Transmitral Septal Myectomy and Complex Mitral Valve Repair for HOCM Through Periareolar Minimally Invasive Access
Through a partial superior periareolar skin incision, a small right
anterolateral thoracotomy was performed at the 4th intercostal space and
a 5 mm 0° thoracoscope was introduced through the same intercostal
space 7 cm laterally. A 2 cm skin incision was used to gain access to
the femoral artery and vein and then the Seldinger technique was used
for cannulation of the vessels for cardiopulmonary bypass. Once
extracorporeal circulation was established, the ascending aorta was
clamped with a Cygnet clamp (Vitalitec, Balgheim, DE) and the heart
stopped with infusion or cold crystalloid cardioplegia (Custodiol) in
the aortic root. The left atrium was opened and retracted using a
standard MICS atrial retractor; a Crown FlexTM atrial retractor was also
installed (Geister, Tuttlingen, DE) to improve the visualization of the
mitral valve. The midline of the anterior mitral annulus and the
trigons were signed with a skin marker, the insertion of the anterior
leaflet was cut between the commissures, and the leaflet fixed to the
posterior annulus with a 4/0 prolene. Transmitral myectomy of the
interventricular septum was performed and extended distally to the
origin of the papillary muscles. The anterior head of the accessory
bifid papillary muscle was identified and isolated with the help of a
surgical hook and then cut 2-3 mm distally from the base of insertion on
the body of the muscle. The chordae that branched out from the head was
cut at the distal end on the insertion on the anterior leaflet of the
valve. A bovine eterologous pericardial patch was cut in a costume-made
size on the basis of the measure of the intertrigone distance that the
cardiologist had previously taken performing the TEE. The patch was then
sutured using a 4/0 prolene running suture to the anterior annulus from
the center to one and then the other trigone to avoid distortion.
Another running suture with a 4/0 prolene was perfomed from the opposite
site of the patch to the detached portion of the anterior leaflet. This
procedure was made to extend the surface of the anterior leaflet and
move backward the coaptation of the mitral valve, thus the risk of
systolic anterior motion is averted. Two 4/0 GoreTex (W.L. Gore and
Assoc, Inc, Flagstaff, AZ, USA) neochords were implanted on the
anterolateral and posteromedial papillary muscles and lead to the free
margin of the anterior leaflet. The length of the neochords was assessed
by a fine-tuning hydrostatic test, filling the left ventricle with
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