Preoperative Planning of Transapical Beating Heart Mitral Valve Repair for Safe Adaptation in Clinical Practice

Objective: Transapical off-pump minimally invasive mitral valve repair (TOP-MINI) is a new technique for the surgical repair of degenerative mitral regurgitation based on mitral valve prolapse. The aim of this study is to demonstrate the preoperative planning tools available for starting this new procedure in a safe manner. Methods: The first patients undergoing TOP-MINI by a single surgeon in 2016 were prospectively included. All patients underwent identical clinical pathways and underwent extensive preoperative planning for a safe start of the program. Patients were discussed in our dedicated mitral valve heart-team consisting of diagnostic and interventional mitral valve specialists. All patients underwent computed tomography, transthoracic and transesophageal echocardiography, and mitral valve replication using rapid prototyping. All procedures were performed by the same surgical team. Results: Thirty-six patients were discussed for isolated mitral valve repair in our dedicated mitral valve heart team of which seven patients were deemed eligible for this novel approach. Three-dimensional (3D) reconstructions of computed tomography images allowed the surgical team to determine skin incision level and ideal level of device insertion near the apex of the heart. Echocardiography and rapid prototyping allowed us to assess surgical success probability by determining the amount of tissue overlap and was used intraoperatively for guidance. All patients were operated on successfully, without any major adverse events. Conclusions: We demonstrate a method to safely start the TOP-MINI program with precise patient selection and preoperative planning, allowing us to determine procedural strategy and assessment of surgical success probability.