MMCTS
(September 14, 2009). doi:10.1510/mmcts.2008.003608
Copyright © 2009 European Association for Cardio-thoracic Surgery
Procedure
Endoscopic robotically-assisted mitral valve repair
Tomislav Mihaljevica,*,1,
A. Marc Gillinova,1,
Craig Jarretta,
Lynn Setoa,1,
Robert Savageb and
Pierre DeVilliersb
a Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue/J4-1, Cleveland, OH 44195, USA
b Department of Cardiothoracic Anesthesia, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue/J4-1, Cleveland, OH 44195, USA
* Corresponding author: Corresponding author. Tel.: +1-216-444 0648; fax: +1-216-636 1260. mihaljt{at}ccf.org
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Summary
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Robotic surgical instrumentation allows minimally invasive mitral valve repair through an endoscopic approach, eliminating the need for a thoracotomy. Robotic instruments are inserted through port-like incisions in the right hemithorax, while cardiopulmonary bypass is established via cannulation of the femoral vessels. We describe triangular resection, a simple and reproducible robotically-assisted technique for repair of posterior leaflet prolapse. The repair is completed with insertion of an annuloplasty ring.
Key Words: Minimally invasive surgical procedures • Mitral valve • Mitral valve prolapse
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Introduction
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Minimally invasive approaches for repair of myxomatous mitral valve (MV) disease have shown excellent results while offering a lesser degree of invasiveness than traditional operations performed through full sternotomies [1, 2]. Initial series of minimally invasive operations were conducted through partial sternotomies or limited right thoracotomies with conventional or long-shafted instruments. Introduction of robotic surgical instrumentation and high-definition three-dimensional imaging allows MV repair through port-like incisions, with further reduction in procedural invasiveness [3]. Although the safety and efficacy of this approach have been well documented, broader acceptance has been limited due to the higher cost and perceived complexity of the procedure [4, 5, 6]. We describe a reproducible and simplified approach to endoscopic robotically-assisted MV repair.
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Surgical technique
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After induction of general anesthesia, the patient is intubated with a double-lumen endotracheal tube and a transesophageal echo probe is placed. A detailed assessment of MV anatomy and function is performed to determine the cause and severity of mitral regurgitation (MR) (Video 1). A retrograde coronary sinus catheter is placed percutaneously via the internal jugular vein and positioned under echo guidance. Bilateral arterial lines are needed if endoaortic balloon technology is to be employed for aortic occlusion and cardioplegia delivery.
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Video 1 Transesophageal echo: severe mitral regurgitation caused by flail of the mid segment (P2) of the posterior leaflet.
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Patient positioning
The patient is positioned with the right side of the chest slightly elevated with a roll caudal to the right scapula (Photo 1). The right arm is suspended along the right side of the operating table allowing exposure of the right axilla (Photo 2). The femoral vessels are exposed through a small skin incision superior and parallel to the inguinal crease. The vessels have to be of an appropriate size ( 7 mm) and free of atherosclerosis. Once the femoral vessels are deemed suitable for cannulation, the robotic port incisions are made. First, the camera port is placed in the fourth intercostal space 2–3 cm lateral to the mid-clavicular line. After inspecting the intrathoracic anatomy and assuring correct geometry and alignment for optimal visualization of the valve, a 2-cm working port is made in the same interspace several centimeters lateral to the camera port. The port for the left robotic arm is placed through the third intercostal space 2–3 cm anterior to the anterior axillary line. The port for the right robotic arm is placed in the fifth or sixth intercostal space slightly anterior to the mid-axillary line. The port for the dynamic left atrial retractor is placed through the fourth or the fifth intercostal space in the mid-clavicular line (Schematic 1 and Photo 3).
Cannulation, cardiopulmonary bypass and myocardial protection
The femoral venous cannula (Edwards Lifesciences, Irvine, CA) is positioned in the superior vena cava under echo guidance (Photo 4). A separate SVC cannula is utilized only if venous drainage is inadequate; this cannula is placed by changing the previously placed right internal jugular line over a wire. Arterial cannulation is accomplished via the femoral artery (Schematic 2 and Photo 5). It is mandatory that the artery is of appropriate size and without evidence of atherosclerosis.
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Photo 4 Bicaval transesophageal view showing classic railroad tracks of the venous cannula correctly positioned into the SVC.
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Schematic 2 Overview of cannulation showing femoral venous and arterial cannulas, retrograde coronary sinus catheter and endo-balloon.
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Once cardiopulmonary bypass is instituted, the pericardium is incised 2–3 cm anterior to the right phrenic nerve and suspended with two silk sutures inserted through the fourth and fifth intercostal spaces in the posterior axillary line (Video 2).
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Video 2 Opening of pericardium.
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The aortic endoballoon is used in patients with normal size of the ascending aorta (<4 cm), no evidence of atherosclerosis, and no evidence of aortic regurgitation. Correct positioning is ensured with the use of transesophageal echo and monitoring of bilateral brachial artery pressures (Video 3).
