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Ultrafast-Track Mini Mitral Valve Repair: Direct Access Transaxillary Approach

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posted on 2019-10-01, 19:19 authored by Marco Di Eusanio, Paolo Berretta, Jacopo Alfonsi, Utz Kappert, Filippo Capestro, Hossein M. Zahedi, Walter Vessella, Mariano Cefarelli

While the number of minimally invasive interventions being offered is gradually growing, patients’ requests for interventions associated with minimized trauma and faster recovery often remain unfulfilled (1).

Currently, most lines of progress in minimally invasive mitral valve interventions always involve more sophisticated and complex endoscopic support. Although such techniques are very elegant and are associated with excellent clinical outcomes, they often require steep learning curves, thus limiting their broader dissemination.

Based on this, the authors recently shifted from a classic endoscopic-supported minimally invasive mitral valve intervention to a simplified transaxillary direct access approach.

The main advantages of this approach include:

  • Superb cosmetic result with no visible incision from a front view.
  • Excellent direct exposition of the mitral valve. In fact, laterally, the ICS is wider compared to more anterior incisions; six or seven stay sutures firmly tied on the skin bring the mitral valve near and in the direction of the incision and the operating surgeon; a transaxillary incision guarantees a 90° alignment with the mitral valve, which is perfectly visualized at the center of the operative field.
  • No need for endoscopy, which, in turn, results in a simpler, faster, and cheaper operative table setup and, most importantly, maximally shortened learning curves.
  • Higher potential for dissemination.

Here the authors would like to share their approach in a step-by-step fashion. The patient was a 50-year-old woman with degenerative mitral valve disease. The severe mitral valve regurgitation was due to annular dilatation and P3 prolapse. Through a direct access transaxillary approach, the authors repaired the valve using the loop technique (2) and annuloplasty with a semirigid complete ring (Medtronic Simulus).


  1. Beckmann A, Funkat AK, Lewandowski J, Frie M, Ernst M, Hekmat K, Schiller W, Gummert JF, Harringer W. German heart surgery report 2016: the annual updated registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2017;65:505-518.
  2. von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg. 2000;70:2166-2168.


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