Robotic mitral valve repair, left atrial appendage exclusion and cryoMAZE in pectus excavatum

6333 

Cardiothoracic Resident Case Report Competition 

Irbaz Hameed (1), Sigurdur Ragnarsson (2), Andrea Amabile (3), Michael LaLonde (4), Markus Krane (5), Arnar Geirsson (6)

(1) N/A, United States, (2) N/A, N/A, (3) Yale School of Medicine, New Haven, CT, (4) Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, (5) N/A, Greenwich, CT, (6) Yale New Haven Hospital, New Haven, CT

Irbaz Hameed    -  Contact Me
N/A

Sigurdur Ragnarsson    -  Contact Me
N/A

Andrea Amabile    -  Contact Me
Yale School of Medicine

Michael LaLonde    -  Contact Me
Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine

Markus Krane    -  Contact Me
N/A

*Arnar Geirsson    -  Contact Me
Yale New Haven Hospital

Irbaz Hameed    -  Contact Me
N/A

Objective: To demonstrate the feasibility and advantages of the robotic approach to the mitral valve in patients with severe pectus excavatum.

Case Video Summary: We present the case of robotic mitral valve repair with left atrial appendage exclusion and cryoMAZE in a patient with pectus excavatum. Our patient is a 69-year-old man with severely restricting chest anatomy due to pectus excavatum with New York Heart Association Class II symptoms of dyspnea on exertion. Pectus excavatum is a relative contraindication to robotic approach to the mitral valve, but surgery is also challenging through sternotomy. Pre-operative imaging showed thickened leaflets with anterior leaflet prolapse causing severe posteriorly directed mitral regurgitation jet. Percutaneous cannulation with 21Fr arterial cannula and 23Fr venous cannula were performed and endoaortic balloon pump was deployed into the aorta. The camera port was placed in the 3rd intercostal space, a left arm port in the 2nd intercostal space and the right arm port in the 5th intercostal space. An additional retractor port was placed in the 4th intercostal space more medially under direct vision.
Exposure was challenging due to the depressed sternum. The low chest height in our patient would have made a non-robotic approach very challenging and the advantage of the robotic approach in this kind of anatomy can be appreciated in the video. After going on bypass and cooling, the pericardium was opened, and retraction sutures were placed. We then inflated the endoaortic balloon, fibrillated the heart and gave 1.2L of antegrade cardioplegia. There was good myocardial arrest. We entered the left atrium through the interatrial groove and used the retractor to expose the mitral valve. The mitral valve was noted to have myxomatous degenerative changes and prolapse of A1 and A2. We placed retraction sutures in the posterior pericardium to the posterior wall of the left atrium, and then proceed to close the left atrial appendage using running Gore-Tex sutures. A left sided cryoMAZE was performed with 2min freezes. The lines were made at the epicardial coronary sinus, mitral line, bilateral pulmonary veins, and base of left atrial appendage. The mitral valve was repaired by placing three separate neochords to A2x2, A1x1. We then placed a 32mm annuloplasty band. Height adjustment of the neochords was performed and the leaflets appeared to coapt nicely on saline testing.
We removed the retractor, closed the atriotomy using Gore-Tex sutures from either side. The heart was deaired and the endoaortic balloon cross-clamp was removed. We placed a bipolar ventricular wire and two 24Fr Blake chest tubes. The patient was weaned off bypass without any problems. There was no mitral regurgitation at the end of the operation with a mean gradient of 1 mmHg.

Conclusions: In summary, with experience, robotic mitral is safe and feasible in select patients with pectus excavatum. It can help avoid sternotomy-related intra- and post-operative complications and provide superior exposure. Compared to right mini-thoracotomy, robotic mitral valve repair also provides three-dimensional instrumentation to the mitral valve with greater flexibility in tight spaces.

Adult Cardiac