MULTIMEDIA MANUAL OF
doi:10.1093/mmcts/mmu016 published online 6 September 2014.
MMCTS
CARDIO-THORACIC SURGERY
Robotic mitral valve replacement Sahin Senaya,*, Ahmet Umit Gullua, Muharrem Kocyigitb, Aleks Degirmenciogluc, Hasan Karabuluta and Cem Alhana Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Istanbul, Turkey Department of Anesthesiology and Reanimation, Acıbadem University Vocational Schools, Istanbul, Turkey c Department of Cardiology, Acıbadem University School of Medicine, Istanbul, Turkey a
b
*Corresponding author. Acibadem Maslak Hastanesi, Maslak, Istanbul, Turkey. Tel: +90-212-3044444; fax: +90-212-3044440; e-mail: [email protected] (S. Senay). Received 16 April 2014; received in revised form 3 July 2014; accepted 1 August 2014
Summary Robotic surgical techniques allow surgeons to perform mitral valve surgery. This procedure has gained acceptance, particularly for mitral valve repair in degenerative mitral disease. However, mitral repair may not always be possible, especially in severely calcified mitral valve of rheumatic origin. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair. Keywords: Minimally invasive surgery • Robotic surgery • Mitral valve • Mitral valve replacement
INTRODUCTION Currently, robotic technology is used in cardiac surgery for performing coronary artery bypass grafting, mitral, tricuspid and aortic valve procedures, atrial septal defect closure, epicardial pacemaker lead implantation and ablation for the treatment of atrial fibrillation [1]. Mitral valve repair has been one of the widely used applications of robotic surgery [2]. However, mitral repair may not always be possible especially in severely calcified mitral valve of rheumatic origin. Among this group of patients, robotic surgery is still feasible with some technical differences from a standard robotic mitral valve repair procedure. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair.
SURGICAL TECHNIQUE Patients should undergo preoperative evaluation of transthoracic echocardiography, coronary angiography and vascular ultrasound or computed tomographic angiographic examination (if needed) of the femoral vessels. The exclusion criteria for this operation are recommended as extensive coronary artery disease, severe peripheral vascular disease, extensive mitral annular calcification (which may require complex debridement procedures) and previous median sternotomy or right thoracotomy.
Anaesthesia, patient positioning and cardiopulmonary bypass set-up A double-lumen endotracheal tube and a transoesophageal echocardiography (TEE) probe are placed after induction of general
anaesthesia. A chest roll is placed under the right shoulder, the right arm is placed at the side of the operation table and the table is rotated 20° right-side up position. The port and incision sites are marked (Figure 1). A 15- or 17-Fr venous cannula (Medtronic BioMedicus, Eden Prarie, MN, USA) is placed percutaneously via the right internal jugular vein and placed into the superior vena cava with its tip being 1 cm inferior to the cavoatrial junction under TEE guidance. The common femoral artery is cannulated with a 17- or 19-Fr aortic cannula (Medtronic Bio-Medicus). A 21- or 24-Fr venous cannula (Medtronic Bio-Medicus) is inserted into the right common femoral vein and placed into the inferior vena cava, with its tip being 1 cm superior to the cavoatrial junction. When performing concomitant tricuspid valve surgery, the tip of the venous cannula at the superior vena cava is placed 1 cm superior to the cavoatrial junction, and the tip of the venous cannula at the inferior vena cava is placed 1 cm inferior to the cavoatrial junction. This manoeuvre provides enough space for clamping the venae cavae. Both venae cavae are occluded with endoscopic clamps. This technique has been described previously [3].
Port implantation, cardioplegia and cross-clamping An incision of 3 cm for anterolateral thoracotomy located in the right fourth intercostal space, 2–3 cm laterally to the nipple, is performed. A small-size soft tissue retractor is placed without using any rib spreader. The camera port is placed through the soft tissue retractor. Carbon dioxide insufflation is applied with 8-mmHg pressure and a flow rate of 6 l/min. The right arm port is placed two intercostal spaces inferior to the thoracotomy, and the left arm port is placed one or two intercostal spaces above. The left atrial retractor port is placed approximately 3 cm medially to the camera port in the fourth intercostal space. After port implantation, the robotic arms are connected to the ports (Figure 2).
