All herein-described procedural steps were performed in accordance with the Institutional Review Board of the University Heart and Vascular Center Hamburg guidelines and after written informed consent was obtained.
1. Fully endoscopic MIS MV repair
<ol>
	<li>Ensure the patient is under general anesthesia, in a supine position, scrubbed with iodine disinfectant, and draped with a sterile drape.</li>
	<li>Gain thoracic access along the peri-mammillary margin through the fourth intercostal space.</li>
	<li>Achieve distension of the intercostal space using a soft-tissue retractor.</li>
</ol>
2. Percutaneous cannulation of groin vessels
<ol>
	<li>Position two cannulas in the femoral artery and vein under transesophageal echocardiogram (TEE) guidance to establish CPB for MIS.</li>
	<li>Perform puncture of the femoral artery using a standard puncture needle and insert a 0.035 mm guidewire under TEE guidance.</li>
	<li>Determine the depth of the initial puncture using a puncture-locating dilator, which is inserted over the wire. This detects puncture depth by outlet backflow/the stop of backflow.</li>
	<li>Define the depth at skin level, which is defined by the visible stop of backflow of the measuring tool. 
	NOTE: For the later release of the vessel closure device, deployment depth is defined as the puncture depth at skin level plus 1 cm.</li>
	<li>Place the arterial cannula (sizes vary according to body surface area) over the wire and connect it to CBP.</li>
	<li>Puncture the femoral vein medial to the artery in the same manner (step 2.2) and after insertion of the venous cannula connects to the CBP.</li>
</ol>
3. MV repair
<ol>
	<li>Insert the 3D-HD camera over the thoracic incision.</li>
	<li>Open the pericardium above the right site phrenic nerve using diathermy.</li>
	<li>Place a transthoracic Chitwood aortic clamp through a small incision for cross-clamping of the aorta under the induced ventricular fibrillation.</li>
	<li>Arrest the heart with antegrade Del-Nido cardioplegia and moderate hypothermia of 32 &#176;C, which is established and maintained by the heart and lung machine. The effectiveness of cardioplegia is documented by an electrocardiogram.</li>
	<li>Open the left atrium with scissors and lift the left atrial roof with a dynamic retractor.</li>
	<li>Expose the MV and inspect the pathology, by prolapse of the posterior mitral leaflet in this case.</li>
	<li>Determine the size for the correct annuloplasty ring and neochordae via an annuloplasty measuring tool and a caliper for the length of native chordae.</li>
	<li>Resuspend the posterior mitral leaflet (PML). Implant the annuloplasty ring by implanting the neochordae at the respective papillary muscle and placing circumferential annulus sutures.</li>
	<li>Secure the neochordae to the papillary muscle, pass twice through the free margin of the posterior leaflet, and knot down.</li>
	<li>Place circumferential sutures around the annulus and then put the sutures through the annuloplasty ring, which is taken down onto the annulus via the sutures.</li>
	<li>Close the left atrium with a polypropylene, non-absorbable 4-0 suture; remove the aortic cross-clamp.</li>
	<li>Close the thoracic access and perform CBP weaning.</li>
</ol>
4. Decannulation and vascular closure
<ol>
	<li>Remove the venous cannula using a Z-suture technique at the cannula entrance site and tie down the suture after pulling out of the cannula.</li>
	<li>For closure of the femoral artery, use the collagen plug-based closure device.</li>
	<li>Clamp the arterial cannula, puncture the cannula, and insert a wire under TEE guidance.</li>
	<li>Retract the cannula over the wire by holding the wire in place to ensure a safe wire position in the descending aorta.</li>
	<li>Insert the closure system sheath fully over the wire and remove the dilator.</li>
	<li>Insert the closure device over the integrated insertion tool and slowly remove the whole system at a steady 45&#176; angle under constant retraction force to the measured depth.</li>
	<li>Observe markings on the sheath, adjust the deployment depth, and rotate the lever for toggle release.</li>
	<li>Retract the system further from the femoral artery until tension appears and the indicator field appears yellow/green.</li>
	<li>Advance the lock advancement tool until a click is heard; the puncture is now sealed via an extravascular collagen plug.</li>
	<li>When hemostasis is obtained, remove the guide wire, cut the lead suture, and close the skin with a single suture.</li>
	<li>Apply a pressure bandage for 6 h. 
	NOTE: This is the end of the surgery.</li>
</ol>

