Ann Thorac Surg 2005;80:1100-1102
© 2005 The Society of Thoracic Surgeons
Case report
Robotic Resection of an Aortic Valve Papillary Fibroelastoma
Y. Joseph Woo, MD
*
,
Todd J. Grand, BS,
Stuart J. Weiss, MD, PhD
Division of Cardiothoracic Surgery, Department of General Surgery, and Division of Cardiothoracic Anesthesia, Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Accepted for publication February 23, 2004.
* Address reprint requests to Dr Woo, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA19104; (Email: wooy{at}uphs.upenn.edu).
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Abstract
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Robotic technology has been applied to multiple cardiac surgical procedures. Purported benefits include decreased tissue trauma, reduced postoperative bleeding, fewer blood product transfusions, and shorter lengths of stay. We describe the case of a 50-year-old man with an incidentally discovered 1-cm mobile mass on the edge of the aortic valve noncoronary leaflet. The patient underwent robotic minimally invasive resection. The pathologic examination revealed papillary fibroelastoma.
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Introduction
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Robotic cardiac surgery is currently being used for mitral valve procedures, atrial septal defect closures, atrial fibrillation ablation, and coronary artery bypass grafting. Various minimally invasive operative approaches to the aortic valve have been described, including partial sternotomy, right parasternal approach with costochondral resection, and right anterior minithoracotomy [1–3]. These approaches offer purported benefits over traditional sternotomy but may limit visualization and add technical challenges. These approaches may be assisted by videothoracoscopic visualization and perhaps robotics, similar to the sequential advantages seen in minimally invasive mitral valve surgery [4]. This case report details a robotic, minimally invasive aortic valve procedure.
The patient, a 50-year-old man with asymptomatic hypertension, diabetes mellitus, and hypercholesterolemia, was referred for a cardiology evaluation of a surveillance electrocardiogram that demonstrated nonspecific T-wave abnormalities. The patient had a negative stress test. On transthoracic echocardiography the patient was found to have a pedunculated, highly mobile 1-cm mass attached the leading edge of the noncoronary leaflet (Fig 1) that was believed to likely represent a fibroelastoma. The patient’s remaining medical history was notable for a prior appendectomy and no evidence of endocarditis. The only significant family history was gastric malignancy. The patient’s medications included aspirin, glyburide, metformin, gemfibrozil, and lisinopril. Physical examination was unremarkable. Given the risk of a potentially catastrophic embolization, the patient was referred for surgical resection. The patient requested a minimally invasive approach, and a robotically assisted right anterior minithoracotomy approach was selected.
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Fig 1. Preoperative echocardiographic long-axis image of aortic valve with fibroelastoma attached to leaflet edge.
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Anesthesia was induced, the patient was placed in the supine position, and a double lumen endotracheal tube was inserted. The patient underwent a 5-cm right anterior second interspace minithoracotomy. Upon pleural entry, the hemithorax was insufflated with carbon dioxide. After visualization of the mediastinum, the patient underwent a right groin incision, and the right common femoral artery and right common femoral vein were isolated. The pericardium was then opened.
The patient underwent systemic heparinization and arterial cannulation of the right common femoral artery with an 18F cannula and venous cannulation of the right common femoral vein with a C22F long venous cannula (Heartport, Redwood City, CA). Under transesophageal echocardiographic guidance, the tip of the venous cannula was positioned at the superior vena caval and right atrial junction.
The da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) was brought to the field and a 30-degree up scope was introduced into the medial aspect of the minithoracotomy. The robotic arms were introduced into the first and third intercostal spaces through separate stab incisions (Fig 2). The transthoracic Chitwood aortic clamp was introduced through a separate axillary stab incision.
The patient was initiated on cardiopulmonary bypass and cooled towards 30°C. Upon spontaneous ventricular fibrillation, the ascending aorta was cross-clamped, and antegrade cardioplegia was administered through a direct cannula in the aortic root at the level of the planned aortotomy. After arrest, the aorta was robotically incised and retracted, and a venting suction cannula was placed across the aortic valve into the left ventricle. The mass and the aortic valve leaflets were inspected. The mass, which was attached by a pedicle to the noncoronary leaflet, was robotically excised and sent for a pathologic examination. The leaflets were again inspected, and the aorta was closed with a double layer of running polypropylene sutures while air was removed from the heart. The cross-clamp was removed, and the heart was reperfused. The total cross-clamp time was 48 minutes.