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery
Figure 1: Patient positioning, marking and general set-up. LAR: left atrial retractor; CP: camera port; RA: right arm; LA: left arm; TEE: transoesophageal echocardiography; DLET: double-lumen endotracheal tube; ChC: Chitwood clamp.
2
Video 2: Transthoracic cross-clamping, cardioplegia delivery and echocardiographic control.
Video 3: Left atriotomy, placement of atrial retractor and atrial exposure.
Figure 2: Set-up after docking.
position of this clamp should be arranged to pass through the upper side of the junction of the atrium and the superior vena cava. The heart is arrested by using 2 l of crystalloid cardioplegia [histidine-tryptophan-ketoglutarate Bretschneider’s solution (Custodiol)], delivered into the aortic root with a transthoracic cannula through the thoracotomy. Cross-clamping and cardioplegia delivery should be confirmed TEE (Video 2).
Exposure, valve resection and implantation of the prosthesis
Video 1: Pericardial stay sutures and external fixation.
Cardiopulmonary bypass is instituted. The pericardium is opened 2–3 cm anteriorly to the phrenic nerve and pericardial edges are suspended on stay sutures, which are then snared and pulled through the lateral chest wall inferior to the thoracotomy. These sutures are fixed externally (Video 1). The ascending aorta is cross-clamped with a transthoracic clamp which is inserted through the chest wall in the direction of the transverse sinus. The
The interatrial approach is used for left atrial exposure. After dissection of the interatrial groove, it is incised and the incision is extended superiorly 1 cm through the superior vena cava. The inferior extension is made through the midline between the right inferior vena cava and the right inferior pulmonary vein. The exposure of the mitral valve is established by properly placing the left atrial retractor (Video 3). In most of the cases, the leaflets are non-pliable with calcifications of various degree. Subvalvular structures may also be calcified. These calcifications may make resection of the valve challenging due to the difficulty of handling the non-pliable and grossly stiff tıssues. In such cases, the valve is grabbed with a prograsper instead of the long tip forceps and excised with a curved scissors. Valve sizing can be done by measuring the excised valve outside the thorax (Video 4). The subvalvular apparatus should be preserved; however, if the subvalvular apparatus is also calcified, resection of this structure is inevitable; then the continuity between the papillary muscles and the annulus can be preserved by using artificial chordae fixed to the annulus.
3
S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery
Video 4: Valve excision and sizing. Video 7: Postoperative echocardiographic control.
Figure 3: Postoperative closure of the incisions. Video 5: Valve implantation.
Video 6: Securing the valve sutures with a Cor-Knot device.
The valve prosthesis is implanted by using 12–14 stitches of pledgeted sutures. The valve should be removed from its holder before placing it into the thoracic cavity and deploying it through the small incision perpendicularly (Video 5). The pledget sutures of the valve can be secured in three different methods. First, all knots can be secured with a knot pusher through the incision. A valve prosthesis with a soft sewing cuff may be preferred with this technique because it is more efficiently implanted since the knot can easily be buried into the cuff and does not loosen easily. Second, an automatic mechanical knotting system (Cor-Knot, LSI Solution, Victor, NY, USA) can be used (Video 6). The advantage of this system is the standardization of knot tying, leading all the knots to an equal strength and quality besides saving up to 15 min
per prosthesis. Third, knotting the sutures can be performed inside the thoracic cavity by the robotic arms which may be preferred by experienced surgeons. If additional procedures are needed, they are performed in a routine fashion. St Jude Medical or OnX mechanical heart valves and St Jude Biocor stented tissue valves were used for replacement. With regard to the prosthesis type selected during the operation, the decision process is the same as in a usual open case. However, if the knot-tying method 1 (using a knot pusher) or 3 (with robotic arms) is used, a valve prosthesis with a soft sewing cuff is mainly preferred. The atriotomy is closed using a premade loop suture. During the de-airing period, the left lung is ventilated and venting from the aortic root is performed. The cross-clamp is removed and adequate haemostasis is achieved. Echocardiographic control of the implanted valve is performed (Video 7). The robotic arms are removed and the drainage tube is placed through the right port incision. After decannulation, heparin is reversed and all incisions are closed in layers (Figure 3).
