The echocardiogram of a 43-year-old male with progressive New York Heart Association (NYHA) class III symptoms confirmed severe degenerative mitral valve regurgitation due to a posterior leaflet chordal rupture (Figure 1A). He underwent an aortic vascular ring correction at the age of 1 year through a left thoracotomy and sustained a subsequent per-manent left recurrent laryngeal nerve paralysis. Our institutional multidisciplinary team favored surgical mitral valve intervention and additional investiga-tions, which included coronary and aorta-iliac axis angiography, thoracic computerized tomography, electrocardiography, and lung function tests; these were all uneventful. The Haller Index (defined as the transverse thoracic and minimum sternovertebral diameter ratio8) and the Correction Index (described as the indentation depth as a percentage of the maximum sternovertebral diameter9) were 3.1 and 33.9%, respectively, as determined by the preopera-tive chest computerized tomography (Figure 1B).
Perioperative and Procedural Images of Staged Endoscopic Mitral Valve Repair and Pectus Excavatum Correction Surgery
The patient elected to have a staged endoscopic assisted Nuss and mitral valve procedure with a cal-culated EuroSCORE II of 3.46. The minimally inva-sive PE correction was performed first. Intraopera-tive sternocostal defect measurements and Nuss bar preparation (Biomet, 36 cm, Wilrijk, Belgium) fol-lowed routine double lumen endotracheal intuba-tion and endoscopic camera port placement (5.5 mm, Olympus, Hamburg, Germany) in the fourth intercostal space, mid-axillary line. The pre-shaped Nuss bar was positioned through a right 2.5 cm anterior-axillary line incision after an introducer de-vice and tape created an endoscopically guided retro-sternal tract to the left hemithorax. A stabilizing metal plate anchored the bar on the right, and resorbable sutures secured the bar through a 2 cm incision on the left. The camera port facilitated the insertion of an intrathoracic drain (Redon CH 8, PMF Medical, Köln, Germany), and the patient was transferred to intensive care for routine analgesia and monitoring after uneventful intraoperative extubation.
Our MI-AVVS technique is well described10 and was performed after an interprocedural time inter-val of 3 days. Routine cardiac anesthesia, which in-cluded single-lung ventilation, was followed by trans-esophageal echocardiographic-guided cannulation of the right internal jugular vein (18Fr, Optisite™, Edwards Lifesciences, Irvine, CA, USA), femoral vein (25Fr, Quickdraw™, Edwards Lifesciences), and right femoral artery cannula (23Fr, Endoreturn™, Edwards Lifesciences). An endo-aortic balloon (IntraClude™, Edwards Lifesciences) was used for aortic occlusion and cold antegrade crystalloid car-dioplegia delivery. The camera port used in the PE correction was re-utilized as a 4 cm working port in the fourth anterior-axillary intercostal space, with easy visualization of the Nuss bar and cardiac structures. The left atrial retractor was positioned in the right parasternal fourth intercostal space. The initiation of cardiopulmonary bypass and subsequent endo-aortic balloon occlusion were uneventful, and access to the mitral valve was unrestricted and easily established. Systematic valve analyses concurred with preoperative imaging findings, and a successful endoscopic mitral valve repair was performed (Fig-ure 1C) using long-shafted instruments that consist-ed of annular ring implantation (CE Physio II™, size 40, Edwards Lifesciences), quadrangular resection of the prolapsing P2 segment, and neochordal attachment of the posterior leaflet to the posterior-medial papillary muscle (Gore-Tex™, Gore & Asso-ciates Inc., Phoenix, AZ, USA). Deairing was en-sured by a venting catheter in the left atrium, ante-grade balloon catheter venting, and transesophageal echocardiogram surveillance for residual air in the left ventricle. Cardiopulmonary bypass and ischemic times were 164 min and 97 min, respectively, with extubation achieved 6 hours postoperatively.
Rapid patient recovery resulted in home dis-charge after 14 days despite urgent re-intubation for acute airway obstruction related to his premorbid laryngeal nerve paralysis on the second postopera-tive day following cardiac surgery. Predischarge echocardiography confirmed a satisfactory mitral valve repair and the absence of any residual mitral valve regurgitation. Follow-up at 6 weeks revealed excellent clinical, cosmetic, radiological, and echo-cardiographic recovery (Figure 1D).