title: Techniques and results of direct-access minimally invasive mitral valve surgery: a paradigm for the future.
abstract: OBJECTIVE
  Our objective was to determine whether direct-access minimally invasive mitral valve surgery can improve recovery and cost while maintaining the efficacy of conventional surgery.
  
  
  METHODS
  Minimally invasive mitral valve operations were performed on 106 patients, 58% male, average age 58.1 years, with good ventricular function. Ninety underwent repair of a regurgitant, myxomatous valve, and 16 underwent mitral valvuloplasty for prematurely calcified mitral stenosis. The valve was approached with standard instruments through a 5- to 8-cm right parasternal incision. Eighty-five had open femoral artery-femoral vein cannulation, but this technique has recently been replaced by direct cannulation of the aorta and percutaneous cannulation of the femoral vein for most patients.
  
  
  RESULTS
  There were no operative deaths. The mean mitral regurgitation score (0-4) decreased from 3.7 to 0.7 after the operation. Although ischemic and bypass times were increased, postoperative recovery was accelerated. Ventilatory support time, intensive care unit stay, hospital stay, need for rehabilitation, and return to "normal activities" all improved. Hospital charges, pain medications, and blood transfusions were also reduced. New atrial fibrillation contributed significantly to increased length of stay and charges. There were no deep wound infections. Other complications included re-exploration for bleeding (n = 1), transient ischemic attacks (n = 2), stroke (n = 1), femoral artery injury (n = 5), pseudoaneurysm (n = 2), and antegrade dissection of the ascending aorta (n = 1). Two patients died and 1 required reoperation during a mean follow-up of 8.8 months.
  
  
  CONCLUSIONS
  Direct-access minimally invasive mitral valve surgery can accelerate recovery, decrease charges, and decrease pain, while maintaining overall surgical efficacy. It has become our standard approach for isolated primary mitral valve operations.
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: L
authors.initials: L
authors.lastname: Aklog
authors.forename: D H
authors.initials: DH
authors.lastname: Adams
authors.forename: G S
authors.initials: GS
authors.lastname: Couper
authors.forename: R
authors.initials: R
authors.lastname: Gobezie
authors.forename: S
authors.initials: S
authors.lastname: Sears
authors.forename: L H
authors.initials: LH
authors.lastname: Cohn
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002114:Calcinosis / Q000191:economics / Q000601:surgery; D006328:Cardiac Catheterization / Q000191:economics / Q000295:instrumentation; D003363:Cost Control; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000191:economics / Q000295:instrumentation*; D008944:Mitral Valve Insufficiency / Q000191:economics / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000191:economics / Q000601:surgery*; D011183:Postoperative Complications / Q000191:economics / Q000601:surgery; D012086:Reoperation; D016896:Treatment Outcome