Initial experience of minimally invasive triple valve surgery in a developing country

Abstract

BACKGROUND

Minimally invasive cardiac surgery for multivalvular heart disease remains technically demanding, particularly in resource-limited settings. Evidence regarding minimally invasive triple valve surgery (TVS) is scarce, especially from developing countries.

AIM

To evaluate the feasibility and early outcomes of minimally invasive concomitant TVS in a developing country.

METHODS

Four consecutive patients with severe multivalve pathology underwent minimally invasive cardiac surgery double valve replacement with tricuspid valve repair via a right mini-thoracotomy approach. Perioperative data, technical challenges, and short-term outcomes were analyzed.

RESULTS

All patients [mean age: 33 years (range 16-41), all male] underwent successful procedures. Mean cardiopulmonary bypass time was 257.5 minutes (range 200-320), and aortic cross-clamp time was 149 minutes (range 114-195). No intraoperative complications occurred. Postoperative ventilation time averaged 5.7 (range 3-12) hours, ICU stay 1.25 (range 1-2) days, and hospital stay 5.5 (range 4-8) days. One patient has postoperative atrial fibrillation. There were no mortalities at 30 days. Postoperative echocardiography showed well-seated prosthetic valves and competent tricuspid valves in all cases.

CONCLUSION

Minimally invasive concomitant TVS is feasible and safe in selected patients, even in resource-limited settings.

Key Words: Minimally invasive cardiac surgery; Rheumatic heart disease; Multiple valve disease; Triple valve surgery; Developing country

Core Tip: Minimally invasive triple valve surgery is rarely reported, particularly in developing countries with limited resources. This retrospective study presents the early experience with concomitant minimally invasive aortic and mitral valve replacement, combined with tricuspid valve repair, via a right mini-thoracotomy. Despite prolonged operative times, the procedure demonstrated excellent early outcomes, no mortality, and rapid postoperative recovery. These findings support the feasibility of minimally invasive multi-valve surgery in carefully selected patients, even in resource-constrained environments.

INTRODUCTION

Triple valve disease involving significant pathology of the aortic, mitral, and tricuspid valves represents a challenge for surgeons owing to the prolonged cardiopulmonary bypass and myocardial ischemic times, with a reported operative mortality of 2.5% to 25%[1].

Since its inception in 1996, the performance of minimally invasive valve surgery has grown significantly[2-4]. The benefits of minimally invasive valve surgery are well recognized when compared with a standard median sternotomy, in terms of reduced surgical trauma, less blood loss, decreased need for transfusions, lower incidence of postoperative pain, shorter hospital stays, and faster return to normal activities[3,5-7].

While the application of MICS to single- and double-valve procedures is well established. Few data are available on the treatment of triple valve disease with a minimally invasive approach, although the benefits of minimally invasive cardiac surgery have been well recognized[8-10].

This retrospective study aims to contribute to the growing body of literature on minimally invasive TVS by presenting the experiences of four patients who underwent this complex procedure for diverse underlying etiologies. We detail the preoperative assessment, surgical techniques employed, postoperative course, and short-to-long term outcomes for each patient, demonstrating the versatility and potential benefits of a minimally invasive approach in managing triple valve disease.

MATERIALS AND METHODS

Study design and patient selection

This study was designed as a retrospective observational study conducted at the Cardiovascular and Kidney Transplantation Center, Taiz University, Taiz, Yemen. Between May and August 2025, four consecutive, selected patients underwent minimally invasive concomitant TVS consisting of aortic valve replacement, mitral valve replacement (MVR), and tricuspid valve repair (TVr).

During the same study period, three additional patients with triple valve disease underwent conventional median sternotomy. These patients were elderly, high-risk patients with reduced LVEF and multiple comorbidities, and were therefore not considered suitable candidates for a minimally invasive approach. The minimally invasive cohort consisted of younger patients with preserved or moderately reduced ventricular function and no history of prior cardiac surgery. Rheumatic heart disease is endemic in Yemen, and all patients in this series had valve pathology consistent with chronic rheumatic involvement, which explains the high prevalence of multivalvular disease in this patient population.

Preoperative assessment

All patients underwent comprehensive preoperative evaluation, including transthoracic and transesophageal echocardiography (TEE) to assess valve pathology, ventricular function, pulmonary pressures, and the presence of intracardiac thrombus. Functional status was classified according to the New York Heart Association classification. Routine laboratory investigations and coronary angiography were performed when indicated.

