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xii Preface
with computerised tomography scanning and trans oesophageal echocardiography but also intra-operative imaging with better endoscopic equipment
and depth perception of three-dimensional cameras. Despite these adjuncts,
the gradual shift away from sternotomy is a big move for surgeons and teams.
This has to be achieved in an era of a lack of tolerance for learning curves
and increased public scrutiny of surgeons and teams. All surgical change
needs a combination of “will and skill”. The cycle of change classically
follows 5 stages and the first three are pre-contemplation, contemplation and
preparation. I hope for many this book helps at one of these stages.We as
authors also hope that this has a place for surgeons who enjoy the details seen
in operative videos and also other clinicians who would like a better
understanding of the beautiful anatomy within the heart that these videos
capture.
The unique feature of this book was the embedded videos created especially for this project, which hopefully helps to explain concepts more easily
than pictures or text. So the hope is that this book will be different and useful
to you readers. This book would not have been possible without the support
of Grant Weston and Antony Joseph from SpringerNature who have backed
the procedure through a global pandemic to make it into a reality.
I have to thank the exceptional line-up of authors who selflessly gave up
their time for this new project. Despite work pressures and new challenges,
these remarkable individuals have contributed their wisdom and I encourage
readers to directly contact them as I know they have so much more to share
and give, which could not be captured in these pages.
This book has tried to distil the experiences of many clinicians who have
successfully navigated the cycle of change and are now well established in
the last two stages, of action and maintenance. There are many ways to
establish an endoscopic cardiac surgery program, and I do hope as a reader
you consider this book as a starting point on a journey of serious contemplation. As my mentor, Dr. Vanerman often, quoted Victor Hugo saying,
“nothing is more powerful than an idea whose time has come!”, has the time
come for endoscopic cardiac surgery? That reality is in the hands of all you
readers. We need to see the partnership between a pill, a saw and a catheter
increased to include an endoscope in the armamentarium of clinicians
involved in the fight against heart disease around the world.
Blackpool, UK Joseph Zacharias
Contents
Operative Planning for Safe Endoscopic Mitral Valve
Surgery
Luca Aerts and Peyman Sardari Nia
............................................... 1
Anaesthesia for Endoscopic Cardiac Surgery
................. 11
Andrew Knowles and Palanikumar Saravanan
Transoesophageal Echocardiography for Safe Endoscopic
Cardiac Surgery
........................................ 41
Palanikumar Saravanan and Andrew Knowles
Endoscopic Conduit Harvesting: Best Practice Training
Guidelines
............................................. 51
Bhuvaneswari Krishnamoorthy and Jared Blackmore
Endoscopic Cardiac Surgery—Tips, Tricks and Traps;
Endoscopic Vessel Harvesting for Coronary Artery
Revascularization Surgery with a Non Sealed Reusable
System
................................................ 69
Fabrizio Rosati, Saurabh Gupta, and Gianluigi Bisleri
Endoscopic Closed Tunnel Conduit Harvesting: Tips, Tricks
and Traps
............................................. 85
Bhuvaneswari Krishnamoorthy and Jared Blackmore
Endoscopic Vein Harvest Using an Open System (Terumo
®
Donna Croft, Steven Power, and Louise Parry
Endoscopic Mitral Valve Surgery Using the External Clamp
Patrick Perier
) .... 109
.... 129
The Endo-Aortic Balloon Technique in Totally Endoscopic
Atrioventricular Valve Surgery
............................ 143
Karel M. Van Praet, Markus Kofler, Axel Unbehaun, Volkmar Falk,
and Jörg Kempfert
Endoscopic Tricuspid Valve Surgery: Planning
and Deployment
......................................... 151
Marco Solinas and Giacomo Bianchi
xiii
xiv Contents
Minimally Invasive Endoscopic Maze Procedure for Atrial
Fibrillation Through Right Mini-thoracotomy
................ 163
Manuel Castella and JesúsRuíz
Totally 3D-Endoscopic Aortic Valve Replacement
............. 175
Soh Hosoba and Toshiaki Ito
Totally Endoscopic Aortic Valve Replacement
................ 183
Antonios A. Pitsis and Aikaterini N. Visouli