RESULTS From March 2010 to April 2014, a total of 92 patients underwent robotic cardiac procedures using the da Vinci Si HD surgical systems (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Among this group, 31 of them were robotic mitral valve replacements. Perioperative variables are presented in Table 1. Eight patients had additional cardiac procedure (Table 2). No operative or hospital mortality was observed. Postoperative complications included one early reoperation for bleeding (3.2%), 1 (3.2%) intensive care unit
4
S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery
Table 1: Basic demographics of the patients (n = 31)
Table 3: Postoperative variables and complications
Age (years) EuroSCORE (%) Body mass index (kg/m2) Gender (female/male) Diabetes mellitus (%) Hypertension (%) Preoperative atrial fibrillation (%) NYHA Class Preoperative creatinine (mg/dl) Preoperative ejection fraction (%)
Cross-clamp time (min) CPB time (min) Postoperative inotropic use (%) Mean drainage (ml) Intubation time (h) Patients extubated within ≤6 h (%) ICU stay time (h) Early reoperation for bleeding (%) Patients with ICU stay ≤24 h (%) Early mortality (%) ICU readmission (%) Postoperative surgical site infection (%) Postoperative new-onset atrial fibrillation (%) Postoperative stroke (%) Postoperative renal failure (%) Late mortality (%) Hospital readmission (%) Mid-term valve dysfunction (%) Mid-term need for reintervention/reoperation (%)
53.5 ± 10 4.3 ± 4 26.2 ± 6.4 22/9 41 45 32 2.7 ± 0.4 1.1 ± 0.5 58.2 ± 10
NYHA: New York Heart Association Classification.
Table 2: Operations performed Operation type
n
MVR MVR + TV repair MVR + ASD closure MVR + maze procedure MVR + TVR
23 2 3 2 1
MVR: mitral valve replacement; TVR: tricuspid valve replacement; TV: tricuspid valve; ASD: asrial septal defect.
readmission and 1 (3.2%) hospital readmission. The reason for ICU readmission and hospital readmission was respiratory dysfunction. Both patients were treated medically. Additional pleural drainage was needed due to pleural effusion for the patient re-admitted to the ICU. There were 5 (16.1%) patients with new-onset postoperative atrial fibrillation. No major postoperative organ dysfunction including stroke or renal failure was observed. No device-related complications were observed. The mean follow-up period was 19 ± 14 months. During the follow-up, there was no valve dysfunction at the echocardiographic examinations, no mortality and no need for reoperation or reintervention (Table 3).
102 ± 24 154 ± 47 6.4 370 ± 280 8.3 ± 6 90.3 26 ± 10 3.2 90.3 0 3.2 0 16.1 0 0 0 3.2 0 0
CPB: cardiopulmonary bypass; ICU: intensive care unit.
Patient selection is an important issue. The strength of the robotic devices would not be suitable for decalcification or annular debridement process in patients with extensive annular calcification. Open surgery or minimally invasive techniques without a robot would be better choices for these patients. Mitral valve replacement can also be performed safely with minimally invasive techniques. The main benefit of robotics when compared with this technique may be a smaller thoracotomy, better visualization and exposure of the valve, and practical suture handling in difficult anatomies [7]. As a conclusion, it can be stated that robotic mitral valve replacement for severe mitral disease that is not suitable for repair is technically safe and feasible. Conflict of interest: none declared.