Anesthesia and patient positioning

All procedures were performed under general anesthesia with double-lumen endotracheal intubation to allow right lung deflation. Standard invasive monitoring was used, including peripheral arterial and central venous access. TEE was routinely employed intraoperatively. Patients were positioned supine with a slight elevation of the right hemithorax using a small roll beneath the right scapula. The right arm was gently abducted to optimize surgical exposure. The chest and right groin were prepared and draped in a sterile fashion.

Cardiopulmonary bypass and peripheral cannulation

Peripheral cardiopulmonary bypass was established via femoral vessel cannulation before chest incision. The right femoral artery and vein were exposed through a 2-3 cm transverse groin incision. Venous cannulation was performed using the Seldinger technique under TEE guidance, with advancement of a multistage venous cannula into the superior vena cava. Arterial cannulation of the femoral artery was performed following systemic heparinization. An additional superior vena cava cannula was used when necessary to optimize venous drainage.

Surgical approach and operative technique

The right minithoracotomy is performed through a 5-7 cm incision in the 3^rd intercostal spaces (ICS) at 2-4 cm from the sternal edge. at the level of the third ICS. Generally, in men, the incision could be made either above or below the nipple, while in a female, the preferred incision site is the inframammary fold. Then, one small (5 mm) opening is placed in the 2^nd ICS at the level of the anterior axillary line, and it is used for aortic cross-clamping (Chitwood clamp) and pericardial stay sutures. The second opening (5 mm) is placed in the 5^th ICS in the anterior-axillary line, and it is used for the vent suction and pericardial stay sutures.

A soft tissue retractor is then inserted into the right minithoracotomy, and a rib-spreader is often used. With lungs gently deflated, the pericardium is opened 2-3 cm above the phrenic nerve, taking care not to injure it; then 2-0 silk stay sutures are placed and passed through the pericardial opening to obtain a better visualization of the operative field.

When the cardiopulmonary bypass (CPB) is started, a combined Y-shape vent/cardioplegia catheter is placed in the ascending aorta, and the aorta is clamped. For aortic cross-clamping, we use an external Chitwood clamp. The cardioplegia is delivered into the aortic root as a single dose/shot (20 mL/kg) of cold Custodial solution.

The sequence of valve procedures was standardized in all patients. The aortic valve was addressed first through a transverse aortotomy, with excision of the native valve and annular decalcification. MVR was subsequently performed via right atriotomy and trans-septal approach using dedicated minimally invasive retractors. After mitral valve implantation, the aortic prosthesis was seated and secured, followed by closure of the aortotomy. The interatrial septum was closed with continuous polypropylene sutures (Figure 1A and B).

Figure 1 Intraoperative photographs. A: Exposure of the mitral valve via intra-atrial septal approach through right atriotomy; B: Exposure of the aortic valve via transverse aortotomy; C: Tricuspid valve repair using a pericardial strip (black arrow), illustrating pericardial strip annuloplasty technique for functional tricuspid regurgitation; D: Right mini-thoracotomy incision site, highlighting the minimally invasive surgical access.

Finally, the tricuspid valve was exposed through the right atrium and repaired using a pericardial strip annuloplasty in all cases (Figure 1C). Associated procedures, including left atrial appendage plication and left atrial thrombus removal, were performed when indicated. The main operative steps are demonstrated in Video 1.

After rewarming and de-airing, CPB is stopped. The venous femoral cannula is removed first, then the femoral artery after testing protamine sulphate. Manual compression of the cannulation site for 5minutes is enough to obtain adequate hemostasis.

Finally, two 28-Fr, 32-Fr chest drains are placed through the two openings of pervious aortic clamp and the cardiac vent. The pericardium is closed with 2-3 single sutures. The minithoracotomy incision is then closed in anatomical layers (Figure 1D).

Postoperative management and follow-up

Postoperative care followed standard institutional protocols. All patients receiving mechanical valve prostheses were anticoagulated with warfarin, targeting an international normalized ratio of 2.5-3.5, with low-molecular-weight heparin bridging until a therapeutic international normalized ratio was achieved. Clinical and echocardiographic follow-up was performed during hospitalization and at outpatient visits. The pre and post operative echo are demonstrated in Figure 2.

Figure 2 Echocardiographic findings. A-C: Preoperative echocardiogram demonstrating severe multivalvular disease with restricted leaflet motion and regurgitation; D-F: Postoperative echocardiogram showing well-functioning prosthetic valves and a competent tricuspid valve, confirming successful surgical outcome.

RESULTS

A total of four consecutive patients underwent minimally invasive double valve replacement (aortic and mitral) with concomitant TVr via a right anterolateral thoracotomy approach. All patients were male, with a mean age of 33 years (range 16-41 years). The predominant preoperative functional status was New York Heart Association class II in two patients and class III in the remaining two. Mean left ventricular ejection fraction (LVEF) was 50.23% (range 42.9%-61%).