Endoscopic Repair of Septal Defects
........................ 209
Joseph Zacharias
Multi-vessel Endoscopic Coronary Artery Bypass Grafting
Alaaddin Yilmaz, Jade Claessens, and Abdullah Kaya
Endoscopic Surgery for Cardiac Tumours
................... 237
Abdelrehman Abdelbar and Joseph Zacharias
Cannulation Techniques for Cardiopulmonary Bypass
in Endoscopic Cardiac Surgery
............................ 245
Karel M. Van Praet, Markus Kofler, and Jörg Kempfert
Endoscopic Mitral Surgery in Cardiogenic Shock
............. 255
Mario Castillo-Sang
The Role of Simulators in Safe Adoption of Endoscopic
Mitral Valve Surgery
.................................... 277
Luca Aerts and Peyman Sardari Nia
Trial of Current 3D Imaging Systems
....................... 287
Ludwig Müller
...... 217
MiECC as Support for Endoscopic Cardiac Surgery
........... 297
Pascal Starinieri
Innovation in Cardiac Surgery: It Takes a Village—Our
Team’s Story: A Quest for Routine Sternal-Sparing CABG
Jude S. Sauer
Psychological Context, Individual Differences
and Adjustment in Relation to Cardiac Surgery Scars
.......... 339
Kate L. Green
Leadership, Interpersonal Dynamics and the Adoption
of Minimally Invasive Endoscopic Mitral Valve Surgery
........ 343
Megan Joffe
Index
................................................. 357
..... 317
Operative Planning for Safe
Endoscopic Mitral Valve Surgery
Luca Aerts and Peyman Sardari Nia
Abstract
The increasing interest in minimally invasive
approaches has induced fast expansion of
minimally invasive mitral valve surgery
(MIMVS) over the past two decades. However,
MIMVS is not included in the most recent
valvular heart disease guidelines due to the lack
of convincing data supporting this approach.
Due to the different techniques applied by
individual surgeons and centers, there has been
no scientific nor expertise-based consensus
developed regarding standardization in
MIMVS and consequently its absolute contra-
indications. Therefore, a change of mindset is
required to shift the focus from the superiority
of a p rocedure toward which particular patients
have the greatest benefit from specific surgical
approaches. In light of personalized medicine,
we have developed a standard procedural
planning to ensure a standard approach to
patients undergoing MIMVS.
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_1. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
L. Aerts (&) P. Sardari Nia
Department of Cardiothoracic Surgery, Maastricht
University Medical Center, Maastricht, the
Netherlands
e-mail: lucaaerts@hotmail.com
Keywords
Mitral valve repairMinimally invasive
surgery
Three-dimensional imagingComputed
tomography (CT)
Preoperative planning
1 Introduction
The increasing interest in minimally invasive
approaches has induced fast expansion of minimally invasive mitral valve surgery (MIMVS)
over the past two decades. However, MIMVS is
not included in the most recent valvular disease
guidelines due to the lack of convincing data
favoring this approach [1–3].
Several studies, including meta-analyses and
single-center retrospective studies, demonstrate
reduced blood loss, ventilation time and postoperative pain as well as shorter intensive care unit
admission and overall hospital stay in comparison to conventional surgery [6–8]. However,
increased cardiopulmonary bypass (CPB) and
clamping times were also reported.
Additionally, the level of complexity and its
steep learning curve contributes to the reticence
of interested surgeons to put their hands to the
plow and start, persevere and fine-tune such
comprehensive surgery [4, 5].
Due to the different techniques applied by
individual surgeons and centers, there has been
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_1
1
2 L. Aerts and P. Sardari Nia
Fig. 1 Concept of personalized medicine. 3D, three
dimensional; CT, computed tomography. Reprinted from
Interactive CardioVascular and Thoracic Surgery, Volume 24, Issue 2, Sardari Nia P, Heuts S, Daemen J,
Luyten P, Vainer J, Hoorntje J, Cheriex E, Maessen J,
no scientific nor expertise-based consensus
developed regarding standardization in MIMVS
and consequently its absolute contra-indications.
There is great variability in technical strategies in
terms of access, vision, perfusion techniques and
conditioning [9].
Therefore, a change of mindset is required to
shift the focus from the superiority of a particular
procedure toward which patients have the greatest benefit from a specific surgical approach.
