Video-atlas on minimally invasive mitral valve surgery-the Mohr technique.

Minimally-invasive mitral valve surgery was introduced into the surgical routine by Alain Carpentier, one of the pioneers of mitral valve surgery, in 1996 (1). It was at this time that minimally-invasive access was also performed at the Leipzig Heart Center for the first time. Since then, this technique has become routine at our institution with an annual number of up to 400 cases (2). It has been shown to be a safe technique not only in patients with impaired left ventricular function (3) and in patients of advanced aged (4), but also in selected patients who have had a previous sternotomy (5). In the majority of cases, the mitral valve is operated under direct vision. However, some cases are performed using pure videoscopic vision, as it has been promoted by Hugo Vanerman and others (6). The goal of minimally-invasive mitral valve surgery is to perform the operation with the same high repair rate compared to conventional mitral valve surgery through a median sternotomy and without putting the patient at a higher surgical risk. Avoiding sternotomy has major advantages for the patient, such as decreased surgical trauma and therefore improved recovery, less postoperative pain and improved cosmesis. These issues are of major importance for patients. There are, however, specific contraindications to this access, which have to be taken into account. In particular, a heavily calcified mitral valve annulus or severe annular abscess formation with the need to perform extensive annular reconstruction techniques should necessitate a conventional approach. Previous right chest surgery with severe adhesions of the right lung to the chest wall is an additional contraindication to minimally-invasive access. In addition, aortic valve regurgitation >I° is in our experience also a reason to perform a conventional sternotomy, in order to avoid insufficient administration of cardioplegia. In all other cases, minimally-invasive access can be used to perform the surgery. An article featured in this issue, “Consensus statement on Minimally Invasive Mitral Valve Surgery”, will address important issues when and when not to perform minimally-invasive access. In 2000 Mohr and von Oppel (7) introduced the “Loop technique”. This technique simplified even complex repairs of mitral disease using initially self-manufactured polytetrafluoroethylene neochordae (Gore-Tex loops), which became later available as premanufactured loops in different lengths. This technique has been shown to achieve excellent surgical results with a very high rate of mitral valve repair even in complex mitral valve pathologies (2). We were further able to demonstrate in a prospective randomized trial, that the “loop technique” had specific advantages compared to the leaflet resection technique in patients with mitral valve prolapse (8). Aside from significantly greater length of coaptation, patients undergoing the “loop technique” also received significantly larger annuloplasty rings in this study. In summary, the “loop technique” simplifies mitral valve repair, especially through a minimally-invasive surgical approach.