The underlying pathology involved complex multivalvular disease with varying degrees of mitral stenosis/regurgitation, aortic stenosis/regurgitation, and tricuspid regurgitation in all cases.

Mean aortic cross-clamp (ACC) time was 149 minutes (range 114-195), and mean CPB time was 257.5 minutes (range 200-320). Mechanical prostheses were used for all mitral and aortic valve replacements: ATS medical mechanical valve or St. Jude medical valves for the mitral position (sizes 27-29 mm) and ATS medical mechanical valve or St. Jude medical valves for the aortic position (sizes 19-21 mm). TVr was performed using the pericardial strip technique in all cases. Tow patient also had LAA plication, one patient had left atrium thrombus removal (Table 1).

Table 1 Preoperative characteristics and operative data of patients undergoing triple valve surgery.

Characteristic	Patient 1	Patient 2	Patient 3	Patient 4
Age (years)	35	41	16	40
Sex	Male	Male	Male	Male
NYHA class	II	II	III	III
LVEF (%)	42.9	47	50	61
Pathology (AS/AR/MS/MR/TR)	MS, MR, AS, AR, TR	MS, MR, AS, AR, TR	MR, MS, AR, AS, TR	MS, MR, AS, AR
ACC time (minute)	195	114	117	170
CPB time (minute)	320	200	270	240
MVR valve (type/size mm)	ATS, 28	SJM, 29	SJM, 27	SJM, 29
AVR valve (type/size mm)	ATS, 20	SJM, 21	SJM19	SJM, 21
TVr technique	Pericardial strip	Pericardial strip	Pericardial strip	Pericardial strip
Association procedure	LAA plication and LA thrombus removal	No	LAA plication	No

NYHA: New York Heart Association; LVEF: Left ventricular ejection fraction; AS: Aortic stenosis; AR: Aortic regurgitation; MS: Mitral stenosis; MR: Mitral regurgitation; TR: Tricuspid regurgitation; ACC: Aortic cross-clamp; CPB: Cardiopulmonary bypass; MVR: Mitral valve replacement; AVR: Aortic valve replacement; TVr: Tricuspid valve repair; ATS: ATS medical mechanical valve; SJM: St. Jude medical mechanical valve; LAA: Left atrial appendage; LA: Left atrium.

Postoperative outcomes

All patients were extubated within a mean of 5.7 hours (range 3-12 hours) and transferred from the intensive care unit after a mean stay of 1.25 days (range 1-2 days). Mean total hospital stay was 5.5 days (range 4-8 days). One patient has post-operative atrial fibrillation (Table 2). The mean clinical follow-up duration was 3.5 months (range 2-6 months). No valve-related complications, thromboembolic events, or reoperations were observed during the follow-up period.

Table 2 Postoperative outcomes of patients undergoing triple valve surgery.

Outcome	Patient 1	Patient 2	Patient 3	Patient 4
Ventilation time (hour)	12	4	3	4
ICU stay (hour)	47	25	22	23
Hospital stays (days)	8	4	5	5
Postoperative complication	None	Postoperative atrial fibrillation	Pericardial effusion (mild-moderate)	None
Transfusion (units)	Intraoperative: 2 whole blood, 3 platelets, 3 FFP	Intraoperative: 1 PRBC, 1 FFP	Intraoperative: 1 PRBC, 1 FFP	Intraoperative: 2 PRBC
	Postoperative: 1 PRBC, 1 whole blood		Postoperative: 1 PRBC
30-day mortality	None	None	None	None

PRBC: Packed red blood cells; ICU: Intensive care unit; FFP: Fresh frozen plasma.

The favorable early outcomes observed in this cohort should be interpreted in the context of young patient age and relatively low operative risk, which likely contributed to the absence of mortality and major postoperative complications.

DISCUSSION

This study describes the initial experience with minimally invasive concomitant TVS at a tertiary cardiac center in a developing country. The findings demonstrate that minimally invasive aortic and MVR combined with TVr can be performed safely in carefully selected patients, even within a resource-limited environment. MICS offers advantages over conventional sternotomy, including reduced morbidity, shorter hospitalization, and faster recovery, and is well established for isolated mitral and aortic valve procedures[11,12]. However, its role in combined double-valve or tricuspid valve surgery remains less defined due to the limited global experience and scarce outcome data[13].

Our patients presented with advanced multivalvular disease; a pattern commonly seen in low-resource environments due to late referrals. Despite the high operative risk historically associated with multiple valve surgery - mortality rates of 10% for mitral - tricuspid, 11% for mitral-aortic, and 13.2% for aortic-tricuspid procedures[14,15]. TVS is a complex procedure, with traditional mortality rates reported around 13%, though this is a challenging procedure with high variability in outcomes, but detailed data specifically for minimally invasive TVS mortality is still limited[16]. Our series achieved zero 30-day mortality.