REFERENCES DISCUSSION Mitral valve disease with a rheumatic aetiology and calcified lesions may not be suitable for repair and they have been described as exclusion criteria for robotic mitral surgery [2, 4]. However, robotic mitral valve replacement can safely be performed with acceptable early results. The main differences when compared with robotic mitral repair is the need for a 3-cm anterolateral thoracotomy and the use of a soft tissue retractor (instead of a working port) to allow valve prosthesis deployment. The camera port can be placed through this incision. The knot tying can be performed inside with robotic arms or from outside the thoracic cavity through the thoracotomy by using a knot pusher or a Cor-Knot device (LSI Solution). This device offers a standard and safe knot tying method and also a shorter operative time. A gain of up to 10 min for annuloplasty in robotic mitral repairs was reported with this device [5]. The use of handmade loops at one end for atrial closure also saves time [6].
[1] Lehr EJ, Rodriguez E, Chitwood WR. Robotic cardiac surgery. Curr Opin Anaesthesiol 2011;24:77–85. [2] Suri RM, Burkhart HM, Rehfeldt KH, Dearani JA, Park SJ, Sundt TM III et al. Robotic mitral valve repair for all categories of leaflet prolapse: improving patient appeal and advancing standard of care. Mayo Clin Proc 2011;86:838–44. [3] Gullu AU, Senay S, Kocyigit M, Alhan C. A simple method for occlusion of both venae cavae in total cardiopulmonary bypass for robotic surgery. Interact CardioVasc Thorac Surg 2012;14:138–9. [4] Rehfeldt KH, Mauermann WJ, Burkhart HM, Suri RM. Robot-assisted mitral valve repair. J Cardiothorac Vasc Anesth 2011;25:721–30. [5] Nifong LW, Alwair H, Parker D, Patel D, Chitwood WR. Significant reduction in operative times using Cor-Knot™ in robot-assisted mitral valve repair. In: International Society for Minimally Invasive Cardiothoracic Surgery Annual Scientific Meeting, Prague, Czech Republic, 12–15 June 2013. [6] Kilic L, Senay S, Gullu AU, Alhan C. Leyla loop: a time saving suture technique for robotic atrial closure. Interact CardioVasc Thorac Surg 2013;17:579–80. [7] Gao C, Yang M, Xiao C, Wang G, Wu Y, Wang J et al. Robotically assisted mitral valve replacement. J Thorac Cardiovasc Surg 2012;143(4 Suppl): S64–7.
doi:10.1093/mmcts/mmu016 published online 6 September 2014.
MMCTS
CARDIO-THORACIC SURGERY
Robotic mitral valve replacement Sahin Senaya,*, Ahmet Umit Gullua, Muharrem Kocyigitb, Aleks Degirmenciogluc, Hasan Karabuluta and Cem Alhana Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Istanbul, Turkey Department of Anesthesiology and Reanimation, Acıbadem University Vocational Schools, Istanbul, Turkey c Department of Cardiology, Acıbadem University School of Medicine, Istanbul, Turkey a
b
*Corresponding author. Acibadem Maslak Hastanesi, Maslak, Istanbul, Turkey. Tel: +90-212-3044444; fax: +90-212-3044440; e-mail: [email protected] (S. Senay). Received 16 April 2014; received in revised form 3 July 2014; accepted 1 August 2014
Summary Robotic surgical techniques allow surgeons to perform mitral valve surgery. This procedure has gained acceptance, particularly for mitral valve repair in degenerative mitral disease. However, mitral repair may not always be possible, especially in severely calcified mitral valve of rheumatic origin. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair. Keywords: Minimally invasive surgery • Robotic surgery • Mitral valve • Mitral valve replacement
INTRODUCTION Currently, robotic technology is used in cardiac surgery for performing coronary artery bypass grafting, mitral, tricuspid and aortic valve procedures, atrial septal defect closure, epicardial pacemaker lead implantation and ablation for the treatment of atrial fibrillation [1]. Mitral valve repair has been one of the widely used applications of robotic surgery [2]. However, mitral repair may not always be possible especially in severely calcified mitral valve of rheumatic origin. Among this group of patients, robotic surgery is still feasible with some technical differences from a standard robotic mitral valve repair procedure. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair.
SURGICAL TECHNIQUE Patients should undergo preoperative evaluation of transthoracic echocardiography, coronary angiography and vascular ultrasound or computed tomographic angiographic examination (if needed) of the femoral vessels. The exclusion criteria for this operation are recommended as extensive coronary artery disease, severe peripheral vascular disease, extensive mitral annular calcification (which may require complex debridement procedures) and previous median sternotomy or right thoracotomy.
