Table 2

Contraindications for minimal access mitral surgery

ContraindicationImplications for mini mitral surgeryMethods to circumvent
Prior right chest surgery or radiationPatients are at increased risk due to pleural adhesionsPreoperative CT scan can allow for operative planning with specific adjuncts and techniques to avoid damage to major structure50
Severe peripheral atherosclerosis or chronic peripheral arterial occlusive disease. Descending aorta aneurysm, aortic dissection, aortic thrombus.Peripheral cannulation for CPB can be particularly challenging for these patientsAlternate routes of cardiopulmonary bypass to be considered or full sternotomy
Prominent ascending aorta calcifications or ascending aorta aneurysm/dilation (>4.5 cm)Aortic clamping and antegrade cardioplegia administration are challenging in these patientsConsider endo-balloon or percutaneous mitral valve repair
Moderate to severe aortic regurgitation (AR)Difficulties with cardioplegia administrationConventional sternotomy
Significant chest wall deformity (particularly severe pectus excavatum)Challenging access to all intrathoracic structuresConventional sternotomy
Severe mitral annular calcificationExtensive decalcification of the mitral annulus and reconstruction with a pericardial patch is very challenging through a minimal invasive approachConventional sternotomy or percutaneous mitral valve replacement