World Journal of Cardiovascular Surgery, 2013, 3, 152-153 http://dx.doi.org/10.4236/wjcs.2013.35031 Published Online September 2013 (http://www.scirp.org/journal/wjcs) Minimally Invasive Valve Surgery via Right Mini-Thoracotomy: Technical Aspects to Facilitate Prosthetic Valve Insertion * Mohammed Hassan 1# , Tomas A. Salerno 2 , Jimmy Windsor 3 , Marco Ricci 1 1 Division of Cardiothoracic Surgery, University of New Mexico Health Science Center, Albuquerque, USA 2 Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA 3 Department of Anesthesiology, University of New Mexico Health Science Center, Albuquerque, USA Email: # MHassan@salud.unm.edu Received July 17, 2013; revised August 15, 2013; accepted August 29, 2013 Copyright © 2013 Mohammed Hassan et al. This is an open access article distributed under the Creative Commons Attribution Li- cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Mitral and tricuspid valve surgery is increasingly being performed through a right mini-thoracotomy approach. Al- though valve repair is preferred over replacement whenever possible, valve replacement may be required in certain pa- tients. In situations where the mitral or tricuspid anatomy are unfavorable and exposure is difficult, seating a prosthetic valve in the annulus through a right mini-thoracotomy approach may be difficult, compared to conventional sternotomy approach. This is complicated by limited tactile feedback in the minimally invasive approach. Herein, we describe sev- eral simple maneuvers that facilitate proper prosthetic valve seating and visualization of the posterior annulus during minimally invasive valve operations via right mini-thoracotomy. Keywords: Mitral Valve Surgery; Minimally Invasive Mitral Valve Surgery; Techniques in Mitral Valve Surgery 1. Introduction Mitral and tricuspid valve operations are increasingly performed through a right mini-thoracotomy approach [1-3]. Although valve repair remains the preferred option over replacement, in some situations mitral or tricuspid prosthetic valve replacement may be required [3]. In conventional valve operations through a sternotomy ap- proach, prosthetic valve insertion and seating in the na- tive valve annulus are easily accomplished as the surgeon has broad direct visual and tactile feedback. Conversely, in minimally invasive valve replacement through a right mini-thoracotomy approach, exposure and tactile feed- back are limited. In situations where exposure of the mi- tral or tricuspid annulus is unfavorable, maintaining the prosthetic valve seated during knot tying and verifying proper seating particularly at the level of the posterior valve annulus may be difficult. Improper positioning of the valve prosthesis may result in longer ischemic time due to the need of placing additional repair sutures or repair paravalvular leaks. Herein, we describe several simple maneuvers that facilitate proper prosthetic valve seating and visualization of the posterior annulus during minimally invasive valve operations via right mini-tho- racotomy. 2. Surgical Technique After a right mini-thoracotomy through the fourth inter- costal space is performed, exposure of the mitral or tri- cuspid valve is obtained by opening the respective atrial chamber. The operative details of the operations as they relate to cardiopulmonary bypass strategy and exposure of the valve have been well described previously [4]. If valve replacement is needed in the setting of mitral or tricuspid valve surgery, we prefer to use annular sutures with the pledgets placed on the atrial side, as this facili- tates confirmation of proper apposition of the annulus to the sewing ring of the valve after the valve is implanted. Following insertion of the sutures through the annulus of the valve (mitral or tricuspid), the sutures are passed though the sewing ring of the prosthesis, and the prosthe- sis is glided down into the native annulus. The valve han- dle is released. At this stage, especially if a tissue valve is used, proper orientation of the struts and proper insertion of the prongs of the prosthesis through the annulus is * The authors have no disclosures in relation to this research. # Corresponding author. Copyright © 2013 SciRes. WJCS