Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Abstract

Central MessageCompared with the complexities and cost of using the endoballoon, the transthoracic clamp is easy to teach, simple to apply, remains stable in position, is reusable, and has an economic benefit.See Commentaries on pages 89 and 90. Compared with the complexities and cost of using the endoballoon, the transthoracic clamp is easy to teach, simple to apply, remains stable in position, is reusable, and has an economic benefit. See Commentaries on pages 89 and 90. "The value of an idea lies in the using of it."—Thomas Edison Throughout the history of cardiac surgery, external clamping of the ascending aorta has been essential to the conduct of both intracardiac and epicardial operations. Endothelial, hemodynamic, and humoral effects of external aortic clamping and unclamping have been studied extensively.1Bianchi G. Pucci A. Matteucci M. Varone E. Romano S. Lionetti V. et al.Mechanical properties and biological interaction of aortic clamps: are these all minimally invasive?.Innovations. 2013; 8: 42-49Crossref PubMed Google Scholar, 2Zammert M. Gelman S. The pathophysiology of aortic cross-clamping.Best Pract Res Clin Anaesth. 2016; 30: 257.e269Crossref Scopus (21) Google Scholar, 3Babin-Ebella J. Gimpel-Henning K. Sievers H. Scharfschwerdt M. Influence of clamp duration and pressure on endothelial damage in aortic cross-clamping.Interactive Cardiovasc Thorac Surg. 2010; 10: 168-171Crossref PubMed Scopus (22) Google Scholar As transmural forces on the internal aorta are more than 8 times the systemic blood pressure when applied, clamp design and application are important to distribute these forces to minimize endothelial injury. Dr Michael DeBakey designed perhaps the best clamp jaws to distribute these forces, and they still provide adequate tissue grip stability. While some cardiac procedures can be performed safely without aortic occlusion, either employing circulatory arrest, ventricular fibrillation, or beating-heart methods, these techniques generally are not applicable to the majority of cardiac operations. In the mid-1990s, Cohn and colleagues4Cohn L.I.I. Adams D.I.I. Couper G.S. Bichell D.P. Rosborough D.M. Sears S.P. et al.Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.Ann Surg. 1997; 226: 421-426Crossref PubMed Scopus (408) Google Scholar and Cosgrove and colleagues,5Cosgrove D.M. Sabik J.F. Navia J.L. Minimally invasive valve surgery.Ann Thorac Surg. 1998; 65: 1535-1538Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar among others, began to perform the first minimally invasive aortic and mitral valve operations through either an upper hemi-sternotomy or parasternal incision using traditional aortic crossclamps. During this period, it was our vision that the best approach for minimally invasive mitral valve surgery would be through a minithoracotomy using hypothermic cardioplegia. Previous right thoracotomy mitral reoperations had shown us that this approach provides excellent visualization and instrument access.6Tribble C.G. Killinger W.A. Harman P.K. Crosby I.K. Nolan S.P. Kron I.L. Anterolateral thoracotomy as an alternate to repeat median sternotomy for replacement of the mitral valve.Ann Thorac Surg. 1987; 43: 380-382Abstract Full Text PDF PubMed Scopus (54) Google Scholar In 1996, a group of innovative surgeons from Stanford developed and applied the catheter-based Heartport endoballoon occlusion device (Edwards Lifesciences Inc, Irvine, Calif) to replace mitral valves and perform coronary surgery through a tiny "working port" or "port-access."7Stevens J.H. Burdon T.A. Peters W.S. Siegel L.C. Pompili M.F. Vierra M.A. et al.Port-access coronary artery bypass grafting: a proposed surgical method.J Thorac Cardiovasc Surg. 1996; 111: 567-573Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar, 8Schwarz D.S. Ribakove G.H. Grossi E.A. Stevens J.H. Siegel L.C. St Goar F.G. et al.Minimally inva