Ann Thorac Surg 2006;81:1095-1098
© 2006 The Society of Thoracic Surgeons
New technology
Robotic-Enhanced Totally Endoscopic Mitral Valve Repair and Ablative Therapy
Belhhan Akpinar, MD
*
,
Mustafa Guden, MD,
Ertan Sagbas, MD,
Ilhan Sanisoglu, MD,
Baris Caynak, MD,
Zehra Bayramoglu, MD
Department of Cardiac Surgery, Florence Nightingale Hospital, Istanbul, Turkey
Accepted for publication September 12, 2005.
* Address correspondence to Dr Akpinar, Department of Cardiac Surgery, Florence Nightingale Hospital, Abidei Hurriyet Cad No. 290, Sisli-Istanbul, PB 80220 Turkey (Email: belh{at}tnn.net).
| Dr Akpinar discloses a financial relationship with Medtronic, Inc.
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Abstract
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PURPOSE: The aim of this article was to assess the feasibility of totally closed robotic mitral valve repair and ablative therapy.
DESCRIPTION: Two patients with mitral valve disease and permanent atrial fibrillation underwent the combined procedure using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). Radiofrequency ablation was performed using the Cardioblate XL unipolar pen (Medtronic Inc, Minneapolis, MN). One patient underwent mitral commissurotomy and the other commissurotomy and Reed annuloplasty.
EVALUATION: There were no procedure-related complications. Sinus rhythm was established in both patients after the operation, and transesophageal echocardiography revealed competent mitral valves without residual gradients.
CONCLUSIONS: Robotic-enhanced mitral valve repair and ablation proved feasible in both patients with good clinical outcome. The described combined method may find broader application in a selected group of patients with the continuing evolution in technology.
Less invasive methods to treat mitral valve disease have been under constant evolution during the last decade. Techniques such as port access and video-assisted mitral valve surgery have been shown to be safe and effective [1, 2]. Recent advances in robotics have enabled surgeons to apply this technology in mitral valve cases and patients with lone atrial fibrillation (AF). Nearly 40% of patients undergoing mitral valve surgery suffer from AF and the treatment of this arrhythmia during concomittant cardiac surgery using minimally invasive methods has also evolved [2].
We report 2 patients who underwent robotic-enhanced totally closed mitral valve repair and radiofrequency ablation for AF in our institution.
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Technology and Technique
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After Institutional Review Board approval and obtained informed consent, 79 patients underwent robotic-enhanced cardiac procedures between March 2004 and July 2005. This report focuses on 2 recent patients from this group who underwent robotic-enhanced totally closed mitral valve repair and ablative therapy. The da Vinci system (Intuitive Surgical, Sunnyvale, CA) was used for robotic enhancement and the Cardioblate XL irrigated RF system (Medtronic Inc, Minneapolis, MN) for ablative therapy. The patients were 29-year-old and 42-year-old woman with a history of rheumatic disease. Left ventricle ejection fractions were 52% and 58%, respectively. The first patient (patient 1) had pure mitral valve stenosis and the other (patient 2) had both valvular stenosis and regurgitation. The transthoracic and transesophageal echocardiographic examinations revealed relatively mobile subvalvular apparatus in both patients without any evidence of annular calcification. The echo-scores were 9 and 10 with transvalvular gradients of 12 and 14 mmHg, respectively. Calculated mean valve areas were 1.2 and 1.4 cm2, respectively. Both patients had documented permanent atrial fibrillation with a functional capacity of the New York Heart Association functional class II, and defined progressive detoriation after the onset of AF.
