Beating Heart Mitral Valve Surgery via Right Thoracotomy: A Case Series and Technical Considerations

Mitral valve surgery is traditionally performed under cardioplegic arrest with aortic cross-clamping. However, in selected high-risk or redo cases, on-pump beating heart mitral valve surgery may represent a valuable alternative strategy. We report two patients who underwent minimally invasive beating heart mitral valve interventions via right thoracotomy. The first patient was a 62-year-old male with severe mitral regurgitation and a mobile mass on the posterior leaflet following previous coronary artery bypass grafting. The second patient was a 67-year-old male presenting with paravalvular leakage after prior mitral valve replacement. Both procedures were performed under normothermic cardiopulmonary bypass with continuous CO₂ insufflation, high-flow perfusion, and careful left heart decompression to minimize the risk of air embolism. In the first case, mitral valve replacement was successfully performed with a mechanical prosthesis after excision of the mobile mass. In the second case, the paravalvular defect was repaired with pledget-reinforced sutures. Postoperative echocardiography confirmed satisfactory valve function and complete resolution of regurgitation in both patients. The postoperative course was uneventful; however, early renal replacement therapy was initiated in the first patient due to pre-existing chronic kidney disease. These cases highlight the feasibility of minimally invasive beating heart mitral valve surgery in selected complex scenarios. Careful attention to technical considerations, such as maintaining a competent aortic valve, continuous venting, high-flow bypass, and CO₂ insufflation, may help reduce the risk of complications.

Keywords: Cardiopulmonary bypass, minimally invasive surgery, mitral valve replacement, reoperation.