Anesthesia for Robotic Repair of the Mitral Valve: A Report of Two Cases

摘要

Robotic techniques are increasingly used in cardiac surgery because they allow precise tissue handling and enable the endoscopic performance of cardiac surgical tasks that require a high degree of dexterity (1). In addition, these techniques can fulfill the main goals of minimally invasive cardiac surgery—namely, a discrete scar, patient comfort, and fast rehabilitation (2). Thus, there is increased impetus to use this emerging technology in cardiac surgery, especially for mitral valve repair (1). The da Vinci™ Surgical System (Intuitive Surgical, Mountain View, CA) consists of a surgeon’s console (Fig. 1), a patient-side cart, a high-performance vision system, and instruments (Fig. 2). Using the da Vinci Surgical System, the surgeon operates while seated comfortably at a console viewing a three-dimensional image of the surgical field. The surgeon’s fingers grasp the instrument controls below the display, with wrists naturally positioned relative to his or her eyes. The robotic technology seamlessly translates the surgeon’s movements into precise, real-time movements of the surgical instruments inside the patient. The surgeon uses a microphone speaker to direct another surgeon positioned at the surgical field, directing the tasks of positioning a sucker to maximize visibility.Figure 1: Picture of the da Vinci robotic module, showing the surgeon’s console, printed with permission from Intuitive Surgical, Inc., Mountain View, CA.Figure 2: Picture of a skeleton with applied robotic arms, printed with permission from Intuitive Surgical, Inc., Mountain View, CA.Mitral valve surgeries with the robotic technique are presently being performed in nine cardiac centers in the United States. The anesthetic care of patients undergoing this procedure is a new challenge for cardiac anesthesiologists and has not been described previously. We present two patients who had successful mitral valve repair in our institution and highlight some of the anesthetic and perioperative issues associated with this procedure. Case Report Case 1 The patient, a 53-yr-old Caucasian man with severe mitral regurgitation (MR), had a history of hypertension and was treated with metoprolol, lisinopril, furosemide, and doxycycline. He was found to have cardiomegaly with bilateral effusions on chest radiography, normal sinus rhythm with left axis deviation, and left anterior fascicular block on electrocardiogram, whereas transthoracic echocardiography revealed normal left ventricular size and function, with a flail posterior mitral valve and severe MR. Cardiac catheterization revealed severe MR and an absence of significant coronary artery disease. The patient weighed 80 kg, had never experienced surgery, and was not known to be allergic to any medications. Before the operation, his hematocrit was 45.8%, blood urea nitrogen was 21 mg/dL, and plasma creatinine was 1.5 mg/dL; coagulation values were within the reference range. Case 2 The patient, a 58-yr-old Caucasian man with severe MR and a history of mitral valve prolapse, hypertension, and gastrointestinal bleeding of unknown etiology, was being treated with lisinopril. He was found to have an aberrant right subclavian artery on computed axial tomogram of the chest, sinus rhythm with first-degree atrioventricular block, and left ventricular hypertrophy on electrocardiogram. Transesophageal echocardiogram (TEE) revealed severe MR from prolapse and flail of the posterior mitral leaflet, with normal left ventricular function. Cardiac catheterization revealed a pulmonary artery pressure of 35/16 mm Hg and a cardiac output of 6.4 L/min. He weighed 91.6 kg, had had general anesthesia in the past without complications, and was not known to be allergic to any medications. Before surgery his hematocrit was 40.8%, blood urea nitrogen was 19 mg/dL, and plasma creatinine was 1.0 mg/dL, with a normal coagulation profile. After placement of standard monitors and a radial arterial line, both patients were anesthetized with a comb