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Clinical Experience
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Surgical Technique
Patients were anesthetized and positioned with the right chest elevated 30° to 40°. A 14-French jugular cannula was introduced to facilitate venous drainage during cardiopulmonary bypass. After deflation of the right lung the camera port was introduced directly in the fourth intercostal space front axillary line. The chest was insufflated with CO2 gas, and two ports were placed under visual control to accommodate the robotic arms. The left arm was introduced through the second intercostal space mid-axillary line and the right arm through the sixth intercostal space mid-axillary line. A 2-cm incision was made in the fourth intercostal space mid-axillary line and a 20-mm trocar (Flexipath, Ethicon Endo-surgery, Inc, Cincinnati, OH) was introduced, which served as a service port (Fig 1). The pericardium was opened and exposed with Gore-Tex stay sutures (W.L. Gore & Assoc, Flagstaff, AZ). Cardiopulmonary bypass was established only after this stage at 26° using femoral arterial inflow and the femoral vein to the right atrial cannula. A custom-made antegrade cardioplegia needle was introduced through the service port and inserted into the aorta through a purse suture. A transthoracic aortic cross clamp and intermittent blood cardioplegia maintained cardiac arrest and myocardial protection. The cardioplegia line was introduced through the same stab wound with the Chitwood clamp (Scanlan International Inc, Minneapolis, MN) (Fig 1). After cardioplegic arrest, the left atrium was opened parallel to the interatrial groove and exposure was maintained by four Gore-Tex stay sutures (W.L. Gore & Assoc) with Teflon felts (B
cakclar Inc, Istanbul, Turkey) taken out of the chest wall (Fig 1). A left atrial retractor was not used. A left atrial sump sucker maintained a dry operative field.
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Fig 1. The placement of the ports for robotic mitral valve repair and radiofrequency ablation is shown. The patient-side surgeon assists the operation through the service port. (A) Left robotic arm port. (B) Camera port. (C) Right robotic arm port. (D) Left atrial sump and CO2 port. (E) Service port. (F) Transthoracic clamp. (G) Cardioplegia line.
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Ablation
The radiofrequency ablation was performed first. The Cardioblate XL pen (Medtronic Inc) was introduced through the service port, and the patient-side surgeon maneuvered the pen inside the service port and performed the ablation lines with the aid of two-dimensional vision (Figs 2, 3). Figure 4
shows the ablation lines being performed.
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Fig 3. Interatrial view of the ablation process through the robotic camera is shown. (A) Ablation pen. (B) Right robotic arm. (MVA = mitral anterior leaflet; MVP = mitral posterior leaflet.)
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Fig 4. The blue lines indicate the left atrial ablation pattern. (a) Ablation around the left atrial appendage. (b) Left atrial isthmus ablation. (LPVs = left pulmonary veins; MV = mitral valve; p2 — p3 = mitral valve posterior leaflet second and third segments; RPVs = right pulmonary veins.)
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Mitral Valve Repair
Patient 1
After the ablative therapy, the inspection of the valve showed fusion in both anterolateral and posteromedial commissures. A commissurotomy was performed on both commissures using the robotic arms. This was followed by decalcification of a small area on the A1 segment of the anterior leaflet.
Patient 2
After ablation the inspection showed fusion in both commissures and slight dilatation of the posterior annulus. A commissurotomy was performed on both commissures. After this a Reed type annuloplasty was performed using 3-0 Gore Tex sutures (W.L. Gore & Assoc) supported with Teflon felts to reduce the posterior annulus (Figs 5, 6).
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Fig 5. (A) The mitral valve anterior leaflet repair was evaluated both by intraoperative saline injection through (B) a nelaton tube and perioperative transesophageal echocardiography. (C) The Teflon felts used during Reed plasty.
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Fig 6. The completed mitral valve repair is shown. (A) The mitral valve anterior leaflet. (B) The right robotic arm.
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Both repairs were checked during the procedure by saline injection. After the repair the left atrium was closed using 3-0 Gore Tex sutures (W.L. Gore & Assoc).
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Results
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The combined procedure was found to be feasible in both patients. There were no procedure-related complications. Transesophageal echocardiographic examination after repair revealed competent valves without any stenosis. The ablation times were 9 and 9.5 minutes, respectively. Both patients were in sinus rhythm and remained so 3 months after the operation. The ischemic times were 69 and 98 minutes, respectively. The cardiopulmonary bypass times were 94 and 132 minutes, respectively. The recovery of both patients was uneventful.
