CONGRESS ABSTRACT

Objective: We present a case of a 18 years old girl with Marfan syndrome presented with severe mitral regurgitation (MR) in a degenerative Barlow disease with prolapse of both leaflets. Methods: Chest X-rays showed a severe kyphoscoliosis combined with a pectus excavatum. The patient refused full sternotomy for psychological and cosmetic reasons. Pulmonary function test showed a restrictive syndrome with hypercapnia and normal oximetry at rest. A 3D rendering CT-scan assessed the feasibility of a minithoracotomy (MT) approach: by rotating the 3D scan surgeons and radiologists realized that the only available option was the access of the 3rd intercostal (IC) space, inserting the 3D endoscope in the 2nd one. An accurate valve analysis was obtained with transoesophageal echocardiography (TEE) that revealed a Barlow valve with multi-scallops prolapse more evident at the level of A2 and P2 segments. A 3D mixed and augmented reality (AR) software was used to examine further chest and mitral valve anatomy before surgery. A percutaneous clip was excluded because of the young age and the complexity of lesions, whereas the surgical treatment was suggested as the best solution due to the necessity to preserve and repair the valve, in spite of a difficult surgical access. Results: A single endotracheal intubation and a femoral cannulation with single venous cannula were performed. A MT was performed in the 3rd IC space and a 10 mm 3D endoscope was inserted in the 2nd IC space port; the aorta was directly cross clamped and the anterograde cardioplegia was delivered. The left atrium was hidden by the vertebrae and its opening was possible with the help of two stay sutures above the right atrium. After positioning the left atrial retractor, we realized that a direct mitral valve (MV) vision was impossible: we could analyze and correct the multi scallop prolapse only through the endoscopic visualization. MV repair was performed by the insertion of 2 pairs or PTFE artificial chords on anterior and posterior leaflets and a complete prosthetic ring. TEE showed a good coaptation and no MR. Conclusions: Due to anatomical complex chest deformity and a Barlow MV, a multi-specialist team approach was fundamental to assess the appropriate surgical access with a dedicated 3D CT scan and AR analysis. A specific endoscopic expertise and a 3D full HD platform were mandatory to achieve a MV repair via small right MT with inadequate direct vision in a minimally invasive approach.