellent outcomes of these contemporary minimally invasive valve surgery platforms provide benchmarks against which fledgling percutaneous technologies should be compared.

Section snippets

Surgical Treatment of the Mitral Valve

Degenerative mitral valve disease, typically characterized by leaflet prolapse secondary to chordal rupture or elongation, is the most common cause of chronic isolated mitral regurgitation in the United States.1 In general, patients with degenerative mitral regurgitation benefit in terms of event-free and overall survival if the mitral valve is repaired instead of replaced. The increased morbidity and mortality associated with mitral replacement is generally from higher reoperation rates due to

Surgical Treatment of the Aortic Valve

Aortic stenosis is one of the most frequently acquired diseases of the cardiac valves.1 Due to its progressive nature, aortic valve disease most commonly affects the elderly. In fact, a population-based study demonstrated that the prevalence of moderate or severe aortic stenosis was less than 1% in adults younger than 65 years and rose to 4.6% in those older than 75 years of age.1 As such, the prevalence of aortic valve disease is expected to increase with the aging population. Current

Conclusions

In the contemporary era of cardiac surgery, equivalent care quality can be provided without complete exposure of the heart. Compared with conventional sternotomy, minimally invasive approaches enable equally successful reconstructions, while reducing bleeding, pain, infection, and length of stay, as well as improving cosmesis, recovery, and patient satisfaction. The excellent results of minimally invasive valve surgery should be used as the reference standard to which emerging technologies are

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