<ol>
	<li>David, T. E., Ivanov, J., Armstrong, S., Rakowski, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Late+outcomes+of+mitral+valve+repair+for+floppy+valves:+Implications+for+asymptomatic+patients.">Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients.</a> The Journal of Thoracic and Cardiovascular Surgery. 125 (5), 1143-1152 (2003).</li><li>David, T. E., David, C. M., Lafreniere-Roula, M., Manlhiot, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+outcomes+of+chordal+replacement+with+expanded+polytetrafluoroethylene+sutures+to+repair+mitral+leaflet+prolapse.">Long-term outcomes of chordal replacement with expanded polytetrafluoroethylene sutures to repair mitral leaflet prolapse.</a> The Journal of Thoracic and Cardiovascular Surgery. 160 (2), 385-394 (2020).</li><li>Beckmann, A., Meyer, R., Lewandowski, J., Markewitz, A., Harringer, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=German+heart+surgery+report+2018:+the+annual+updated+registry+of+the+German+Society+for+Thoracic+and+Cardiovascular+Surgery.">German heart surgery report 2018: the annual updated registry of the German Society for Thoracic and Cardiovascular Surgery.</a> The Thoracic and Cardiovascular Surgeon. 67 (5), 331-344 (2019).</li><li>Abdelbar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+tricuspid+valve+surgery+is+a+safe+and+effective+option.">Endoscopic tricuspid valve surgery is a safe and effective option.</a> Innovations. 15 (1), 66-73 (2020).</li><li>Pfannmueller, B., Misfeld, M., Davierwala, P., Weiss, S., Borger, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Concomitant+tricuspid+valve+repair+during+minimally+invasive+mitral+valve+repair.">Concomitant tricuspid valve repair during minimally invasive mitral valve repair.</a> The Thoracic and Cardiovascular Surgeon. 68 (6), 486-491 (2020).</li><li>Ko, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+mitral+valve+surgery:+a+systematic+safety+analysis.">Minimally invasive mitral valve surgery: a systematic safety analysis.</a> Open Heart. 7 (2), e001393 (2020).</li><li>Pozzi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+percutaneous+femoral+vessels+cannulation+for+minimally+invasive+mitral+valve+surgery.">Total percutaneous femoral vessels cannulation for minimally invasive mitral valve surgery.</a> Annals of Cardiothoracic Surgery. 2 (6), 739-743 (2013).</li><li>Kim, J., Yoo, J. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Totally+endoscopic+mitral+valve+repair+using+a+three-dimensional+endoscope+system:+initial+clinical+experience+in+Korea.">Totally endoscopic mitral valve repair using a three-dimensional endoscope system: initial clinical experience in Korea.</a> Journal of Thoracic Disease. 12 (3), 705-711 (2020).</li><li>Kroon, H. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dedicated+plug+based+closure+for+large+bore+access-The+MARVEL+prospective+registry.">Dedicated plug based closure for large bore access-The MARVEL prospective registry.</a> Catheterization and Cardiovascular Interventions. 97 (6), 1270-1278 (2021).</li><li>Van Praet, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+MANTA+vascular+closure+device+for+percutaneous+femoral+vessel+cannulation+in+minimally+invasive+surgical+mitral+valve+repair.">The MANTA vascular closure device for percutaneous femoral vessel cannulation in minimally invasive surgical mitral valve repair.</a> Innovations. 15 (6), 568-571 (2020).</li><li>Otto, C. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ACC/AHA+guideline+for+the+management+of+patients+with+valvular+heart+disease:+a+report+of+the+American+College+of+Cardiology/American+Heart+Association+Joint+Committee+on+Clinical+Practice+Guidelines.">ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.</a> Journal of the American College of Cardiology. 77 (4), 450-500 (2020).</li><li>Vergnat, M., Finet, G., Rioufol, G., Obadia, J. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+femoral+artery+access+with+Prostar+device+for+innovative+mitral+and+aortic+interventions.">Percutaneous femoral artery access with Prostar device for innovative mitral and aortic interventions.</a> European Journal of Cardiothoracic Surgery. 39 (4), 600-602 (2011).</li><li>Ramponi, F., Yan, T. D., Vallely, M. P., Wilson, M. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+percutaneous+cardiopulmonary+bypass+with+Perclose+ProGlide.">Total percutaneous cardiopulmonary bypass with Perclose ProGlide.</a> Interactive Cardiovascular and Thoracic Surgery. 13 (1), 86-88 (2011).</li><li>Sahin, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+PeRcutanEous+and+surgical+femoral+aCcess+for+endovascuLar+aOrtic+repair+in+patientS+with+typE+III+aortic+Dissection+(PRECLOSE+Trial).">Comparison between PeRcutanEous and surgical femoral aCcess for endovascuLar aOrtic repair in patientS with typE III aortic Dissection (PRECLOSE Trial).</a> Vascular. 29 (4), 616-623 (2020).</li><li>Malkawi, A. H., Hinchliffe, R. J., Holt, P. J., Loftus, I. M., Thompson, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+access+for+endovascular+aneurysm+repair:+a+systematic+review.">Percutaneous access for endovascular aneurysm repair: a systematic review.</a> European Journal of Vascular and Endovascular Surgery. 39 (6), 676-682 (2010).</li><li>Kastengren, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+vascular+closure+device+in+minimally+invasive+mitral+valve+surgery.">Percutaneous vascular closure device in minimally invasive mitral valve surgery.</a> The Annals of Thoracic Surgery. 110 (1), 85-91 (2020).</li><li>Ahmad, A. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+experiences+with+MANTA+vascular+closure+device+in+minimally+invasive+valve+surgery.">First experiences with MANTA vascular closure device in minimally invasive valve surgery.</a> The Thoracic and Cardiovascular Surgeon. 69 (5), 455-460 (2021).</li><li>Wood, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pivotal+clinical+study+to+evaluate+the+safety+and+effectiveness+of+the+MANTA+percutaneous+vascular+closure+device.">Pivotal clinical study to evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device.</a> Circulation. Cardiovascular Interventions. 12 (7), e007258 (2019).</li><li>De Palma, R., Settergren, M., R&#252;ck, A., Linder, R., Saleh, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+percutaneous+femoral+arteriotomy+closure+using+the+MANTATM+device+on+vascular+and+bleeding+complications+after+transcatheter+aortic+valve+replacement.">Impact of percutaneous femoral arteriotomy closure using the MANTATM device on vascular and bleeding complications after transcatheter aortic valve replacement.</a> Catheterization and Cardiovascular Interventions. 92 (5), 954-961 (2018).</li></ol>

