MULTIMEDIA MANUAL OF
doi:10.1093/mmcts/mmu022 published online 1 November 2014.
MMCTS
CARDIO-THORACIC SURGERY
Robot-assisted mitral valve repair: surgical technique, outcomes and perspective Khaled D. Algarnia,b, Rakesh M. Surib,* and Richard C. Dalyb King Saud University, Riyadh, Saudi Arabia Mayo Clinic, Rochester, MN, USA
a
b
*Corresponding author. Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +1-507-2557067; fax: +1-507-2557378; e-mail: [email protected] (R.M. Suri). Received 24 July 2014; revised 1 September 2014; accepted 22 September 2014
Summary Robot-assisted mitral valve repair represents the least invasive surgical approach currently available for anatomical mitral valve repair in patients with myxomatous mitral valve disease. Standard mitral valve repair techniques utilized during conventional sternotomy/right thoracotomy are exactly replicated with robotic instrumentation through 1–2 cm port-like incisions, affording superior 3D visualization. The procedure is currently performed using cardiopulmonary bypass employing peripheral cannulation of the femoral vessels/right internal jugular vein. The ascending aorta is occluded with a transthoracic aortic cross-clamp. Antegrade cardioplegia is delivered centrally into the aortic root through a cardioplegia vent catheter. By replicating conventional mitral valve repair done via an open sternotomy approach, the quality of mitral valve repair is ensured while providing the patients with advantages of less invasive surgery including shorter hospital stay, rapid recovery and return to normal activities, less blood transfusion, superior cosmesis and complete elimination of sternotomyrelated morbidities such as deep sternal wound infection and sternal dehiscence. A significant reduction in operative duration with experience and diminished resource utilization over time has been observed. Keywords: Robotic assisted • Mitral repair • Minimally invasive
INTRODUCTION Surgical repair of mitral valve is recommended as Class I indication in patients with symptomatic chronic severe primary mitral regurgitation (MR). Surgery is also indicated in asymptomatic patients with evidence of left ventricular (LV) dysfunction (left ventricular ejection fraction [LVEF] 60% and left ventricular end systolic dimension [LVESD] 95% with an expected mortality rate of 450 s, full cardiopulmonary bypass is initiated while monitoring the descending thoracic aorta by TEE to confirm normal flow and the absence of a dissection flap. Patient temperature is allowed to drift to 34°C. The pericardiotomy is extended cranially over the ascending aorta towards the pulmonary artery. A 3.0 polypropylene purse-string suture with a felt pledget is placed in the ascending aorta. The previously placed cardioplegia tack is inserted through the purse-string and snared into place (Video 2). The transthoracic clamp is inserted through the chest wall as high and posterior as possible in the right axilla to avoid conflict with the left robotic arm. The aorta is cross-clamped, taking care to avoid injury of the right pulmonary artery and left atrial appendage. The heart is arrested with 1 l of cold blood high potassium cardioplegia, which is repeated every 20 min throughout the cross-clamp time (Video 3).
Mitral valve exposure and valve analysis The left atriotomy is carried out posterior to the interatrial groove allowing a sufficient cuff on the anterior surface of the right pulmonary veins to permit closure. The robotic left atrial retractor is positioned and the mitral valve is analysed (Video 4).
Leaflet repair and annuloplasty band Our philosophy is that the highest quality mitral valve repair techniques with proven durability should not be altered to facilitate performance of the operation through small incisions. We therefore employ exactly the same standard techniques of mitral valve repair regardless of the surgical approach as previously
Video 3: Transthoracic aortic cross-clamp.
Video 4: Exposure of the mitral valve.
published [17, 18]. We do not advocate the acceptance of inferior results that would be considered suboptimal in an open operation merely to facilitate the performance of robotic mitral valve repair. For posterior leaflet disease, we typically perform standard triangular resection with two-layer running polypropylene reconstruction (Video 5). For anterior leaflet prolapse, we use artificial chords with polytetrafluoroethylene (Gore-Tex; W.L. Gore & Associates, Inc., Flagstaff, AZ, USA). Patients with bileaflet prolapse undergo prolapse correction utilizing a combination of these techniques (Videos 6 and 7). Repair adjuncts include commissural or leaflet plication, leaflet shortening/ventricularisation and posterior leaflet neochord placement - all of which are employed as indicated. All repairs are supported with a standard length 63 mm posterior annuloplasty band inserted in the standard manner with 2.0 Ethibond interrupted sutures between left
K.D. Algarni et al. / Multimedia Manual of Cardio-Thoracic Surgery
Video 5: Repair of the posterior leaflet of the mitral valve.
