Minimally invasive heart valve surgeries are surgeries that use smaller incisions than the ones typically used to operate on the heart valves. During a minimally invasive heart valve surgery, the breastbone is not completely divided and retracted. Rather, surgeons use a variety of smaller incisions to gain access to the heart.

There are a number of advantages to minimally invasive heart surgery. Chief among them are limited blood loss during surgery, fewer side effects associated with large incisions, a reduced stay in the hospital and superior cosmetic results as patients are spared the large incisions and scars typically associated with open-heart surgery.

However, these surgeries may take longer and often require a surgeon with a higher level of surgical skill. Not all people are good candidates for this type of surgery. For example, people may not be eligible if they have atherosclerosis (hardening of the arteries) or obesity.

Like all patients scheduled for surgery, people scheduled for a minimally invasive heart valve surgery must avoid eating and drinking anything for at least eight hours before the procedure. Smokers must avoid smoking for at least two weeks beforehand. After surgery, patients can expect to remain in the hospital for four to five days, and full recovery may take several weeks.

Minimally invasive heart valve surgeries are surgical techniques that use smaller incisions, compared to traditional open-heart surgery, when repairing or replacing a defective heart valve. The actual surgical repair is the same in the minimally invasive and the traditional procedures. However, minimally invasive surgery involves a much smaller incision to enter the chest and then the heart. There is also a difference in how long the surgeries take, with the minimal procedures usually taking longer because of their higher level of complexity.

The types of valvular heart disease that can be repaired by minimally invasive surgery include valves that have narrowed (stenosis) or valves that do not close properly and allow blood to leak back in the wrong direction (regurgitation).

Most commonly, minimally invasive techniques for valve surgery are performed on one of the following valves:

• Mitral valve. Located between the upper-left chamber (left atrium) and the lower-left chamber (left ventricle) of the heart.
  
  
• Aortic valve. Located between the left ventricle and the aorta (the main artery carrying oxygen-rich blood from the heart to the rest of the body).

All minimally invasive heart valve surgeries rely on cardiopulmonary bypass with a heart-lung machine. By contrast, minimally invasive bypass surgery can be performed with or without bypass. This means that minimally invasive valve surgery carries all the risks associated with the heart-lung machine (e.g., blood clots, confusion). However, by relying on smaller incisions, minimally invasive valve surgery offers a few advantages, including:

• Limited blood loss during surgery
• Reduced hospitalization
• Reduced chance of infection from large incisions
• Less scarring

Because it is more complicated than standard open-heart surgery, not all patients are suitable candidates for this surgical technique. People with conditions such as “hardening of the arteries” (atherosclerosis) or obesity (body mass index greater than 30) may not be eligible. Additionally, the minimally invasive technique is generally best for a single, isolated valve disorder instead of multiple forms of valvular heart disease, and high-risk elderly patients may not be suitable candidates.

Minimally invasive techniques in heart surgery have been in full use only since the late 1990s, and different forms are still being tested. For example, one experimental procedure, known as percutaneous heart valve implantation, allows a physician to replace a heart valve using a balloon catheter and a stent. The stent is inserted into the femoral artery through a puncture in the skin in the groin. The replacement valve is then threaded through the artery to the heart via the stent. Once in the heart, the stent is expanded, allowing the physician to implant the replacement valve. Early research has shown the procedure may be a good option for patients in need of an aortic valve replacement who are not able to undergo open-heart surgery because of poor overall health or life-threatening conditions.

Another strategy involves a voice-activated robot, which performs much of the operation under the direction of a surgeon who is viewing, and performing, the operation through an endoscope (a slim optical tube positioned in the chest cavity). The robot’s “hands” are smaller than human hands and require a smaller incision. Robotic visualization techniques are considered to be safe and reliable, causing less pain to the patient, less surgical trauma and a shortened recovery time. Robotically assisted surgery has been used for mitral valve repairs with good results. It is available only in limited centers around the world.

Eight hours before surgery, all patients are placed on NPO (non per os; nothing by mouth) status. That means they are not permitted to eat, drink or take anything by mouth until after their surgery. Smokers will have been advised to completely avoid smoking for at least two weeks before their surgery to prevent problems in breathing, reduce secretions and facilitate necessary coughing. Certain medications may need to be reduced or stopped temporarily, so patients should discuss their medication schedules with their cardiologist before surgery.

