Endoscopic treatment of hypertrophic obstructive cardiomyopathy performed via a transmitral approach through a right-sided mini-thoracotomy

The patient was positioned supine with the right chest slightly elevated. Following induction of general anaesthesia and intubation using an endotracheal tube, connection to the cardiopulmonary bypass was established via the groin vessels under the guidance of transoesophageal echocardiography. Additionally, a venous cannula was inserted through the right internal jugular vein to facilitate bicaval cannulation. The surgery was performed via a 5 cm right mini-thoracotomy at the fourth intercostal space. After soft tissue retraction and pericardial traction sutures, a 3D camera port (Aesculap EinsteinVision, Germany) and a Chitwood clamp for aortic cross-clamping were inserted through separate incisions. Antegrade cold blood cardioplegia was administered via a catheter in the ascending aorta. The surgery involved several steps. For the 1st step, transatrial approach to the mitral valve through Waterston's groove was used. After that transmitral approach to the interventricular septum and submitral structures of the left ventricle was performed. Next step was septal myectomy and secondary chordae resection to the mitral valve. Finally, the anterior mitral valve leaflet reattachment to the annulus was done.