Video 6: Repair of the anterior and posterior commissures.
4
Video 8: Posterior annuloplasty band insertion.
Video 9: Testing of the mitral valve repair and left atriotomy closure.
which the pericardium is closed, and a 32-F right pleural chest tube is positioned in the posterior thorax is and secured in place. Incisions are closed in the standard manner.
RESULTS
Video 7: Repair of the anterior leaflet prolapse with artificial chords.
and right fibrous trigones that are tied by the bedside surgeon (Video 8). Once the repair is tested with saline insufflation and found to be perfect, the left atrium is closed with running 3.0 Prolene sutures starting at both ends of the left atriotomy and the sutures are tied in the middle (Video 9). After deairing of the left heart, the aortic cross-clamp is removed. The patient is separated from cardiopulmonary bypass (CPB) and TEE is performed to assess the adequacy of the repair. CPB full flow is temporarily resumed for safe removal of the cardioplegia/vent tack and tying of the stitch. Decannulation and reversal of heparin are then performed following which, meticulous haemostasis is ensured. A 19-F soft silicone (Blake; Ethicon) pericardial drain inserted through the oblique sinus after
We have previously published our results of robotic mitral valve repair [9, 13–16]. In summary, we reviewed the first consecutive 200 patients undergoing robotic mitral valve repair at Mayo Clinic Rochester between 24 January 2008 and 28 January 2011 [16]. Successful mitral valve repair was completed in all patients, which was confirmed with intraoperative and pre-dismissal TEE. This series included the full spectrum of unselected degenerative mitral valve disease, encompassing all prolapse categories (posterior, anterior and bileaflet prolapse). Concomitant procedures included a left-sided ablation procedure in 5 (2.5%) patients and an atrial septal defect or patent foramen ovale closure in 12 (6.0%) patients. There were no early (30-day) deaths. One patient suffered a stroke (0.5%). One patient required reoperation for bleeding (0.5%). Two patients (1%) required reoperation for recurrent MR, one due to dehiscence of the annuloplasty band on postoperative day 30 and the second who had new anterior leaflet chordal rupture and underwent successful robot-assisted mitral valve re-repair on postoperative day 2. These 2 cases occurred during the first quartile of our experience. Twelve patients (6%) required transfusion of allogeneic blood products. We have noted a significant reduction in operative times and resource utilization over time, as demonstrated in Table 1.
5
K.D. Algarni et al. / Multimedia Manual of Cardio-Thoracic Surgery
Table 1: Resource utilization in the first 200 robotic mitral valve repair cases at Mayo Clinic, Rochester, stratified by quartile Variable
Quartile 1 (n = 50)
Quartile 2 (n = 50)
Quartile 3 (n = 50)
Quartile 4 (n = 50)
P-value
Operative time (min) CPB time (min) Cross-clamp time (min) Any blood products, n (%) OR extubation, n (%) ICU LOS (h) Hospital LOS (days)
461.4 ± 110.1 (429) 128.6 ± 42.8 (122.5) 94.9 ± 30.0 (89.5) 15 (30) 1 (2) 20.7 (18.5, 23.2) 4.0 (3.0, 4.0)
379.8 ± 64.6 (367.5) 92.9 ± 28.9 (84.5) 68.9 ± 22.3 (62.0) 3 (6) 34 (68) 16.3 (6.0, 18.5) 3.0 (3.0, 4.0)
373.1 ± 76.7 (357.5) 83.0 ± 20.0 (78.0) 59.7 ± 20.2 (54.0) 3 (6) 44 (88) 6.8 (5.0, 13.5) 3.0 (3.0, 4.0)
354.8 ± 49.5 (343) 73.5 ± 17.6 (69.0) 54.7 ± 15.1 (50.5) 0 (0) 43 (86) 7.3 (6.0, 19.5) 3.0 (3.0, 4.0)
doi:10.1093/mmcts/mmu022 published online 1 November 2014.