Immediately before surgery, the patient will be given specific pre-operative medications and then prepped for surgery. First, the chest area is shaved. Next, the surgical team provides a sterile environment by swabbing the patient’s chest with an antiseptic solution and covering the patient in sterile surgical drapes. An intravenous (I.V.) line will also be started, usually in the forearm or back of the hand.

The patient is then given a sleep-inducing medication through the I.V. line. The patient will continue to breathe a mixture of oxygen and anesthetic gas (general anesthesia) to make sure he or she remains asleep throughout the entire surgery.

After the patient is asleep, a device called the Swan-Ganz catheter is often inserted into the jugular vein in the neck and threaded to the pulmonary artery (which goes from the heart to the lungs). The catheter can be used to give medication, measure the oxygen levels in the blood and measure pressures in the heart. A breathing tube (endotracheal tube) will also be inserted into the mouth and down the windpipe (trachea) to maintain an airway.

There are a variety of incisions the physician might use to gain access to the heart. The choice of incisions depends on the valve being operated on. The physician might use a:

• “J” incision, which is made just below the collarbone or near the manubrium, the upper part of the breast bone (sternum).
  
  
• “T” incision, which is made by partially separating the sternum and is often used for patients undergoing a second valve replacement or who have had bypass surgery previously.
  
  
• Partial rib removal, which involves removing the cartilage portion of the second or third ribs.
  
  
• Right thoracotomy, or small incision in the side of the chest.

In general, these incisions will be relatively small (3.5 to 6 inches long) as opposed to the 11- to 12-inch incision that is standard in traditional open-heart surgery.

The heart will be stopped for the surgery and drained of blood. However, working through smaller incisions, the physician may not be able to use the heart-lung machine in a conventional manner. In this case, a special port-access technique is available that was developed specifically for minimally invasive cardiac surgery. In this technique, the blood is routed through small “ports” in the skin, and the heart-lung machine is often utilized via the femoral artery in the leg or aorta in the chest. The heart is worked on through small “ports” with specialized instruments. The port-access technique may also be combined with endoscopic procedures, in which the physician performs the surgery with fiberoptic endoscopes that are inserted through small incisions in the chest to further reduce the size of the incisions.

Once the surgeon has gained access to the heart, the damaged valve can be replaced or repaired. After the procedure is completed, the heart incision is closed and the heart is restarted. When the surgical team is satisfied that the heart is beating strongly again, the heart-lung machine is removed and the chest incisions are closed. The patient will spend only about five nights in the hospital, and full recovery is expected within several weeks.

After surgery, the patient will be transferred to a cardiac intensive care unit, where he or she will be monitored continually. Once the patient is awake and able to breathe independently, the breathing tube and respirator are removed. Painkillers may be administered, blood samples will be taken and electrocardiogram (EKG) monitors will continuously record the electrical activity of the heart. Reports from physicians and patients indicate that painkiller use is lower after a minimally invasive procedure than an invasive one.

Barring any unforeseen complications, an individual will typically spend four or five days in the hospital before being discharged. The cardiologist will discuss further medical treatment, including the use of pain medications, antibiotics and medications that reduce the risk of blood clot formation anticoagulants. The physician will also update any medications that the patient had already been taking.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to minimally invasive heart valve surgery:

1. Do you think that I am a good candidate for minimally invasive heart valve surgery?
   
   
2. What sort of risks will I be exposed to during minimally invasive heart valve surgery?
   
   
3. What, specifically, will you be trying to correct with the surgery?
   
   
4. Why do you recommend minimally invasive heart valve surgery over open-heart surgery?
   
   
5. Will I need to prepare for the surgery in any special way? Will I need to quit smoking?
   
   
6. Am I currently taking any medications that might interfere with the success of the surgery?
   
   
7. How long do you expect my recovery to take? Will I have to stay in the hospital?
   
   
8. Are there any activities that I should not engage in prior to the surgery, such as sports or sex? Will I be able to engage in these activities following a successful procedure?
   
   
9. Will I need any additional therapy or surgery following this procedure?
   
   
10. Is it safe to undergo minimally invasive heart valve surgery if I am pregnant? Could this type of procedure impact my ability to have children in the future?