The Periareolar Approach in Minimally Invasive Surgical Mitral Valve Repair—A Feasible, Safe, and Cosmetically Appealing Technique: A Report on 64 Patients

Objective: Minimally invasive surgical MV repair (MIS-MV repair) is becoming widely accepted. Besides superior cosmetic results, patients enjoy earlier return to activity, fewer wound infections and faster recovery. MIS-MVRepair entails peripheral CPB and a right-anterolateral minithoracotomy. In this study we report our results of a “periareolar approach”: via a convex incision that straddles the right areolar border (±3cm), we gained access to the heart through the 4th intercostal space without traumatic rib-spreading and aiming for an optimal cosmetic result.

Methods: From 11/2015–08/2017 we performed MIS-MVRepair utilizing the periareolar-approach in 64 patients. Indications were moderate to severe MR and left-atrial-myxoma. Surgery was performed through full-3D endoscopy. Aortic X-clamping was achieved using the Intra-Aortic-Occlusion Device (Edwards Lifesciences). Analyzed data: procedure times, conversion to MV replacement, sternotomy, postoperative pulmonary herniation, MACCE, hospital stay and overall survival. To assess cosmetic result a battery of patient questionnaire tests was utilized: Vancouver Scar Scale (VSS), Manchester Scar Scale (MSS), Patient Scar Assessment Scale (PSAS), Dermatology Quality of Life Index (DQLI) and Stony Brook Scar Evaluation Scale (SBSES).

Results: MV repair was performed in 62 patients (97%), and involved ring annuloplasty. A leaflet repair was performed in addition to annuloplasty in 42 patients (66%); no patients underwent MV replacement. Of the 62 patients, 9 received cryoMAZE ablation (14%), 4 patients underwent PFO closure (7%) and 2 patients had the tricuspid valve repaired concomitantly (3%). Two patients underwent myxoma resection only (3%). Mean procedure time, CPB and X-clamp time was 171, 112 and 68 minutes, respectively. No patients needed their periareolar incision converted to a minithoracotomy or sternotomy. No postoperative pulmonary herniation or MACCE occurred. Mean hospital stay was 6.5 days and overall survival was 100%.

Conclusion: The periareolar-approach is safe, efficient and cosmetically appealing. Compared with the conventional minithoracotomy for MIS-MVR, this technique has proved to be feasible and allows MV repair through an elegant incision without rib-spreading. SAS scores suggest that this technique for MIS-MVR delivers patient-satisfying results.