Careful patient selection and extensive preoperative planning is mandatory for MIMVS and
accentuating the advantages of this approach,
leading to less conversions and reducing periand postoperative complications.
In light of personalized medicine, we have
developed a standard preoperative procedural
planning to ensure personalized treatment
(Fig. 1).
2 Teamwork Approach
In cardiac surgery, teamwork and communication are the key to success. It is well established
that failures in coordinated teamwork contribute
to avoidable harm and inefficiency in the surgical
field. Complex procedures, such as MIMVS, are
even more in need of a dedicated team to minimize these failures.
In our center, all patients referred for a mitral
valve procedure are discussed in our weekly
mitral valve heart team, consisting of
Preoperative planning with three-dimensional reconstruction of patient's anatomy, rapid prototyping and
simulation for endoscopic mitral valve repair, 163–168,
2017 with permission from Elsevier [27]
interventional cardiologists, imaging cardiologists and cardiothoracic surgeons with expertise
in the mitral valve. After careful consideration,
the patients are allocated to their designated
treatment [10].
We have shown in a recent retrospective
cohort that patients treated by a dedicated mitral
heart team have superior survival compared to
patients treated by a nonspecialist heart team.
Between July 2009 and December 2014, a total
of 504 patients with mitral valve pathologies
were discussed in the general heart team. This
team consisted of two members: a specialized
cardiothoracic surgeon and an interventional
cardiologist. If they concluded that additional
imaging was required, patients would be discussed a second time by this team after substantial imaging was acquired.
Additionally, 641 patients were presented in a
dedicated mitral valve heart team in a four-year
time period from December 2014 to December
2018. This larger team consisted of dedicated
mitral valve surgeons (>25 mitral valve procedures per year), interventional and imaging cardiologists, both specialized in mitral valve
pathology. As for the general heart team, when
required, further inves tigation was obtained in
order to make a final decision.
When comparing the results of both multidisciplinary teams, these are in favor of the
dedicated mitral valve heart team in our clinic.
The 5-year survival probability was 0.70 (95%
confidence interval (CI) 0.66 – 0.74) for the
Operative Planning for Safe Endoscopic Mitral Valve Surgery 3
general heart team in comparison to 0.74 (95%
CI 0.68 – 0.79, P = 0.040) for the dedicated
mitral valve heart team. A subgroup of cases was
identified where the advice of the team was not
followed and compared to the patients when it
was followed. The adjusted relative risk of
mortality was reduced by 61% (hazard ratio 0.39,
95% CI 0.25 – 0.62, P < 0.001) when following
the advice of the dedicated mitral valve heart
team and reduced by 43% (HR 0.57, 95% CI
0.37 – 0.87, P = 0.010) when following the
advice of the general heart team. These results
were independent of the baseline characteristics,
the mitral valve pathology and the allocated
treatment [11].
3 Procedural Planning
All patients with an indication for mitral valve
surgery in our center are subjected to standard
procedural planning to identify comorbidities and
anatomical variations. Relative contraindications are identified and taken into consideration during the preoperative process (Table 1).
3.1 Electrocardiography
At the first outpatient visit, our patients are
screened for the presence of atrial fibrillation
(AF) or ventricular dys-synchrony. If AF is
detected by electrocardiography, the patient will
be reviewed in our rhythm heart team, composed
of rhythm surgeons and electrophysiologists.
During this consultation, the team decides whether a concomitant surgical ablation will be performed according to the most recent guidelines
[12].
3.2 Chest X-ray
The second step in the workup process is radiography. The standardly performed chest X-ray is
evaluated for anomalous thoracic anatomy, acute
or chronic pulmonary pathology and the position
of the diaphragm, with a special interest in the
right hemi-diaphragm. Additional diagnostic
modalities can be opted for during the screening
pathway, or a pulmonologist can be consulted for
further evaluation.
3.3 Echocardiography
When referring a patient to our center, the cardiologist is usually sending a transthoracic
echocardiography (TTE) performed at their own
hospital in advance. During the multidisciplinary
meeting, all the echocardiographic images will
be analyzed by a dedicated mitral heart team
including an imaging cardiologist with expertise
in mitral valve pathology.