The patient was weaned from cardiopulmonary bypass, the cannulas were removed, and heparin anticoagulation was reversed with protamine. Postbypass transesophageal echocardiography demonstrated no evidence of aortic insufficiency. A thoracostomy tube was inserted through the lower robotic arm port, and the wound was closed with multiple layers of absorbable sutures.
The patient was taken to the intensive care unit. He awoke neurologically intact and had no hemodynamic issues or evidence of hemorrhage. The patient was extubated 3 hours postoperatively, went to the floor the following day, and was discharged on the third postoperative day. He received no blood products. The patient had no complaints of incisional pain. The final pathology report revealed papillary fibroelastoma (Fig 3). One month postoperatively, the patient was seen in the office. The patient had a well-healed incision. He felt extremely well and had returned to work.
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Fig 3. (Left) Fibroelastoma specimen immersed in saline reveals sea anemone appearance. (Middle) Low-magnification and (right) high-magnification cross-sectional photomicrographs stained with hematoxylin & eosin demonstrate multiple fronds of tissue that contain fibrous material, interposed areolar tissue, and an endothelial lining.
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Comment
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This case report illustrates a robotic aortic valve procedure. Robotic technology has been applied to a range of cardiac surgical procedures, facilitating minimally invasive approaches and in some cases, totally endoscopic operations [5]. Purported benefits include decreased tissue trauma, reduced postoperative bleeding, fewer blood product transfusions, and shorter lengths of stay. Patients seem to describe less pain, more rapid recovery, improved cosmesis, and great overall satisfaction. Minimally invasive approaches to the aortic valve through a partial sternotomy and parasternal and right anterior thoracotomy have been extensively used. Robotic technology, with its microinstrumentation and high-resolution three-dimensional optics, may further facilitate these procedures, particularly when very small incisions are used and sternal division is avoided altogether.
Cardiac fibroelastomas account for 2.5% to 7.5% of primary cardiac tumors but comprise 73% to 89% of cardiac valve tumors [6]. Fibroelastomas involve the atrioventricular and semilunar valves with equal frequency. Although most commonly found on valves, fibroelastomas can derive from any intracardiac surface. It is thought that fibroelastomas arise from chronic turbulence and endothelial injury, although congenital development and neoplasia have also been postulated as etiologic processes. Fibroelastomas are benign tumors without malignant degeneration potential. Typically these lesions are asymptomatic and are most commonly detected during echocardiography performed for other reasons. The natural history involves embolization of the tumor or an associated thrombus formed from the large effective surface area, with associated end-organ malperfusion and dysfunction. Intermittent coronary ostial obstruction has also been described. Surgical resection of left-sided heart fibroelastomas is the only therapy currently available.
Macroscopically, fibroelastomas are typically pedunculated, less than 1 cm in diameter, and possess multiple fronds of tissue that resemble a sea anemone when immersed in water or saline. Microscopically, the fibroelastoma fronds consist of a dense fibrous core with interposed loose areolar tissue and endothelial lining that is contiguous with the adjacent valve or endocardium (Fig 3).
This patient’s presumptive preoperative diagnosis was fibroelastoma and thus probability was high that simple excision without aortic valve replacement would be the appropriate therapy. This, coupled with the patient’s strong desire for a nonsternotomy approach, provided the setting for a robotically assisted aortic valve procedure. This case illustrates the potential feasibility of a robotic aortic valve replacement or a perhaps a totally endoscopic robotic procedure of the aorta or aortic valve.
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References
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- Gillinov AM, Banbury MK, Cosgrove DM. Hemisternotomy approach for aortic and mitral valve surgery J Card Surg 2000;15:15-20.[Medline]
- Byrne JG, Hsin MK, Adams DH, et al. Minimally invasive direct access heart valve surgery J Card Surg 2000;15:21-34.[Medline]
- Sharony R, Grossi EA, Saunders PC, et al. Minimally invasive aortic valve surgery in the elderlya case–control study. Circulation 2003;108II-43–7.
- Nifong LW, Chu VF, Bailey Bm, et al. Robotic mitral valve repairexperience with the da Vinci system. Ann Thorac Surg 2003;75:438-442.[Abstract/Free Full Text]
- Argenziano M, Oz MC, Kohmoto T, et al. Totally endoscopic atrial septal defect repair with robotic assistance Circulation 2003;108II-191–4.
- Shahian DM. Papillary fibroelastomas Semin Thorac Cardiovasc Surg 2000;12:101-110.[Medline]
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Abstract
Introduction
