title: New innovative instruments facilitate both direct-vision and endoscopic-assisted mini-mitral valve surgery.
abstract: OBJECTIVE
  The efficacy of new, innovative, original instruments, including a left atrial retractor, silicon annuloplasty ring sizer, modified Cosgrove aortic clamp, and reusable clip for fixing knots of polytetrafluoroethylene (Gore-Tex; WL Gore & Associates, Inc, Flagstaff, Ariz) suture, to allow surgical exposure in an ideal operative setting of mini-mitral valve repair surgery was verified.
  
  
  METHODS
  Since 1998, a great deal of innovation has contributed to establishing mitral valve repair via right minithoracotomy as a routine surgical approach for mitral valve insufficiency in 252 cases. During the last 2 years, a newly launched left atrial retractor system attachable to the minithoracotomy spreader has been used. An additional retractor for the posterior wall of the left atrium was attached to the minithoracotomy spreader. The retractor moves flexibly and can be fixed in any favorable position to realize optimal exposure of the mitral valve. A 5 blade size was available depending on the left atrial size and target legion. By using the smallest size, even papillary muscles were exposed easily and clearly. Furthermore, a flexible silicon ring sizer, which could easily pass thorough a narrow working port without tissue damage, was used for sizing the annuloplasty ring. For the surgical technique, multiple chordal reconstructions by the loop technique with polytetrafluoroethylene (Gore-Tex CV-5 sutures) were applied. A reusable clip for fixing knots made it easy to tie the Gore-Tex suture in the correct position without slipping.
  
  
  RESULTS
  No operative mortality occurred. There were 2 conversions to sternotomy for correction of aortic dissection (1) and for coronary artery bypass grafting (1). There were 2 early reoperations for failure of mitral valve repair. The mean aortic crossclamp time was 163.5 ± 41.6 minutes. Annuloplasty with a ring or band was performed in all cases except one. The loop technique was used in 173 cases. Among them, a combination of the loop technique and resection and suture technique was used in 56 cases.
  
  
  CONCLUSIONS
  Newly innovated mini-mitral valve surgical instruments and techniques facilitate both direct-vision and endoscopic-assisted approaches and accomplish a favorable surgical outcome even in the complex pathology of mitral valve insufficiency.
authors: Department of Cardiovascular Surgery, Keio University, Tokyo, Japan.
authors: Ryohei
authors: R
authors: Yozu
authors: Kazuma
authors: K
authors: Okamoto
authors: Mikihiko
authors: M
authors: Kudo
authors: Hidenori
authors: H
authors: Nonaka
authors: David H
authors: DH
authors: Adams
mesh_terms: D000328:Adult; D000368:Aged; D019723:Endoscopes; D004724:Endoscopy / Q000009:adverse effects / Q000295:instrumentation*; D004867:Equipment Design; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000295:instrumentation*; D009519:New York City; D012086:Reoperation; D056346:Sternotomy; D013908:Thoracotomy / Q000009:adverse effects / Q000295:instrumentation*; D016896:Treatment Outcome