Anaesthesia, patient positioning and cardiopulmonary bypass set-up A double-lumen endotracheal tube and a transoesophageal echocardiography (TEE) probe are placed after induction of general
anaesthesia. A chest roll is placed under the right shoulder, the right arm is placed at the side of the operation table and the table is rotated 20° right-side up position. The port and incision sites are marked (Figure 1). A 15- or 17-Fr venous cannula (Medtronic BioMedicus, Eden Prarie, MN, USA) is placed percutaneously via the right internal jugular vein and placed into the superior vena cava with its tip being 1 cm inferior to the cavoatrial junction under TEE guidance. The common femoral artery is cannulated with a 17- or 19-Fr aortic cannula (Medtronic Bio-Medicus). A 21- or 24-Fr venous cannula (Medtronic Bio-Medicus) is inserted into the right common femoral vein and placed into the inferior vena cava, with its tip being 1 cm superior to the cavoatrial junction. When performing concomitant tricuspid valve surgery, the tip of the venous cannula at the superior vena cava is placed 1 cm superior to the cavoatrial junction, and the tip of the venous cannula at the inferior vena cava is placed 1 cm inferior to the cavoatrial junction. This manoeuvre provides enough space for clamping the venae cavae. Both venae cavae are occluded with endoscopic clamps. This technique has been described previously [3].
Port implantation, cardioplegia and cross-clamping An incision of 3 cm for anterolateral thoracotomy located in the right fourth intercostal space, 2–3 cm laterally to the nipple, is performed. A small-size soft tissue retractor is placed without using any rib spreader. The camera port is placed through the soft tissue retractor. Carbon dioxide insufflation is applied with 8-mmHg pressure and a flow rate of 6 l/min. The right arm port is placed two intercostal spaces inferior to the thoracotomy, and the left arm port is placed one or two intercostal spaces above. The left atrial retractor port is placed approximately 3 cm medially to the camera port in the fourth intercostal space. After port implantation, the robotic arms are connected to the ports (Figure 2).
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery
Figure 1: Patient positioning, marking and general set-up. LAR: left atrial retractor; CP: camera port; RA: right arm; LA: left arm; TEE: transoesophageal echocardiography; DLET: double-lumen endotracheal tube; ChC: Chitwood clamp.
2
Video 2: Transthoracic cross-clamping, cardioplegia delivery and echocardiographic control.
Video 3: Left atriotomy, placement of atrial retractor and atrial exposure.
Figure 2: Set-up after docking.
position of this clamp should be arranged to pass through the upper side of the junction of the atrium and the superior vena cava. The heart is arrested by using 2 l of crystalloid cardioplegia [histidine-tryptophan-ketoglutarate Bretschneider’s solution (Custodiol)], delivered into the aortic root with a transthoracic cannula through the thoracotomy. Cross-clamping and cardioplegia delivery should be confirmed TEE (Video 2).
Exposure, valve resection and implantation of the prosthesis
Video 1: Pericardial stay sutures and external fixation.
Cardiopulmonary bypass is instituted. The pericardium is opened 2–3 cm anteriorly to the phrenic nerve and pericardial edges are suspended on stay sutures, which are then snared and pulled through the lateral chest wall inferior to the thoracotomy. These sutures are fixed externally (Video 1). The ascending aorta is cross-clamped with a transthoracic clamp which is inserted through the chest wall in the direction of the transverse sinus. The
The interatrial approach is used for left atrial exposure. After dissection of the interatrial groove, it is incised and the incision is extended superiorly 1 cm through the superior vena cava. The inferior extension is made through the midline between the right inferior vena cava and the right inferior pulmonary vein. The exposure of the mitral valve is established by properly placing the left atrial retractor (Video 3). In most of the cases, the leaflets are non-pliable with calcifications of various degree. Subvalvular structures may also be calcified. These calcifications may make resection of the valve challenging due to the difficulty of handling the non-pliable and grossly stiff tıssues. In such cases, the valve is grabbed with a prograsper instead of the long tip forceps and excised with a curved scissors. Valve sizing can be done by measuring the excised valve outside the thorax (Video 4). The subvalvular apparatus should be preserved; however, if the subvalvular apparatus is also calcified, resection of this structure is inevitable; then the continuity between the papillary muscles and the annulus can be preserved by using artificial chordae fixed to the annulus.