The application of vascular closure devices for arterial CPB cannulation is a transcatheter technique that has the potential to improve outcomes in cardiac surgery is. Application of this technique in cardiac surgery procedures, and especially EMS valve surgery, has been adopted in specialized centers over recent years to avoid surgical cutdown and the exposure of groin vessels. ProStar and ProGlide systems are the most commonly used devices7,12. In a series of 300 patients who underwent MV MIS surgery with application of the ProStar device for arterial CPB cannulation, no postoperative bleeding complications were observed. However, in 1.6% of patients, bleeding events caused by the closure device were seen, retroperitoneal bleeding was seen in 0.6% of cases, and in 2.0% of patients, bleeding events necessitating surgical cutdown were observed. Similar results for the ProStar device have been reported by other authors7,12. For the ProGlide device, only small series of applications in EMS are documented13. The ProGlide device success rate is 92% to 95% in aortic procedures14,15.
In our first experience using this novel device, excellent results were documented, with a device success rate of 97.1%. In one patient, pull trough of the collagen plug occurred due to toggle release at the wrong height. Therefore, documentation of puncture depth is of paramount importance. When the initial puncture depth is not remembered, de novo determination of the puncture depth can be achieved after the puncture and removal of the arterial cannula. In cases of device failure, surgical cutdown can be conducted, and direct suturing of the femoral artery can be performed. In this case, manual compression of the femoral artery proximal to the puncture site is necessary for surgical cutdown. The device success rate is excellent and suggests ease of application, even when physicians are unfamiliar with the commercial system used in our protocol. Further advantages include the absence of suture material and the remaining extravascular stainless-steel lock, indicating the position of vessel entry in cases of re-interventions subsequent to later vessel complications. Although earlier studies suggest higher rates of vessel complications with this percutaneous device compared to surgical cutdown16,&#160;our series presented no postoperative vascular complications in terms of bleeding, wound healing disorders/seroma formation, or pseudoaneurysms. This is comparable to a previous study17, indicating that the described technique may simplify EMS. However, the results differ in TAVI, most likely due to application of the device in older patients with smaller and more calcified vessels18,19.
The treated patient cohort in this protocol presented with non-calcified vessels. Therefore, the results may differ in calcified vessels, as seen in TAVI procedures. Furthermore, no patient was randomized to a specific treatment, therefore hidden confounders may be apparent.

