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 pledgetreinforced 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.