MMCTS
CARDIO-THORACIC SURGERY
Robot-assisted mitral valve repair: surgical technique, outcomes and perspective Khaled D. Algarnia,b, Rakesh M. Surib,* and Richard C. Dalyb King Saud University, Riyadh, Saudi Arabia Mayo Clinic, Rochester, MN, USA
a
b
*Corresponding author. Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +1-507-2557067; fax: +1-507-2557378; e-mail: [email protected] (R.M. Suri). Received 24 July 2014; revised 1 September 2014; accepted 22 September 2014
Summary Robot-assisted mitral valve repair represents the least invasive surgical approach currently available for anatomical mitral valve repair in patients with myxomatous mitral valve disease. Standard mitral valve repair techniques utilized during conventional sternotomy/right thoracotomy are exactly replicated with robotic instrumentation through 1–2 cm port-like incisions, affording superior 3D visualization. The procedure is currently performed using cardiopulmonary bypass employing peripheral cannulation of the femoral vessels/right internal jugular vein. The ascending aorta is occluded with a transthoracic aortic cross-clamp. Antegrade cardioplegia is delivered centrally into the aortic root through a cardioplegia vent catheter. By replicating conventional mitral valve repair done via an open sternotomy approach, the quality of mitral valve repair is ensured while providing the patients with advantages of less invasive surgery including shorter hospital stay, rapid recovery and return to normal activities, less blood transfusion, superior cosmesis and complete elimination of sternotomyrelated morbidities such as deep sternal wound infection and sternal dehiscence. A significant reduction in operative duration with experience and diminished resource utilization over time has been observed. Keywords: Robotic assisted • Mitral repair • Minimally invasive
INTRODUCTION Surgical repair of mitral valve is recommended as Class I indication in patients with symptomatic chronic severe primary mitral regurgitation (MR). Surgery is also indicated in asymptomatic patients with evidence of left ventricular (LV) dysfunction (left ventricular ejection fraction [LVEF] 60% and left ventricular end systolic dimension [LVESD] 95% with an expected mortality rate of 450 s, full cardiopulmonary bypass is initiated while monitoring the descending thoracic aorta by TEE to confirm normal flow and the absence of a dissection flap. Patient temperature is allowed to drift to 34°C. The pericardiotomy is extended cranially over the ascending aorta towards the pulmonary artery. A 3.0 polypropylene purse-string suture with a felt pledget is placed in the ascending aorta. The previously placed cardioplegia tack is inserted through the purse-string and snared into place (Video 2). The transthoracic clamp is inserted through the chest wall as high and posterior as possible in the right axilla to avoid conflict with the left robotic arm. The aorta is cross-clamped, taking care to avoid injury of the right pulmonary artery and left atrial appendage. The heart is arrested with 1 l of cold blood high potassium cardioplegia, which is repeated every 20 min throughout the cross-clamp time (Video 3).
Mitral valve exposure and valve analysis The left atriotomy is carried out posterior to the interatrial groove allowing a sufficient cuff on the anterior surface of the right pulmonary veins to permit closure. The robotic left atrial retractor is positioned and the mitral valve is analysed (Video 4).
Leaflet repair and annuloplasty band Our philosophy is that the highest quality mitral valve repair techniques with proven durability should not be altered to facilitate performance of the operation through small incisions. We therefore employ exactly the same standard techniques of mitral valve repair regardless of the surgical approach as previously
Video 3: Transthoracic aortic cross-clamp.
Video 4: Exposure of the mitral valve.
published [17, 18]. We do not advocate the acceptance of inferior results that would be considered suboptimal in an open operation merely to facilitate the performance of robotic mitral valve repair. For posterior leaflet disease, we typically perform standard triangular resection with two-layer running polypropylene reconstruction (Video 5). For anterior leaflet prolapse, we use artificial chords with polytetrafluoroethylene (Gore-Tex; W.L. Gore & Associates, Inc., Flagstaff, AZ, USA). Patients with bileaflet prolapse undergo prolapse correction utilizing a combination of these techniques (Videos 6 and 7). Repair adjuncts include commissural or leaflet plication, leaflet shortening/ventricularisation and posterior leaflet neochord placement - all of which are employed as indicated. All repairs are supported with a standard length 63 mm posterior annuloplasty band inserted in the standard manner with 2.0 Ethibond interrupted sutures between left
K.D. Algarni et al. / Multimedia Manual of Cardio-Thoracic Surgery
Video 5: Repair of the posterior leaflet of the mitral valve.
