Sir Laurence Olivier as Hamlet (1948); transthoracic aortic clamp; endoballoon.
Central Message.
During endoscopic mitral surgery, endoballoon is an excellent alternative to transthoracic clamp without the need for intrafield clutter, additional access sites, and ascending aortic dissection.
“Leaders honor their core values, but they are flexible in how they execute them.”
—Colin Powell, 65th US Secretary of State (2001-2005)
See Article page 84.
Drs Chitwood and Bates have given us an excellent summary of the 2 primary techniques used for aortic clamping in minimally invasive mitral valve surgery.1 While there is little we can add to this analysis, we can offer additional insight into the conclusions. We wholeheartedly agree that as cardiac surgeons begin their minimally invasive mitral experience with a minithoracotomy, an external clamp is the most logical and safest approach. As their experience evolves and the trauma of rib spreading is sought to be avoided, the endoballoon technique offers advantages, as it obviates another interspace incision and frees the field from the clutter of a cardioplegia needle in the ascending aorta and the attendant necessity of aortic suturing. Likewise, even the most arduous reoperative surgery becomes manageable and possibly even straightforward by avoiding the necessity of “digging out an aorta” to provide access for an external clamp.
The cardiac surgeon's core value is to perform a safe, technically excellent mitral valve repair or, if necessary, replacement. As one develops a credible minimally invasive and robotic experience, the use of an endoballoon provides another option that will, depending upon the clinical situation, add benefit for the patient. Nevertheless, the endoballoon is not to be used sparingly nor infrequently, since it is an acquired skill set. Instead, it should be a reliable part of the surgeon's armamentarium, permitting maximal flexibility in executing the best operation for a given patient.
Footnotes
Disclosures: Dr Eugene A. Grossi has intellectual property and receives royalties from Medtronic for valve repair devices and has intellectual property and receives royalties from Edwards Lifesciences. Dr James reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Reference
- 1.Bates M.J., Chitwood W.R. Minimally invasive and robotic approaches to mitral valve surgery: transthoracic aortic crossclamping is optimal. J Thorac Cardiovasc Surg Tech. 2021;10:84–88. doi: 10.1016/j.xjtc.2021.09.034. [DOI] [PMC free article] [PubMed] [Google Scholar]