The gold standard for the treatment of primary, degenerative mitral regurgitation (MR) is surgical mitral valve (MV) repair. The efficacy of this approach has been proven in large clinical studies with conclusive long-term data1. Due to a large armamentarium of surgical techniques for MV repair, such as annuloplasty or the insertion of Gore-Tex neochordae, almost all pathologies of the MV are treatable. This includes complex circumstances like Morbus Barlow with prolapse of both MV leaflets, with proven safety and efficacy as well as excellent results up to 20 years2. Furthermore, the majority of isolated MV surgery in Germany is performed via minimally invasive approaches, like a right anterolateral minithoracotomy3. Also, concomitant tricuspid valve (TV) surgery is amenable by minimally invasive access, even in a beating heart fashion4,5.
Surgical cutdown to access groin vessels has traditionally been a routine procedure for the implementation of cardiopulmonary bypass (CPB). However, this approach inherits a certain risk of postoperative wound healing disorders or seroma formation6. The adaption of transcatheter techniques for fully percutaneous insertion of a cannula for the establishment of CPB has been described7,8, and this may reduce possible groin complications. Already used devices for percutaneous vessel closure in endoscopic mitral valve surgery (EMS) include suture-based systems7,8. Recently, a collagen plug-based vascular closure device was introduced for transcatheter heart valve procedures. This large bore closure device can be used for the closure of arterial access sites of up to 25 French (Fr.). Safety and efficacy of the system have previously been demonstrated in a real-world transcatheter aortic valve implantation (TAVI) patient cohort9. The first data of minimally invasive surgery (MIS) of the MV or TV utilizing this system for the closure of the femoral artery showed promising results regarding postoperative groin complications10.
We herein describe the fundamental steps of fully endoscopic mitral valve surgery, including percutaneous groin cannulation and decannulation using a novel vascular closure device. The fully endoscopic approach differs from the MIS non-endoscopic technique in terms of a very small thoracic incision (3-5 cm), avoidance of rib-spreading, and visualization of cardiac structures with an endoscope with no direct view of the heart.
This surgery can be performed on patients with significant heart valve regurgitation or stenosis of atrioventricular heart valves, who are suitable for cardiac surgery. Preoperative diagnostics include transthoracic/transesophageal echocardiography and computed tomography of the chest and iliac vessels in elderly patients or patients with a history of peripheral artery disease.

