Totally Endoscopic, Robotic-Assisted Mitral Valve Replacement in a Congenital Patient with Parachute Mitral Valve and Severe Mitral Stenosis

MP074 

Case Video Submission 

Andrea Amabile (1), Madonna Lee (2), Michael LaLonde (3), Markus Krane (4), Arnar Geirsson (5), Peter Gruber (5)

(1) Yale School of Medicine, New Haven, CT, (2) N/A, 0, United States, (3) Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, (4) Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, (5) Yale New Haven Hospital, New Haven, CT

Andrea Amabile    -  Contact Me
Yale School of Medicine

Madonna Lee    -  Contact Me
N/A

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

Markus Krane    -  Contact Me
Division of Cardiac Surgery, Yale School of Medicine

*Arnar Geirsson    -  Contact Me
Yale New Haven Hospital

*Peter Gruber    -  Contact Me
Yale New Haven Hospital

Madonna Lee    -  Contact Me
N/A

Objective: This case demonstrates feasibility of a mitral valve replacement in an adult congenital patient with parachute mitral valve using a totally endoscopic robotic-assisted approach.

Case Video Summary: A 33-year-old, 120 kg male presented with severe mitral stenosis and parachute valve. His past medical history was significant for coarctation of the aorta status post repair in infancy. Although he was followed closely with yearly imaging, he recently described decreasing activity levels. Pre-operative transesophageal echo (TEE) demonstrated a parachute mitral valve, with both leaflets attached to the posterior papillary muscle, and severe mitral stenosis with mean gradient 16 mmHg. He was referred for surgery.

The patient was brought into the OR and general anesthesia was induced. Percutaneous access of the femoral vessels was obtained for peripheral cannulation. One camera port, two working robotic arms, and a retractor port were placed into the right intercostal spaces. An endoaortic balloon was placed into the ascending aorta. CPB was initiated. The pericardium was opened. Prompt cardioplegic arrest was accomplished with antegrade cardioplegia. The left atrium was access through the interatrial groove with excellent exposure of the parachute mitral valve. One attempt at mitral valve repair was undertaken with inadequate result. The valve was too deformed to repair. A mechanical mitral valve replacement with 29 mm St. Jude Mechanical Valve was performed. Using pledgeted sutures and Cor-knot device, the sewing ring was secured to the mitral valve annulus. Total bypass time was 203 minutes and cross-clamp time 143 minutes. Post-operative TEE demonstrated a properly functioning valve with no regurgitation and mean gradient 5 mmHg. The patient was extubated in the OR.

Post-operatively, the patient had an unremarkable course. On POD#2 he went into atrial fibrillation with stable hemodynamics. He was treated with ASA, furosemide, and beta-blocker. For anticoagulation, coumadin was started with heparin bridge. He was discharged POD#4 with TTE demonstrating normal biventricular function and properly functioning mechanical valve.

Conclusions: Using a totally endoscopic robotic-assisted approach is feasible and should be considered when treating adult patients with congenital mitral valve disease.

Congenital Mitral Valve Disease