Robotic mitral valve repair in a patient with cardiac dextroversion

Abstract

Central MessageMitral regurgitation and left ventricular outflow tract obstruction can be effectively approached and treated with complex robotic mitral valve repair in a patient with cardiac dextroversion.See Commentaries on pages 17 and 19. Mitral regurgitation and left ventricular outflow tract obstruction can be effectively approached and treated with complex robotic mitral valve repair in a patient with cardiac dextroversion. See Commentaries on pages 17 and 19. A 25-year-old woman with dextroversion was found to have moderate mitral regurgitation (MR) complicated by systolic anterior motion (SAM) of the anterior leaflet, causing obstruction of the aortic valve and left ventricular outflow tract (LVOT). The patient presented with increasing symptoms of intermittent nonexertional chest pressure and dyspnea on exertion. A preoperative transthoracic echocardiogram revealed worsening MR and LVOT obstruction with a peak resting gradient of 37 mm Hg and 70 mm Hg on provocative testing. Further imaging with computed tomography and magnetic resonance imaging was obtained for surgical planning employing the da Vinci Xi surgical robot (Intuitive Surgical, Inc, Sunnyvale, Calif). The heart was positioned in the right chest, with the apex pointing towards the right. The left ventricle was anterior to the right ventricle, with the mitral valve positioned anterior to the aortic valve and LVOT (Figure E1, A). It was noted that the posteriorly leaflet was quite long and that the acute angle from the anterior leaflet of the mitral valve to the aortic root was causing the LVOT obstruction (Figure E1, B). Intraoperative transesophageal echocardiogram showed SAM, moderate MR, anterior mitral leaflet height of 4.0 cm, posterior mitral leaflet height of 2.50 cm, LVOT of 1.1 cm, and C-sept distance of 2.39 cm (Figure E2, A). The patient was positioned supine with gel pad under the left side to rotate the chest slightly toward the right. A small access incision was made in the left fourth intercostal space and robotic ports placed in second, fourth, and sixth intercostal space (Figure 1, A). Femoral cannulation was used for cardiopulmonary bypass and IntraClude (Edwards Lifesciences) intra-aortic occlusion device for cardioplegia delivery. The robot was connected in place, the left lung was deflated, and the chest was explored. Exposure through the pericardium was carefully achieved without injury to the left phrenic nerve, which was running quite anteriorly on the pericardium. Cardiopulmonary bypass was initiated, and cardioplegia was administered after confirming a robust seal of the inflated endoballoon. The left atrium was entered just above the left superior pulmonary veins and posterior to the coronary sinus, which contained the persistent left superior vena cava. A retractor placed for exposure to the mitral valve, which was uniquely oriented in that the morphologically posterior leaflet faced anteriorly (Figure 2, A). No leaflet prolapse was observed (Figure 2, B).Figure 2Intraoperative picture showing (A) morphologic anterior mitral valve leaflet positioned inferiorly; (B) saline testing before mitral valve repair with coaptation line in center of the valve due to excessive length of morphological posterior leaflet; (C) annular advancement technique used to effectively shorten the height of the morphological posterior leaflet; and (D) saline testing after mitral valve repair with semirigid annuloplasty band restoring the normal one-third posterior to two-thirds anterior height ratio.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The valve was repaired by decreasing the height of the posterior leaflet using annular advancement technique also known as imbrication technique.1Hashim P.W. Assi R. Hashim S.W. The imbrication technique: an alternative to the sliding leaflet technique.Ann Thorac Surg. 2014; 98: 1124-1126Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar This decreases the height of the leaflet