Minimally invasive mitral valve repair using external clamping— pearls and pitfalls

Minimally invasive mitral valve surgery is safe, effective and increasingly popular for patients with valvular pathology. After minimally invasive mitral valve surgery, patients report less pain, shorter hospital stay and better cosmetic results compared to other more invasive approaches. To perform this, cardiopulmonary bypass is needed and aortic occlusion is a critical step in its setup. It is performed worldwide with the use of either trans-thoracic external aortic cross-clamping or endo-aortic balloon occlusion. Both possibilities present peculiar advantages and limitations whose current evidence is based on few observational studies. This article will present the use of the trans-thoracic external aortic cross-clamp in further detail within the setting of minimally invasive mitral valve surgery. We conducted a literature search and discuss the differences in perioperative outcomes and complications between the endo-aortic balloon and the trans-thoracic external aortic cross-clamp technique during elective minimally invasive mitral valve surgery. According to a systematic review and meta-analysis published in 2019 by the Bristol group, the endo-aortic balloon technique was associated with a higher risk of aortic dissection. Endo-aortic balloon occlusion with aortic cannulation offers the shortest extracorporeal support times. Both techniques are safe and have similar rates of cerebrovascular accident and survival.