<table><tbody><tr><td>30&amp;deg; camera head</td><td>Aesculap Einstein Vision</td><td>PV 632</td><td></td></tr><tr><td>3D-HD camera&amp;nbsp;</td><td>Aesculap Einstein Vision</td><td>PV 630</td><td></td></tr><tr><td>Annuloplasty ring&amp;nbsp;</td><td>Edwards</td><td>93381</td><td></td></tr><tr><td>Aortic clamp</td><td>Cardio Vision</td><td>CV 195.10</td><td></td></tr><tr><td>Aterial Cannula</td><td>Medtronic</td><td>96570-121</td><td></td></tr><tr><td>Femoral Cannula</td><td>Metronic</td><td>96670-125</td><td></td></tr><tr><td>Full HD 3D Monitor</td><td>Aesculap Einstein Vision</td><td>PV 646</td><td></td></tr><tr><td>Giude wire</td><td>Merit Medica</td><td>6678-71</td><td></td></tr><tr><td>Heart valve retractor set</td><td>Cardio Vision</td><td>CV 100.00</td><td></td></tr><tr><td>LED light source</td><td>Aesculap Einstein Vision</td><td>OP 950</td><td></td></tr><tr><td>Manta</td><td>Teleflex Medical Inc.</td><td>2115</td><td></td></tr><tr><td>Neo chordae</td><td>Serag Wiesner</td><td>MCL14A</td><td></td></tr><tr><td>Soft Tissue Retractor</td><td>Cardio Vision</td><td>Cv100/80</td><td></td></tr><tr><td>Stative table arm for endoscopes</td><td>Cardio Vision</td><td>CV 281.73</td><td></td></tr><tr><td>Stative table arm for instruments</td><td>Cardio Vision</td><td>CV 281.72</td><td></td></tr><tr><td>Suture for fixing Loops</td><td>Gore-Tex Suture</td><td>4N02</td><td></td></tr></tbody></table>

fully endoscopic mitral valve repair with percutaneous cannulation of groin vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

In a preliminary patient cohort undergoing EMS and using this novel vascular closure device at our center, promising results were documented11. This cohort included 35 patients, with the most common accompanying diseases being arterial hypertension (10/35, 28.6%) and atrial fibrillation (9/35, 25.7%). Valve failure mechanisms included primary, degenerative MR (30/35, 85.7%), secondary, functional MR (3/35, 8.6%), and endocarditis (2/35, 5.7%). Concomitant procedures in MV MIS MV were tricuspid valve repair (6/35, 17.1%), ablation for atrial fibrillation (AF) (6/35, 17.1%), and left atrial appendage closure (8/35, 22.9%). For cannulation of the femoral artery, a 19 Fr. Cannula was most frequently utilized (25/35, 71.4%), followed by 21 Fr. cannula (9/35, 25.7) and a 17 Fr. cannula in one case. Isolated femoral vein cannulation was common (22/35, 62.9 %). In 13 patients, additional venous drainage was established via the jugular vein (13/35, 37.1%). With the commercial device presented in this protocol, success with immediate hemostasis was achieved in 34/35 cases (97.1%). In one patient, pull trough of the collagen plug occurred due to toggle release at the wrong height. Here, surgical cutdown was conducted and direct suturing of the femoral artery with immediate hemostasis was performed.
A 30 day follow-up presented no cases of death, stroke, myocardial infarction, or kidney injury. Permanent pacemaker implantation due to atrioventricular block was necessary in one case. A wound healing disorder occurred in one patient. Major bleeding, access site complications, or access site-related transfusion were not documented during the 30 day follow-up (see Table 1).
These results confirm that the described method of EMS is safe and effective for MV repair even in complex pathologies. The closure device is simple, easy to use, and provides immediate hemostasis, and therefore, has the potential to further simplify EMS and reduce groin wound healing disorders/seroma formation and potential durations of hospital stay.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64714/64716fig01.jpg" /> 
Figure 1: Collagen plug-based vascular closure device in the femoral artery. The device is fully inserted before closure of the femoral artery. The next steps include retrieval, adjustment of deployment depth, and advancing of the lock advancement tool. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64714/64716fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2"></td>
			<td>Study group (n = 35)</td>
		</tr>
		<tr>
			<td colspan="2">All-cause mortality (30 days), % (n)</td>
			<td>0.0 (0)</td>
		</tr>
		<tr>
			<td colspan="2">Stroke, % (n)</td>
			<td>0.0 (0)</td>
		</tr>
		<tr>
			<td colspan="2">Wound healing disorder (thoracotomy), % (n)</td>
			<td>2.9 (1)</td>
		</tr>
		<tr>
			<td colspan="2">Intensive care unit stay, days&#160;</td>
			<td>1.6&#177;0.9</td>
		</tr>
		<tr>
			<td colspan="2">Hospital stay, days</td>
			<td>11.2&#177;5.1</td>
		</tr>
		<tr>
			<td colspan="2">Bleeding, major/life threatening, % (n)</td>
			<td>0.0 (0)</td>
		</tr>
		<tr>
			<td colspan="2">Access site complications, % (n)</td>
			<td>0.0 (0)</td>
		</tr>
		<tr>
			<td colspan="2">Access site related transfusion, % (n)</td>
			<td>0.0 (0)</td>
		</tr>
	</tbody>
</table>
Table 1: Clinical outcome at 30 days after minimally invasive heart valve surgery using a collagen plug-based large bore closure device.

