Minimally Invasive Mitral Valve Repair With Situs Inversus

This video shows a minimally invasive mitral valve repair on a patient with situs inversus. The patient is a 66 year old male presenting with progressive dyspnea on exertion, paroxysmal nocturnal dyspnea and orthopnea, who had a recent heart failure admission and was diagnosed with severe mitral valve regurgitation. The patient underwent a diagnostic workup. He had a known history of situs inversus and was referred for surgical correction of severe mitral valve regurgitation. Intra-operatively there were 5 ruptured chords on P2.

The cardiac anesthesiologist placed a right radial a-line, single-lumen ETT, and right IJ pulmonary artery catheter per the program’s usual routine. A 2 cm oblique left groin incision was made parallel to the inguinal ligament using bovie electrocautery to dissect down to the level of the femoral canal. The femoral artery and vein were identified. We dissected down to the fourth intercostal space with bovie electrocautery after making a 4 cm minimally invasive left lateral thoracotomy incision. Administration of heparin achieved an ACT of greater than 400. Using the seldinger technique, we placed a pacing wire into the superior vena cava and a 25-french femoral venous cannula was placed with the tip in the superior vena cava. The wire was then placed into the aorta and a 17-french flexible arterial cannula wire was placed. The patient was placed on cardiopulmonary bypass and cooled to 34 degrees celcius.

The pericardium was opened and pericardial retraction stitches were placed. An antegrade cardioplegia cannula was placed in ascending aorta. Cross clamp was applied and antegrade cardioplegia was administered achieving excellent mechanical and electrical arrest. Blood-based del Nideo cardioplegia strategy was utilized with a single re-dose. Waterston groove was dissected in entirety and the left atrium was opened with excellent exposure of the mitral valve. The ruptured chords were excised and 4-0 gore-tex neo-chords were attached to the anteromedial papillary muscle that was secured to the posterior leaflet and reduction was performed with 4-0 ethibond. The cleft between P1 and P2 and P2 and P3 was closed with 4-0 ethibond and on saline testing there was trace residual mitral valve regurgitation. On the competent valve, the annulus sized to a 32 mm ring. 2-0 ethibond annuloplasty sutures were placed and the ring was parachuted in place and was secured down with the Cor-Knot device. On saline testing, there was trace residual mitral valve regurgitation and therefore decision was made to close the left atrium. We used 3-0 prolene 2 layer running closure and atrial and ventricular wires were placed along with blake drains.

References

Tiller GE, Hamid R. Situs Inversus. NORD Guide to Rare Disorders. 2003; https://rarediseases.org/rare-diseases/dextrocardia-with-situs-inversus/

Health Jade team,. Situs Inverses. Health Jade. https://healthjade.net/situs-inversus/