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Comment
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Robotics has launched the era of totally endoscopic cardiac surgical procedures, and this development has had a considerable impact on the evolution of minimally invasive valve surgery. In 1998, Carpentier and Mohr serially performed the first mitral valve repairs using the da Vinci system (Intuitive Surgical) [3, 4]. In the United States Chitwood and colleagues have shown the feasibility of robotic-enhanced mitral valve surgery in a series of 100 patients, which remains to be the largest series of robotic mitral valve repairs to date [5]. These surgeons used a 4-cm to 5-cm small thoracotomy during their series, but efforts were soon directed toward a totally closed mitral valve procedure using robotic systems. This was made possible with the use of 20-mm and 30-mm service ports. These not only enabled suture material delivery and removal, but also made it possible for the patient-side surgeon to assist the console surgeon more efficiently and to reduce operation times.
In the cases covered in this study it was possible to introduce the antegrade cardioplegia system and the suture material through the service port so that the sutures could be pulled more efficiently with tactile feedback by the patient-side surgeon. It was also feasible to introduce and maneuver the ablation pen through this service port. The longer shaft of the Cardioblate XL pen (Medtronic Inc) enabled us to perform the lesions of the modifed Maze procedure (Fig 4).
Proper patient selection is crucial for the success of robotic surgery, and patients with depressed left ventricle function, annular calcification, and complex valvular pathologies should be avoided [4]. Correctly placing the robotic arms is also important; failure to do so may cause collision of the arms and failure to complete the procedure. The ischemic and cardiopulmonary bypass times are longer than conventional operations, and special care must be given to myocardial protection.
Both cases in this report were straightforward valve repair cases. We did not use a ring because the posterior annular dilatation was not severe and was localized to the P2-P3 segment. When a ring is used, tying the knots complicates the repair process and the use of Nitanol U-Clips (Coalescent Surgical, Sunnyvale, CA) will certainly facilitate this procedure. The use of the Chitwood clamp and custom-made antegrade cardioplegia system has proved to be safe and effective throughout our experience of over 200 port-access and robotic surgery patients [2].
Studies of robotic-enhanced totally endoscopic ablative therapy have been previously published [6]. These were cases with lone AF, and the general approach was to create a box lesion around the four pulmonary veins using a microwave probe. This method is invaluable during off-pump minimally invasive AF treatment, but the left atrium has to be opened anyway during mitral valve surgery, and it seems that the Cardioplate pen (Medtronic Inc) is more efficient and easier to manipulate in cases such as these [2].
We believe that this is the first report on combined totally endoscopic mitral valve repair and radiofrequency ablation using the da Vinci robotic system (Intuitive Surgical). The combined procedure proved feasible in these carefully selected cases. The wider application of a number of coapting technologies that are being developed may further facilitate such combined procedures.
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Disclosures and Freedom of Investigation
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This study was funded by the Florence Nightingale Hospital Foundation. Both the da Vinci system (Intuitive Surgical) and the Cardioblate system (Medtronic, Inc) for ablation were purchased by the hospital. The authors had full control of the design of the study, methods used, outcome measurements, and production of the written report.
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Disclaimer
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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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- Mohr FW, Falk V, Diegeler A, Walther T, Van Son JA, Autschbach R. Minimally invasive port-access mitral valve surgery J Thorac Cardiovasc Surg 1998;115(3):567-574.[Abstract/Free Full Text]
- Akpinar B, Guden M, Sagbas E, et al. Combined radiofrequency modified maze and mitral valve procedure through a port access approachearly and mid-term results. Eur J Cardiothorac Surg 2003;24:223-230.[Abstract/Free Full Text]
- Carpentier A, Loulmet D, Aupecle B, et al. Computer assisted open heart surgery. First case operated on with success C R Acad Sci III 1998;321(5):437-442.[Medline]
- Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced "robotic" cardiac surgeryexperience in 148 patients. J Thorac Cardiovasc Surg 2001;121(5):842-853.[Abstract/Free Full Text]
- Nifong LW, Chu VF, Bailey BM, et al. Robotic mitral valve repairexperience with the da Vinci system. Ann Thorac Surg 2003;75(2):438-446.[Abstract/Free Full Text]
- Loulmet D, Patel C, Patel NU, et al. First robotic endoscopic epicardial isolation of the pulmonary veins with microwave energy in a patient with atrial fibrillation Ann Thorac Surg 2004;78:e24-e25.[Abstract/Free Full Text]
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Abstract
Introduction
