MINIMALLY INVASIVE CARDIAC VALVE SURGERY

Heart valve disease affects a growing number of US population. There is a significant increase in the prevalence of heart valve problems after age 65. The increase becomes more pronounced after 75 year of age.  One out of every 25 people over 75 years of age will develop moderate to severe aortic valve disease which may require surgical intervention. This number increases to one out of every 10 people for mitral valve disorders. Untreated valve disease has significant impact on the longevity and quality of life of the individual. However many patients with severe valve disease are not referred for valve repair or replacement due to perceived high surgical risks and possible complications in the elderly with other coexisting medical problems.
Heart valve surgery using smaller incisions has evolved in the last 10 years with the hopes of decreasing surgical trauma and to speed up recovery in this patient population. Initially employed for aortic valve replacements, these procedures are now enjoy extended utilization for a variety of valve repair and replacements including mitral and tricuspid valves.

Minimally Invasive Aortic Valve Surgery:
Traditional aortic valve surgery is performed through a 12 inch incision in the middle of the chest (full sternotomy). Almost 90% of aortic valve surgeries are still performed through this approach.
 
Minimally Invasive Aortic Valve procedures can be performed through a 3 inch incision on the upper part of the chest hence a ministernotomy. This incision currently represents around 10% of the aortic valve surgeries in the US.            

Less invasive aortic valve surgery can also be performed through a small incision between the upper ribs on the right side of the chest hence a minithoractomy. Only 3% of aortic valve replacements are done with this approach.

The core part of the surgical procedure is identical to traditional aortic valve surgery. The most important benefits of smaller incisons are less surgical trauma and less pain after the surgery, less blood transfusion, shorter hospital stay and faster recovery. There is also increased patient acceptance and better cosmetic results compared to the traditional full sternotomy.
Outcomes after minimally invasive valve aortic valve surgery have been found to be pretty much similar to traditional aortic valve surgery with the exception of shorter stay in the Intensive Care Unit and less blood product transfusions. There might be faster return to daily activities due to less perceived pain by the patient. One has to also remember that Aortic Valve Replacement has excellent outcomes regardless of the approach and incison with a surgical mortality around 3%. 
  
Minimally Invasive Mitral Valve Surgery:
A 12 inch incision in the front of the chest is still the most commonly used approach for mitral valve surgery.
 
However a two inch incision on the right of the chest (right mini-thoracotomy) is being used more commonly for isolated mitral valve operations in the last 10 years.
Some centers also employ the surgical robot through small incisions in the right chest for mitral valve surgery. Robotic mitral valve surgery however still represents the minority and the necessity of robot is controversial according to the recent literature. 
The small incision approach can provide better visualization of the valve and therefore may increase the chances of valve repair.  It has also been shown to decrease the amount of blood product transfusion. The conduct of the operation and techniques of valve repair in minimally invasive mitral valve surgery are identical to the traditional full sternotomy approach.