MP76. Totally Endoscopic, Robotic-Assisted Papillary Muscles Cryoablation and Mitral Valve Repair
Presented During: Moderated E-Posters
University of Pittsburgh Medical Center
PITTSBURGH, PA
United States - Contact Me
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Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
New York Hilton Midtown
Room: Grand Ballroom Foyer
Description
Objective: Over the past 20 years, many centers have progressively adopted the use of robotic assistance as part of their mitral valve repair armamentarium. The magnified stereoscopic vision and the enhanced technical dexterity offered by the robotic platform allow for optimal visualization of both the valve and the sub-valvular apparatus. We present the case of a 67-year-old male with severe, symptomatic, bileaflet mitral valve prolapse and history of ventricular tachycardia and prior ablation attempt.
Case Video Summary: Port configuration consisted of the working port and camera being placed in the third intercostal space at the left anterior axillary line; the left robotic arm port placed in the second intercostal space, halfway between the anterior axillary line and the midclavicular line; the right robotic arm port placed in the fifth intercostal space, slightly below the anterior axillary line; and the left atrial retractor placed in the fourth intercostal space two centimeters medial to the midclavicular line. Cardiopulmonary bypass was achieved by percutaneous femoral cannulation. Aortic cross-clamp and cardioplegia delivery were provided using the endoaortic balloon occlusion device. After exposure through the Waterston's groove, the mitral valve was inspected and had myxomatous degenerative changes leading to bileaflet prolapse and severe annular dilatation. We also noted mitral annular disjunction at the base of P1 and P2 scallops. We closed the left atrial appendage and then performed cryo-ablation of the tip of both papillary muscles under magnified direct visualization, with a freezing time of 2 minutes each. We then turned our attention to the mitral valve, which was repaired by a combination of various techniques: we excised the thickened, disjunct basal portion of P1 and P2 with subsequent reattachment to the native annulus, we placed two separate neochords to P2, and we finally completed the repair with a 38-mm annuloplasty band. A small PFO was noted and closed. CPB and AXT were 193 minutes and 148 minutes, respectively. Postoperative transesophageal echocardiography revealed trace mitral regurgitation with a mean gradient of 3 mmHg. The patient had an uneventful postoperative recovery, with no subsequent ventricular arrhythmic events.
Conclusions: Using a totally endoscopic, robotic-assisted approach is safe and effective for the treatment of bileaflet arrhythmic mitral regurgitation.
Case Video Summary: Port configuration consisted of the working port and camera being placed in the third intercostal space at the left anterior axillary line; the left robotic arm port placed in the second intercostal space, halfway between the anterior axillary line and the midclavicular line; the right robotic arm port placed in the fifth intercostal space, slightly below the anterior axillary line; and the left atrial retractor placed in the fourth intercostal space two centimeters medial to the midclavicular line. Cardiopulmonary bypass was achieved by percutaneous femoral cannulation. Aortic cross-clamp and cardioplegia delivery were provided using the endoaortic balloon occlusion device. After exposure through the Waterston's groove, the mitral valve was inspected and had myxomatous degenerative changes leading to bileaflet prolapse and severe annular dilatation. We also noted mitral annular disjunction at the base of P1 and P2 scallops. We closed the left atrial appendage and then performed cryo-ablation of the tip of both papillary muscles under magnified direct visualization, with a freezing time of 2 minutes each. We then turned our attention to the mitral valve, which was repaired by a combination of various techniques: we excised the thickened, disjunct basal portion of P1 and P2 with subsequent reattachment to the native annulus, we placed two separate neochords to P2, and we finally completed the repair with a 38-mm annuloplasty band. A small PFO was noted and closed. CPB and AXT were 193 minutes and 148 minutes, respectively. Postoperative transesophageal echocardiography revealed trace mitral regurgitation with a mean gradient of 3 mmHg. The patient had an uneventful postoperative recovery, with no subsequent ventricular arrhythmic events.
Conclusions: Using a totally endoscopic, robotic-assisted approach is safe and effective for the treatment of bileaflet arrhythmic mitral regurgitation.