Watch this Scientific Journal Video about Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels at JoVE.com

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

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1.4K Views.  University Heart and Vascular Center Hamburg. This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step. 

Video: Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Full-root aortic valve replacement by stentless aortic xenograft is a viable option in patients with small aortic roots. We describe, a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses, and discuss its limitations and alternative options.

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg

Antegrade endoscopic harvesting of autografts for bypass grafting may be an optimal strategy addressing excellent graft quality and reduced post-operative wound complications. This standardized protocol for antegrade endoscopic vein harvesting (EVH) from the lower leg has the potential to be introduced to routine coronary artery bypass grafting (CABG). Patients undergoing CABG surgery are positioned on a surgical table with two additional foam rollers below the extended legs, enabling antegrade EVH from the lower leg. Following minimally invasive surgical access through a bridging vein harvest technique, an endoscopic optical dissector is inserted antegrade into the wound. The main vessel and side branches are dissected under continuous optical control of vein quality status and the working channel. After, an endoscopic optical retractor is inserted with an internal bipolar electrocoagulation device for precise, safe, and tissue-protective interruption of side branches. After release of the vein, the vessel is cut off at the proximal and distal ends under optical control, retrieved from the wound, then cannulated and flushed with heparinized saline. Finally, all side branches of the vein graft are double-clipped. Vascular histology is analyzed in a randomized selection of vein samples. After applying this standardized EVH protocol, the learning curve was shown to be steep, and graft quality was sufficient for coronary artery bypass grafting in every case. There was no conversion to surgical harvesting and low risks for tissue damage and bleeding. Leg positioning and synergizing EVH with bridging vein harvesting improved procedural success and vein graft quality. In our hands, antegrade EVH from the lower leg was feasible, demonstrating straightforward graft dissection as well as adequate macroscopic and microscopic graft quality with preserved endothelial integrity. In conclusion, the introduced technique is safe, shows excellent vein autograft quality, and illustrates feasibility for elective and urgent isolated CABG and combined CABG scenarios.

Presented here is a protocol for antegrade endoscopic vein harvesting from the lower leg, which can safely be introduced in routine coronary artery bypass grafting. Vein grafts present excellent graft quality following this standardized protocol with positioning of the legs, minimally invasive access to the vein, and antegrade endoscopic vein harvesting.

Antegrade endoscopic harvesting of autografts for bypass grafting may be an optimal strategy addressing excellent graft quality and reduced post-operative ...