3
S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery
Video 4: Valve excision and sizing. Video 7: Postoperative echocardiographic control.
Figure 3: Postoperative closure of the incisions. Video 5: Valve implantation.
Video 6: Securing the valve sutures with a Cor-Knot device.
The valve prosthesis is implanted by using 12–14 stitches of pledgeted sutures. The valve should be removed from its holder before placing it into the thoracic cavity and deploying it through the small incision perpendicularly (Video 5). The pledget sutures of the valve can be secured in three different methods. First, all knots can be secured with a knot pusher through the incision. A valve prosthesis with a soft sewing cuff may be preferred with this technique because it is more efficiently implanted since the knot can easily be buried into the cuff and does not loosen easily. Second, an automatic mechanical knotting system (Cor-Knot, LSI Solution, Victor, NY, USA) can be used (Video 6). The advantage of this system is the standardization of knot tying, leading all the knots to an equal strength and quality besides saving up to 15 min
per prosthesis. Third, knotting the sutures can be performed inside the thoracic cavity by the robotic arms which may be preferred by experienced surgeons. If additional procedures are needed, they are performed in a routine fashion. St Jude Medical or OnX mechanical heart valves and St Jude Biocor stented tissue valves were used for replacement. With regard to the prosthesis type selected during the operation, the decision process is the same as in a usual open case. However, if the knot-tying method 1 (using a knot pusher) or 3 (with robotic arms) is used, a valve prosthesis with a soft sewing cuff is mainly preferred. The atriotomy is closed using a premade loop suture. During the de-airing period, the left lung is ventilated and venting from the aortic root is performed. The cross-clamp is removed and adequate haemostasis is achieved. Echocardiographic control of the implanted valve is performed (Video 7). The robotic arms are removed and the drainage tube is placed through the right port incision. After decannulation, heparin is reversed and all incisions are closed in layers (Figure 3).
RESULTS From March 2010 to April 2014, a total of 92 patients underwent robotic cardiac procedures using the da Vinci Si HD surgical systems (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Among this group, 31 of them were robotic mitral valve replacements. Perioperative variables are presented in Table 1. Eight patients had additional cardiac procedure (Table 2). No operative or hospital mortality was observed. Postoperative complications included one early reoperation for bleeding (3.2%), 1 (3.2%) intensive care unit
4
S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery
Table 1: Basic demographics of the patients (n = 31)
Table 3: Postoperative variables and complications
Age (years) EuroSCORE (%) Body mass index (kg/m2) Gender (female/male) Diabetes mellitus (%) Hypertension (%) Preoperative atrial fibrillation (%) NYHA Class Preoperative creatinine (mg/dl) Preoperative ejection fraction (%)
Cross-clamp time (min) CPB time (min) Postoperative inotropic use (%) Mean drainage (ml) Intubation time (h) Patients extubated within ≤6 h (%) ICU stay time (h) Early reoperation for bleeding (%) Patients with ICU stay ≤24 h (%) Early mortality (%) ICU readmission (%) Postoperative surgical site infection (%) Postoperative new-onset atrial fibrillation (%) Postoperative stroke (%) Postoperative renal failure (%) Late mortality (%) Hospital readmission (%) Mid-term valve dysfunction (%) Mid-term need for reintervention/reoperation (%)
53.5 ± 10 4.3 ± 4 26.2 ± 6.4 22/9 41 45 32 2.7 ± 0.4 1.1 ± 0.5 58.2 ± 10
NYHA: New York Heart Association Classification.
