Mitral Valve Surgery: Current Minimally Invasive and Transcatheter Options

The mitral valve is a highly complex structure, the competency and function of which relies on the harmonious action of its component parts. Minimally invasive cardiac surgery (MICS) for mitral valve repair or replacement (MVR/r) has been performed successfully with incremental improvements in techniques over the past decade. These minimally invasive procedures, while attractive to patients and referring physicians, should meet the same high bar for optimal clinical outcomes and long-term durability of valve repair as traditional sternotomy procedures. The majority of MICS MVR/r procedures are performed via a right minithoracotomy approach with direct or camera-assisted visualization, with a minority of centers performing robotic MVR/r. Outcomes with MICS MVR/r have been shown to have similar morbidity and mortality rates as traditional sternotomy MV procedures but with the advantage of reduced transfusions, postoperative atrial fibrillation, and time to recovery. More recently, transcatheter mitral valve repair and replacement (TMVR/r) has become a reality. Percutaneous MV repair technology is currently FDA approved for patients with nonsurgical high-risk degenerative mitral regurgitation. Other TMVR/r technology is at various levels of preclinical and clinical investigation, although these devices are proving to be more challenging compared to transcatheter aortic valve replacement (TAVR) due to the significantly more complex mitral anatomy and the greater heterogeneity of mitral disease requiring treatment. In this article, we review current techniques for MICS MVR/r and upcoming catheter-based therapies for the mitral valve.