To date, TTE is the golden standard for the
evaluation of mitral valve disease. The mechanism of mitral regurgitation (MR) is identified by
valve morphology, color jet flow, vena contracta
Table 1 Relative contra-indications for MIMVS in our center. BMI: body mass index; MIMVS: Minimally Invasive
Mitral Valve Surgery
Relative contra-indications for MIMVS at the beginning of the learning curve
Significant mitral annular calcification
More than grade I + aortic valve regurgitation
Extensive aortic dilatation
Morbidly obese and extremely muscular patients
Large chest with a distance between the MV annulus and right-sided chest wall of more than 25 cm
Extensive pulmonary adhesions
Extensive abdominal aortic atherosclerosis or peripheral arterial diameters <7 mm
High BMI
4 L. Aerts and P. Sardari Nia
width, pulmonary vein flow, time-velocity integral of mitral inflow, effective orifice regurgitant
orifice and regurgitant volume [13]. The severity
of MR is determined multifactorial, rather than
by solely one parameter.
For example, a small jet reaching just above
the mitral valve annulus is classified as ‘nonsevere’, but can be potentially misinterpreted by
increased pressure in the left atrium [14]. On the
other hand, patients with Barlow’s disease (extensive myxomatous valve disease) can conceal
signs of severe MR due to ‘ mitral valve disjunction’. This physiological phenomenon is
characterized by a total displacement of the mitral valve into the left atrium, without a
large flow jet presented on echocardiogra phy
[15, 16].
Additionally, TTE gives a global overview of
cardiac function and other valvular abnormality.
Preoperatively we are specifically interested in
the mitral valve; we evaluate left and right ventricular function, pulmonary artery pressure and
concomitant aortic and tricuspid regurgitation.
Right ventricular dysfunction has been proven to
be a substantiate predictor for postoperative
mortality [17].
According to recent guidelines, tricuspid repair during the same procedure is advocated
when there is a tricuspid annular dilatation
of >40 mm regardless of the severity of tricuspid
regurgitation. This is associated with a better
outcome of mitral valve surgery [18].
If repair is possible on grounds of the TTE
images, the patient will need transesophageal
echocardiography (TEE). TEE is superior to TTE
regarding the identification of the localization
and mechanism of the mitral valve prolapse that
is used to envision the repair strategy [19]. Furthermore, the TEE is a resourceful modality
when predicting the exact ring size of the mitral
valve annulus. By measuring the anterior mitral
leaflet length and intercommissural distance, the
required ring size can be calculated [20].
By using dedicated software, threedimensional printing of the mitral valve can be
used to visualize the anatomy and pathology of
an individual valve (Video 1). This will be discussed in another chapter.
3.4 Coronary Angiography
All patients who meet the criteria for MIMVS
will undergo a coronary angiography
(CAG) mainly to exclude subclinical coronary
artery disease (CAD) requiring sequential coronary artery grafting (CABG). Secondl y, CAG is
used to preoperatively strategize the procedure
by investigating the patient’s coronary anatomy.
The CAG is evaluated to identify potential
impediments, such as mitral annular calcification
and the circumflex artery (RCx) trajectory and to
determine the dominance of the cardiac vascular
system. In a left dominant coronary system, RCx
runs closer to the mitral valve annulus [ 22 ].
One of the most dangerous but uncommon
complications of mitral valve surgery is accidental (partial) occlusion of the RCx [23, 24].
This presents itself postoperatively with reduced
ventricular function and ischemia-like features,
due to either kinking of the artery toward the
mitral valve or a fully obliterated lumen of the
artery by annular sutures (Fig. 2, Video 2).
3.5 Computed Tomography
Computed Tomography (CT) plays a major role
in the preoperative process. MIMVS is accomplished by peripheral cannulation due to the
keyhole approach. For this reason, an
electrocardiography-triggered computed tomography angiography is made to visualize the aortic
root and ascending aorta, followed by a high
pitch spiral computed tomography angiography
to visualize the aortic arch down to the femoral
bifurcation. Relative contra-indications such as
calcification, dilatation and stenosis in the trajectory of the peripheral arteries will be traced to
minimize the risk of vessel wall damage and
consequently stroke peri- and postoperative
(Fig. 3, Video 3).