An Image Guided Transapical Mitral Valve Leaflet Puncture Model of Controlled Volume Overload from Mitral Regurgitation in the Rat

Mitral regurgitation (MR) is a widely prevalent heart valve lesion, which causes cardiac remodeling and leads to congestive heart failure. Though the risks of uncorrected MR and its poor prognosis are known, the longitudinal changes in cardiac function, structure and remodeling are incompletely understood. This knowledge gap has limited our understanding of the optimal timing for MR correction, and the benefit that early versus late MR correction may have on the left ventricle. To investigate the molecular mechanisms that underlie left ventricular remodeling in the setting of MR, animal models are necessary. Traditionally, the aorto-caval fistula model has been used to induce volume overload, which differs from clinically relevant lesions such as MR. MR represents a low-pressure volume overload hemodynamic stressor, which requires animal models that mimic this condition. Herein, we describe a rodent model of severe MR in which the anterior leaflet of the rat mitral valve is perforated with a 23G needle, in a beating heart, with echocardiographic image guidance. The severity of MR is assessed and confirmed with echocardiography, and the reproducibility of the model is reported.&#160;&#160;

A rodent model of left heart volume overload from mitral regurgitation is reported. Mitral regurgitation of controlled severity is induced by advancing a needle of defined dimensions into the anterior leaflet of the mitral valve, in a beating heart, with ultrasound guidance.&#160;

Mitral regurgitation (MR) is a widely prevalent heart valve lesion, which causes cardiac remodeling and leads to congestive heart failure. Though the ...

A Novel Right Ventricular Volume and Pressure Loaded Piglet Heart Model for the Study of Tricuspid Valve Function.

Heart conditions in which the tricuspid valve (TV) faces either increased volume or pressure stressors are associated with premature valve failure. Mechanistic studies to improve our&#160;understanding of the underlying pathophysiology responsible for the development of premature TV failure are lacking. Due to the inability to conduct these studies in humans, an animal model is required. In this manuscript, we describe the protocols for a novel chronic recovery infant piglet heart model for the study of changes in the TV when placed under combined volume and pressure stress. In this model, volume loading of the right ventricle&#160;and the TV is achieved through the disruption of the pulmonary valve. Then pressure loading is accomplished through the placement of a pulmonary artery band. The success of this model is assessed at four weeks post intervention surgery through echocardiography, intracardiac pressure measurement, and pathologic examination of the heart specimens.

A novel recovery piglet heart model with combined pressure and volume overload on the right ventricle is described for the study of tricuspid valve function.

Heart conditions in which the tricuspid valve (TV) faces either increased volume or pressure stressors are associated with premature valve failure. ...

A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral regurgitation in patients with high surgical risk. Echocardiographic guidance in addition to fluoroscopy is the gold standard and should be performed using a standardized technique.
This article lays out our reproducible step by step echocardiographic guide including views, measurements as well as highlighting possible difficulties that may arise during the procedure.
This article provides detailed and chronological echocardiographic views for each step of the procedure, especially preferences between 2D and 3D imaging. If needed, pulse wave, continuous wave and color doppler measurements are described. Furthermore, as there are no official recommendations for the quantification of mitral regurgitation during the percutaneous edge-to-edge-repair procedure, advice is also included for echocardiographic quantification after grasping the mitral leaflets and after device deployment. In addition, the article deals with important echocardiographic views to prevent and deal with possible complications during the procedure.
Echocardiographic guidance during transcatheter mitral valve repair is mandatory. A structured approach improves the collaboration between interventionist and imager and is indispensable for a safe and effective procedure.

This protocol presents in detail how to perform real-time echocardiographic guidance during transcatheter mitral valve repair. The fundamental views and the necessary measurements are described for each stage of the procedure.

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral ...

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP),&#160;remains a significant cause of morbidity and mortality worldwide if left untreated.&#160;Therapies for the treatment of RV shock range&#160;from medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.

The present protocol provides a detailed description of a percutaneous dual lumen right ventricular assist device and illustrates step-by-step instructions on the safe implanting, managing, and removing the device. Guidance on its use and troubleshooting complications from one of the most significant single-center experiences is also included.

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and ...

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted in&#160;sheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

This study demonstrates the feasibility and safety of developing an autologous pulmonary valve for implantation at the native pulmonary valve position by using a self-expandable Nitinol stent in an adult sheep model. This is a step toward developing transcatheter pulmonary valve replacement for patients with right ventricular outflow tract dysfunction.

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow ...