MP58. Robotic-Assisted Redo Mitral Valve Replacement for Severe Patient-Prosthetic Valve Mismatch
Presented During: Moderated E-Posters
Houston, TX
United States - Contact Me
Dr. Alin Cheran is a currently a cardiothoracic surgery fellow at Baylor College of Medicine. He grew up in Toronto, Canada, where he attended the Universtiy of Toronto for his undergraduate degree before traveling to Ross Universisty School of Medicine to receive his MD. He then completed a general surgery residency at University of Illinois at Mt. Sinai. His career interest is general cardiac surgery with a focus on developing and refining minimally invasive cardiac surgery techniques.
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
New York Hilton Midtown
Room: Grand Ballroom Foyer
Description
Objective: To demonstrate a robotic assisted redo mitral valve replacement is feasible in a patient with an undersized prosthesis installed via sternotomy due to inadequate debridement of mitral annular calcification (MAC).
Case Video Summary: Patient is a 59-year-old male with HTN, LVH, ESRD on HD, BMI 38 that presented with progressive SOB and fatigue. Workup revealed CAD and severe mitral stenosis with MAC. The patient initially underwent a CABG x2 and MVR with a 21mm mechanical valve via median sternotomy. The initial surgery was complicated by inadequate debridement of MAC, resulting in an undersized valve. The patient also required postoperative LAD stenting one week post operation. Redo MVR was indicated for pulmonary edema and ventilator dependance due to elevated mean MV gradient >10mmHg.
The robotic procedure was performed with general anesthesia, dual lumen ETT intubation, peripheral femoral cardiopulmonary bypass, a 5cm anterolateral 4th intercostal thoracotomy and cardiac arrest. Three robotic instruments were inserted in a triangular fashion. The left atrium was entered via Sondergaard's groove and an atrial retractor was inserted. The prosthesis was explanted, and the remaining MAC was thoroughly debrided. We reconstructed the mitral annulus using bovine pericardium strips circumferentially. A larger 27mm mechanical valve was implanted with good leaflet movement. The patient was weaned off cardiopulmonary bypass without difficulty. TEE showed good prosthesis function without perivalvular leak and mean MV gradient of 3mmHg.
A 30-degree robotic camera with enhanced 3D imaging provided deep ventricular view of mitral annular calcium deposits and visualization of the mitral annulus junction with the myocardium. This allowed more thorough debridement while maintaining mitral annular integrity. With seven degrees of freedom, the fine instruments allowed accurate suture placement into the mitral annulus particularly at the aorto-mitral junction; a common location for perivalvular leakage. Intra-atrial perpendicular view of the prosthetic sewing cuff ensured optimal prosthesis position and securement. Finally, limited incision via robotic access allowed prompt surgery despite recent anticoagulation and anti-platelet therapy.
Conclusions: With optimal visualization, robotic-assisted MVR was superior to a redo sternotomy approach in this obese patient with a deep chest cavity, hypertrophied heart and poor exposure of the mitral valve.
Case Video Summary: Patient is a 59-year-old male with HTN, LVH, ESRD on HD, BMI 38 that presented with progressive SOB and fatigue. Workup revealed CAD and severe mitral stenosis with MAC. The patient initially underwent a CABG x2 and MVR with a 21mm mechanical valve via median sternotomy. The initial surgery was complicated by inadequate debridement of MAC, resulting in an undersized valve. The patient also required postoperative LAD stenting one week post operation. Redo MVR was indicated for pulmonary edema and ventilator dependance due to elevated mean MV gradient >10mmHg.
The robotic procedure was performed with general anesthesia, dual lumen ETT intubation, peripheral femoral cardiopulmonary bypass, a 5cm anterolateral 4th intercostal thoracotomy and cardiac arrest. Three robotic instruments were inserted in a triangular fashion. The left atrium was entered via Sondergaard's groove and an atrial retractor was inserted. The prosthesis was explanted, and the remaining MAC was thoroughly debrided. We reconstructed the mitral annulus using bovine pericardium strips circumferentially. A larger 27mm mechanical valve was implanted with good leaflet movement. The patient was weaned off cardiopulmonary bypass without difficulty. TEE showed good prosthesis function without perivalvular leak and mean MV gradient of 3mmHg.
A 30-degree robotic camera with enhanced 3D imaging provided deep ventricular view of mitral annular calcium deposits and visualization of the mitral annulus junction with the myocardium. This allowed more thorough debridement while maintaining mitral annular integrity. With seven degrees of freedom, the fine instruments allowed accurate suture placement into the mitral annulus particularly at the aorto-mitral junction; a common location for perivalvular leakage. Intra-atrial perpendicular view of the prosthetic sewing cuff ensured optimal prosthesis position and securement. Finally, limited incision via robotic access allowed prompt surgery despite recent anticoagulation and anti-platelet therapy.
Conclusions: With optimal visualization, robotic-assisted MVR was superior to a redo sternotomy approach in this obese patient with a deep chest cavity, hypertrophied heart and poor exposure of the mitral valve.