Totally endoscopic port access for rheumatic mitral valve replacement: Clinical outcomes and a single surgeon's learning curve experience

Figures

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  Endoscopic scars before discharge.

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  Figure 1. Port and trocars installation. A, The port and trocars consisted of (1) a 3- to 4-cm main working port positioned at the fifth intercostal space (ICS) on the anterior axillary line, (2) a 5.5-mm trocar at the fourth ICS on the midaxillary line for the left-hand instruments, which is later replaced by the Chitwood clamp, (3) a 5-mm trocar at the fifth ICS on the midaxillary line for 2-dimensional endoscopic camera and CO2 insufflation (arrow), and (4) a 5-mm incision for left vent. B, The small port was precisely sized to allow passage of the mechanical valve.

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  Figure 2. The operation steps. A, Retrograde Custodiol cardioplegia via a Foley catheter (arrow) in cases of aortic valve insufficiency. B, Tricuspid ring annuloplasty was performed under beating heart condition to minimize aortic crossclamp time. C, The anterior mitral leaflet (white arrow) was resected. D, Redundant tissue was thinned to preserve the integrity of the posterior mitral leaflet (white arrow). E, Annular sutures were placed, the white arrow indicates the remaining part of the posterior leaflet of the mitral valve. F, Assessment of mechanical valve function.

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  Figure 3. Left atrial reduction. A, The left atrium was significantly dilated, with excess tissue located in the inferior, posterior wall, and atrial roof (highlighted in blue). B, Preoperative radiograph of the chest demonstrated cardiomegaly, indicative of severe atrial enlargement. C, After plication suturing (highlighted in yellow), the left atrial volume was markedly reduced. D, Postoperative radiograph of the chest reveals a substantially decreased cardiac silhouette, confirming effective atrial volume reduction. LAA, Left atrial appendage; MV, mitral valve; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.

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  Figure 4. The learning curve analysis, based on aortic cross-clamp time, was conducted for a cohort of 130 patients, excluding those who underwent atrial fibrillation ablation and tricuspid ring annuloplasty. A, The cumulative sum control chart (CUSUM) analysis and (B) the risk-adjusted (RA) CUSUM failure analysis showed the cutoffs of the mastery phase were 86 and 60, respectively.

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  Figure 5. Research highlights. AF, Atrial fibrillation. CUSUM, cumulative sum control; RA, risk adjusted.

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  Figure E1. The postoperative results. The patient's surgical scars at discharge.

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  Figure E2. The learning curve analysis (continued). A, The CUSUM is based on aortic cross-clamp time for atrial fibrillation ablation. B, The CUSUM is based on cardiopulmonary bypass time for the tricuspid ring annuloplasty procedure. CUSUM, Cumulative sum control; ACC, aortic crossclamp; CPB, cardiopulmonary bypass.