With the help of three-dimensional reconstructing nowadays, we can create a threedimensional reconstruction of each individual
patient’s anatomy preoperatively. Using this
technology, we get insight into the visuospatial
relations between anatomic structures to enhance
Operative Planning for Safe Endoscopic Mitral Valve Surgery 5
Fig. 2 Contrast-enhanced cardiac CT in a patient with
postoperative iatrogenic occlusion of the RCx after mitral
valve repair. A Preoperative CT revealing an intact RCx
(dotted arrow) and B postoperative CT 3 months after
mitral valve repair showing a fully obliterated RCx
Fig. 3 Reconstruction of the
iliofemoral vessels and aorta
based on CT images for
simulation of arterial cannula
introduction and
advancement. A A21Ch
arterial cannula can safely be
introduced in the right
femoral artery while B the
right femoral artery has an
insufficient luminal diameter
for a 23 Ch cannula.
Reprinted with permission
from The Journal of
Visualized Surgery, https://
doi.org/10.21037/jovs.2018.
09.07 [21]
(arrows) due to annular sutures. CT, computed tomography; RCx, circumflex artery. Reprinted with permission
from The Journal of Visualized Surgery, https://doi.org/
10.21037/jovs.2018.09.07 [21]
6 L. Aerts and P. Sardari Nia
Video 1 Mitral valve repair for posterior leaflet prolapse.
Available online: http://www.asvide.com/article/view/
32378. Reprinted with permission from The Journal of
surgical intervention and analyze the procedure
layer by layer to enhance safety, efficacy and
reproducibility.
Approximately 30% of patients referred to our
clinic for minimally invasive aortic or mitral
valve surgery workup have anatomic variations
based on three-dimensional reconstruction based
on CT-imaging. The following features can be
seen: severe calcification of the abdominal aorta
or the pericardium, iliofemoral vessel tortuosity
and aortic elongation [26]. This does not mean
these patients cannot be accepted for a minimally
invasive approach, but it requires a modified
approach and change in strategy.
To illustrate the full trajectory of a patient, a
case is presented:
Mitral valve repair for posterior leaflet prolapse
A 64-year-old man visited the outpatient clinic
with progressive dyspnea. There was no medical
history and no use of medication. TTE was performed to evaluate overall cardiac function. This
imaging technique showed a left ventricular
function of 68%, left ventricle diastolic diameter
of 52 mm, left ventricle systolic diameter of
32 mm and mitral regurgitation classified as
‘severe’ with an effective regurgitant orifice of
Visualized Surgery, https://doi.org/10.21037/jovs.2018.
09.07 [25](▶ https://doi.org/10.1007/000-a6j)
0.53 cm
2
. There were no other valvular
pathologies. TEE was added to the diagnostic
pathway and clarified the mechanism of regurgitation. There was a P2 segment prolapse of the
posterior leaflet.
The mitral valve heart team decided to accept
the patient for MIMVS. A CT scan was performed, and no contra-indications were found.
To determine the preoperative strategy, a threedimensional printed mitral model was reconstructed. Using a simulation model, this threedimensional model was implanted and it was
determined preoperatively to use 3 pairs of neochordae and a stabilizing ring (See Video 1).
4 Future Perspectives
The ultimate aim is to strive for the best outcomes in mitral valve surgery by putting an
excessive focus on the prevention of adverse
events. Adverse events should not form any
barrier in developing a programme, but should be
a trigger to improve and excel. Measurement is
fundamental to evolve, and the process, structure
and outcome are helpful resources to achieve this
(See Videos 2, 3 and 4).
Operative Planning for Safe Endoscopic Mitral Valve Surgery 7
Video 2 Three-dimensional mitral valve reconstruction
based on TEE images. The model can be stopped at any
moment during the cardiac cycle for optimal assessment
of valvular pathology. TEE: transesophageal echocardiography. Available online:
http://www.asvide.com/article/view/27630. Reprinted
with permission from The Journal of Visualized Surgery,
https://doi.org/10.21037/jovs.2018.09.07 [21]
(▶ https://doi.org/10.1007/000-a6h)
Video 3 Direct postoperative invasive coronary angiography after mitral valve repair, revealing an iatrogenic total
occlusion of the proximal RCx. RCx: circumflex artery.
Available online:
http://www.asvide.com/article/view/27631. Reprinted with
permission from The Journal of Visualized Surgery,
https://doi.org/10.21037/jovs.2018.09.07 [21]
(▶ https://doi.org/10.1007/000-a6g)
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