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Video 3 Transesophageal echo: correct positioning of aortic endoballoon and delivery of antegrade cardioplegia.
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In patients with enlargement of the ascending aorta or aortic regurgitation, a transthoracic aortic cross-clamp is used (Video 4). In this instance, a separate antegrade cardioplegia catheter is inserted in the proximal ascending aorta (Schematic 3 and Video 5). Myocardial protection is accomplished with the combination of antegrade and retrograde cardioplegia. In addition, all patients undergo moderate hypothermia (30 °C).
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Video 4 Placement of transthoracic aortic cross-clamp.
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Video 5 Insertion of direct antegrade cardioplegia catheter.
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Exposure, inspection and repair of the mitral valve
A limited left atriotomy is performed after dissection of the interatrial groove. The dynamic left atrial retractor is inserted and the atriotomy extended to a degree that allows complete exposure of the MV (Video 6).
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Video 6 Left atriotomy.
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Inspection of the MV shows a flail P2 segment of the posterior leaflet. The flail segment is resected in a triangular fashion to the level of the annulus (Video 7).
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Video 7 Valve inspection and partial leaflet resection.
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The leaflet edges are then re-approximated with figure-of-eight 4-0 Prolene sutures (Video 8).
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Video 8 Leaflet repair.
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The repair is completed with the insertion of a partial flexible annuloplasty ring using running 2-0 non-absorbable suture. Sutures are placed on the outer surface of the ring to prevent ring crimping. Competency of the valve is confirmed by administration of antegrade cardioplegia or saline test (Video 9).
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Video 9 Valve annuloplasty.
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The left atrium is closed using a running Gore-Tex suture. Prior to securing the suture line, the heart is gently volume loaded and ventilation of the left lung is performed to de-air the left atrium (Video 10).
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Video 10 Closure of left atriotomy.
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The success of the repair is verified before undocking the robot (Video 11).
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Video 11 Transesophageal echo: successful repair.
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Once the operation is completed, the patient is left with a 2-cm incision, which was made for the working port, and four subcentimeter incisions. The chest tube is inserted through the incision made for the right robotic arm (Photo 6).
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Photo 6 Completed operation: the largest incision, which was used for the working port, is 2 cm in length.
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Results
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At the beginning of our experience, we performed the operations via a limited anterolateral thoracotomy. Gradual conversion to a total endoscopic approach occurred over approximately 30 operations.
From 1 December 2006 to 31 December 2008, 402 robotically-assisted MV repairs were performed at our institution (Graph 1). Of those, there were 148 cases of MV repair for degenerative MR using the aforementioned technique of triangular resection and annuloplasty only. In this cohort, there was no hospital mortality and MV repair was accomplished in >99% of patients. The conversion rate was 3%. Most conversions were due to suboptimal myocardial protection or the inability to acquire adequate peripheral cannulation because of small or diseased femoral vessels. No failures of the robotic surgical system occurred. After repair, >98% of patients in the cohort had MR of  1+ on intraoperative transesophageal echo. Median ICU length of stay and operative length of stay for this cohort were 25 h and 4 days, respectively.
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Discussion
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Robotically-assisted MV repair is a novel and unique approach for the treatment of myxomatous MV disease [3, 4, 5, 6]. Besides the novelty of improved surgical instrumentation and visualization that allows conduction of the operation through port-like incisions, robotic cardiac surgery is a true team effort. The safety and success of the surgery depend on the well-coordinated execution of the operative plan by the console surgeon and the bedside team. The use of simplified techniques for MV repair, such as triangular resection and insertion of an annuloplasty ring using a running mattress suture, expedites the surgery while preserving excellent short- and long-term clinical outcomes [7]. We prefer partial flexible annuloplasty bands for repair of degenerative MR, although we routinely use complete rings for robotic repair of functional MR. We believe that the stepwise approach described in this article can lead to increased adoption of robotically-assisted MV repair.
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Footnotes
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1 Disclosures: Dr. Mihaljevic is a consultant for Intuitive Surgical, St. Jude Medical and Edwards Lifesciences. Dr. Gillinov is a consultant for Edwards Lifesciences, St. Jude Medical, receives research support from St. Jude Medical and Medtronic and has equity in Viacor. Dr. Seto receives speakers honoraria from Edwards Lifesciences. 
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References
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- Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: mini-sternotomy with extended transseptal approach. Semin Thorac Cardiovasc Surg 1999;11:206–211.[Medline]
- Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations: early and late results. Ann Surg 2004;240:529–534; discussion 534.[Medline]
- Mohr FW, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, Jacobs S, Autschbach R. Computer-enhanced "robotic" surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001;121:842–853.[Abstract/Free Full Text]
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- Suri RM, Schaff HV, Dearani JA, Sundt TM III, Daly RC, Mullany CJ, Enriquez-Sarano M, Orszulak TA. Survival advantage and improved durability of mitral valve repair for leaflet prolapse in the current era. Ann Thorac Surg 2006;82:819–826.[Abstract/Free Full Text]
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Summary
Introduction