Video 6: Repair of the anterior and posterior commissures.
4
Video 8: Posterior annuloplasty band insertion.
Video 9: Testing of the mitral valve repair and left atriotomy closure.
which the pericardium is closed, and a 32-F right pleural chest tube is positioned in the posterior thorax is and secured in place. Incisions are closed in the standard manner.
RESULTS
Video 7: Repair of the anterior leaflet prolapse with artificial chords.
and right fibrous trigones that are tied by the bedside surgeon (Video 8). Once the repair is tested with saline insufflation and found to be perfect, the left atrium is closed with running 3.0 Prolene sutures starting at both ends of the left atriotomy and the sutures are tied in the middle (Video 9). After deairing of the left heart, the aortic cross-clamp is removed. The patient is separated from cardiopulmonary bypass (CPB) and TEE is performed to assess the adequacy of the repair. CPB full flow is temporarily resumed for safe removal of the cardioplegia/vent tack and tying of the stitch. Decannulation and reversal of heparin are then performed following which, meticulous haemostasis is ensured. A 19-F soft silicone (Blake; Ethicon) pericardial drain inserted through the oblique sinus after
We have previously published our results of robotic mitral valve repair [9, 13–16]. In summary, we reviewed the first consecutive 200 patients undergoing robotic mitral valve repair at Mayo Clinic Rochester between 24 January 2008 and 28 January 2011 [16]. Successful mitral valve repair was completed in all patients, which was confirmed with intraoperative and pre-dismissal TEE. This series included the full spectrum of unselected degenerative mitral valve disease, encompassing all prolapse categories (posterior, anterior and bileaflet prolapse). Concomitant procedures included a left-sided ablation procedure in 5 (2.5%) patients and an atrial septal defect or patent foramen ovale closure in 12 (6.0%) patients. There were no early (30-day) deaths. One patient suffered a stroke (0.5%). One patient required reoperation for bleeding (0.5%). Two patients (1%) required reoperation for recurrent MR, one due to dehiscence of the annuloplasty band on postoperative day 30 and the second who had new anterior leaflet chordal rupture and underwent successful robot-assisted mitral valve re-repair on postoperative day 2. These 2 cases occurred during the first quartile of our experience. Twelve patients (6%) required transfusion of allogeneic blood products. We have noted a significant reduction in operative times and resource utilization over time, as demonstrated in Table 1.
5
K.D. Algarni et al. / Multimedia Manual of Cardio-Thoracic Surgery
Table 1: Resource utilization in the first 200 robotic mitral valve repair cases at Mayo Clinic, Rochester, stratified by quartile Variable
Quartile 1 (n = 50)
Quartile 2 (n = 50)
Quartile 3 (n = 50)
Quartile 4 (n = 50)
P-value
Operative time (min) CPB time (min) Cross-clamp time (min) Any blood products, n (%) OR extubation, n (%) ICU LOS (h) Hospital LOS (days)
461.4 ± 110.1 (429) 128.6 ± 42.8 (122.5) 94.9 ± 30.0 (89.5) 15 (30) 1 (2) 20.7 (18.5, 23.2) 4.0 (3.0, 4.0)
379.8 ± 64.6 (367.5) 92.9 ± 28.9 (84.5) 68.9 ± 22.3 (62.0) 3 (6) 34 (68) 16.3 (6.0, 18.5) 3.0 (3.0, 4.0)
373.1 ± 76.7 (357.5) 83.0 ± 20.0 (78.0) 59.7 ± 20.2 (54.0) 3 (6) 44 (88) 6.8 (5.0, 13.5) 3.0 (3.0, 4.0)
354.8 ± 49.5 (343) 73.5 ± 17.6 (69.0) 54.7 ± 15.1 (50.5) 0 (0) 43 (86) 7.3 (6.0, 19.5) 3.0 (3.0, 4.0)
![[Mitral valve repair versus mitral valve replacement].](/assets/img/hold.png)