The relatively young mean age of our patients (33 years) is an important consideration when interpreting the results. In Yemen, rheumatic heart disease is endemic and frequently results in advanced multivalvular pathology at a younger age, contributing to the age profile of our cohort. Careful patient selection was critical to the success of this series; during the same study period, elderly patients with reduced LVEF and significant comorbidities underwent conventional sternotomy and were not considered suitable candidates for a minimally invasive approach. Younger patients with relatively preserved ventricular function generally tolerate prolonged CPB and ACC times better, which likely contributed to the absence of mortality and the low incidence of postoperative complications observed in this study.

When compared with previously published series (Table 3), our outcomes appear favorable, even in the context of longer operative times. Lio et al[13] reported a series of 69 patients, of whom 12 (17.4%) underwent TVS, with no operative mortality, a stroke incidence of 2.9%, and permanent pacemaker implantation in 4.3%. Similarly, Elmahdy et al[17] described six high-risk elderly patients who underwent minimally invasive TVS, noting a 30-day mortality rate of 33% and two cases of postoperative atrial fibrillation. In another series, Moront et al[18] reported on 18 patients undergoing minimally invasive TVS, with zero mortality and only manageable complications, including neurologic events and the need for pacemaker implantation.

Table 3 Comparison of minimally invasive multi-valve surgery outcomes.

Ref.	Number of patients	Age (year), mean ± SD	Procedure type	Cross-clamp time (minute)	CPB time (minute)	ICU stay (days)	Hospital Stay (days)	30-Day Mortality	Major complications1
Lio et al[13]	12	66 ± 12	AVR + MVR + TVr	95 ± 32	135 ± 41	NR	NR	0%	Stroke 29%, PPM 4.3%
Elmahdy et al[17]	6	76.7 ± 5.4	AVR + MVR + TVr	136 (IQR 119-188)	185 (IQR 145-231)	2.58 (62 hours)	12 (IQR 7-23)	33% (2 patients)	Post-op AF 2 patients
Moront et al[18]	18	Not reported	AVR + MVR + TVr	NR	NR	1.22 (IQR 1.16-1.31)	9 (IQR 6-17)	0%	Neurologic 2, AKI 2, PPM 5
Current our Series	4	33	MVR + AVR + TVr	149	257.5	1.25	5.5	0%	Post-op AF one patients

¹Major complications include re-exploration for bleeding, stroke, acute kidney injury, postoperative atrial fibrillation, or permanent pacemaker implantation.

CPB: Cardiopulmonary bypass; ICU: Intensive care unit; AVR: Aortic valve replacement; MVR: Mitral valve replacement; TVr: Tricuspid valve repair; IQR: Interquartile range; NR: Not reported; AF: Atrial fibrillation; AKI: Acute kidney injury; PPM: Permanent pacemaker.

The cardiopulmonary bypass and ACC times in this series were longer than those reported in larger studies (Table 3)[13]. These extended operative times can be attributed to the complexity of triple valve pathology, the use of mechanical prostheses in all valve positions, and the learning curve associated with the initial adoption of minimally invasive multi-valve surgery. Despite this, postoperative recovery was rapid, with short ventilation times, brief ICU stays, and early hospital discharge.

TVr was performed using a pericardial strip annuloplasty in all patients. This technique was selected due to its effectiveness, simplicity, and practicality in a resource-limited setting where commercially available annuloplasty rings may not always be accessible[19,20]. Early postoperative echocardiography demonstrated satisfactory tricuspid valve competence in all cases.

Our experience adds to the growing body of evidence indicating that complex minimally invasive TVS can be safely performed in developing countries with appropriate patient selection and meticulous surgical technique. However, the present study is limited by its small sample size, retrospective design, and short follow-up period; therefore, larger studies with extended follow-up are required to assess long-term outcomes, valve durability, and the broader applicability of this approach.

CONCLUSION

Minimally invasive concomitant TVS is feasible and safe in selected patients, even in resource-limited settings. This approach offers potential benefits of reduced morbidity and faster recovery in this complex patient cohort.

ACKNOWLEDGEMENTS

The authors would like to thank the surgical, anesthesia, perfusion, and nursing teams at the Cardiovascular and Kidney Transplantation Center, Taiz, Yemen, for their support and contribution to patient care. The authors also sincerely acknowledge the independent biostatistical review for its valuable evaluation and verification of the statistical methods used in this study.