Table 2: Operations performed Operation type
n
MVR MVR + TV repair MVR + ASD closure MVR + maze procedure MVR + TVR
23 2 3 2 1
MVR: mitral valve replacement; TVR: tricuspid valve replacement; TV: tricuspid valve; ASD: asrial septal defect.
readmission and 1 (3.2%) hospital readmission. The reason for ICU readmission and hospital readmission was respiratory dysfunction. Both patients were treated medically. Additional pleural drainage was needed due to pleural effusion for the patient re-admitted to the ICU. There were 5 (16.1%) patients with new-onset postoperative atrial fibrillation. No major postoperative organ dysfunction including stroke or renal failure was observed. No device-related complications were observed. The mean follow-up period was 19 ± 14 months. During the follow-up, there was no valve dysfunction at the echocardiographic examinations, no mortality and no need for reoperation or reintervention (Table 3).
102 ± 24 154 ± 47 6.4 370 ± 280 8.3 ± 6 90.3 26 ± 10 3.2 90.3 0 3.2 0 16.1 0 0 0 3.2 0 0
CPB: cardiopulmonary bypass; ICU: intensive care unit.
Patient selection is an important issue. The strength of the robotic devices would not be suitable for decalcification or annular debridement process in patients with extensive annular calcification. Open surgery or minimally invasive techniques without a robot would be better choices for these patients. Mitral valve replacement can also be performed safely with minimally invasive techniques. The main benefit of robotics when compared with this technique may be a smaller thoracotomy, better visualization and exposure of the valve, and practical suture handling in difficult anatomies [7]. As a conclusion, it can be stated that robotic mitral valve replacement for severe mitral disease that is not suitable for repair is technically safe and feasible. Conflict of interest: none declared.
REFERENCES DISCUSSION Mitral valve disease with a rheumatic aetiology and calcified lesions may not be suitable for repair and they have been described as exclusion criteria for robotic mitral surgery [2, 4]. However, robotic mitral valve replacement can safely be performed with acceptable early results. The main differences when compared with robotic mitral repair is the need for a 3-cm anterolateral thoracotomy and the use of a soft tissue retractor (instead of a working port) to allow valve prosthesis deployment. The camera port can be placed through this incision. The knot tying can be performed inside with robotic arms or from outside the thoracic cavity through the thoracotomy by using a knot pusher or a Cor-Knot device (LSI Solution). This device offers a standard and safe knot tying method and also a shorter operative time. A gain of up to 10 min for annuloplasty in robotic mitral repairs was reported with this device [5]. The use of handmade loops at one end for atrial closure also saves time [6].
[1] Lehr EJ, Rodriguez E, Chitwood WR. Robotic cardiac surgery. Curr Opin Anaesthesiol 2011;24:77–85. [2] Suri RM, Burkhart HM, Rehfeldt KH, Dearani JA, Park SJ, Sundt TM III et al. Robotic mitral valve repair for all categories of leaflet prolapse: improving patient appeal and advancing standard of care. Mayo Clin Proc 2011;86:838–44. [3] Gullu AU, Senay S, Kocyigit M, Alhan C. A simple method for occlusion of both venae cavae in total cardiopulmonary bypass for robotic surgery. Interact CardioVasc Thorac Surg 2012;14:138–9. [4] Rehfeldt KH, Mauermann WJ, Burkhart HM, Suri RM. Robot-assisted mitral valve repair. J Cardiothorac Vasc Anesth 2011;25:721–30. [5] Nifong LW, Alwair H, Parker D, Patel D, Chitwood WR. Significant reduction in operative times using Cor-Knot™ in robot-assisted mitral valve repair. In: International Society for Minimally Invasive Cardiothoracic Surgery Annual Scientific Meeting, Prague, Czech Republic, 12–15 June 2013. [6] Kilic L, Senay S, Gullu AU, Alhan C. Leyla loop: a time saving suture technique for robotic atrial closure. Interact CardioVasc Thorac Surg 2013;17:579–80. [7] Gao C, Yang M, Xiao C, Wang G, Wu Y, Wang J et al. Robotically assisted mitral valve replacement. J Thorac Cardiovasc Surg 2012;143(4 Suppl): S64–7.
