Mitral Valve Infective Endocarditis: Transareolar Endoscopic Complex Mitral Valve Repair

<p> </p> <p>This video demonstrates the feasibility of a MV repair, also one in the setting of destruent infective process, and proposes a physiological technique to restore the natural geometry of the valve. In experienced centers, complex and extensive repair are doable in a completely endoscopic fashion.</p> <p><br></p> <p>A fifty-five-year-old man with past medical history consistent for heart failure with reduced ejection fraction, neuropathy, beta thalassemia trait, recent COVID 19 infection, COPD requiring BiPAP, severe morbid obesity with a BMI of 41.5, and recent a<em>cute kidney injury</em> presented in severe sepsis requiring pressors. Blood cultures grew Serratia and a transthoracic echocardiogram (TEE) revealed a 13x10 mm vegetation for the PML with mild mitral regurgitation (MR). A conservative strategy was chosen. </p> <p><br></p> <p>One month later, the patient was admitted with intermittent fever, lower limb swelling and shortness of breath. Deep vein thrombosis was diagnosed and a new TEE demonstrated a worsening of the infective process with a vegetation actually 10x25 mm and severe MR. Patient was considered for an endoscopic mitral valve (MV) repair versus replacement. </p> <p>Endoscopic setup did not differ from the one for standard elective cases and consisted of a periareolar working port at the fourth intercostal space, two 5 mm miniports at the second and and fifth intercostal spaces for the 30° thoracoscope and the LV venting line respectively. </p> <p><br></p> <p>Peripheral veno-arterial cannulation was achieved, and in this specific patient—because of his BMI—a internal jugular vein cannula was added to improve venous drainage. </p> <p>Through a transareolar completely endoscopic fashion, a complex reconstruction of the posterior leaflet with a bovine pericardium patch from P1 to P3, replacing the entire P2 scallop, was achieved. Two pairs of GTX neochords for the neoleaflet were implanted. A custom-made pericardial band was also trimmed and implanted. Because of annular dilatation, a tricuspid valve repair under beating heart was performed.</p> <p><br></p> <p>Patient was extubated six hours after surgery and stepped down on postoperative day two. The postop TEE showed a well-functioning MV with a very physiological behave of the neo posterior leaflet with no residual MR. </p>