Robot-Assisted Resection of Tricuspid Valve Papillary Fibroelastoma

摘要

We report 3 cases of papillary fibroelastoma of the tricuspid valve. Two of them manifested with atypical symptoms of chest pressure and chest pain. Robot-assisted resection was performed to remove the mass while preserving the native valve. All patients recovered well. The 2 symptomatic patients experienced complete symptom resolution. We demonstrate the safety and feasibility of robotic resection in treating tricuspid valve papillary fibroelastoma. We report 3 cases of papillary fibroelastoma of the tricuspid valve. Two of them manifested with atypical symptoms of chest pressure and chest pain. Robot-assisted resection was performed to remove the mass while preserving the native valve. All patients recovered well. The 2 symptomatic patients experienced complete symptom resolution. We demonstrate the safety and feasibility of robotic resection in treating tricuspid valve papillary fibroelastoma. Tricuspid valve papillary fibroelastomas (TVPFEs) are typically asymptomatic with unclear surgical indications. Although robot-assisted surgery for other valve diseases has been reported, its efficacy in treating TVPFEs is unknown. In this series, we present 3 cases of robot-assisted TVPFE resection with good outcomes. We highlight the benefits of the robotic approach in resecting TVPFEs and the potential importance of surgical resection for symptom relief. A 71-year-old man was found to have a heart murmur at an annual checkup. Transthoracic echocardiography found mild tricuspid regurgitation and a mobile 2.5-cm mass located on the anterior and septal leaflets of the tricuspid valve. The patient denied symptoms. Robot-assisted resection was performed with the da Vinci Xi system (Intuitive Surgical). A 5-cm anterolateral thoracotomy incision was made in the fourth intercostal space. The femoral artery was cannulated with a 19F arterial cannula. A 25F multistage venous cannula was advanced to the inferior vena cava (IVC) through the femoral vein. A 19F venous cannula was inserted through the right internal jugular vein to the proximal superior vena cava. Cardiopulmonary bypass (CPB) was induced, and vacuum-assisted venous drainage was applied. The superior vena cava cannula was snared, whereas the IVC cannula was not. An antegrade cardioplegic catheter was placed. The aortic cross-clamp was applied before antegrade cardioplegia was given. A robotic grasper, atrium retractor, and scissors were inserted into the third, fourth, and fifth intercostal spaces, respectively. The right atrium was opened to expose the tricuspid valve. A 2.5 × 2.2 × 1.5-cm mass involving the anterior and septal tricuspid leaflets was noted (Figure 1A). The mass had a 1-cm attachment to the anterior leaflet and a loose attachment to the septal leaflet. On resection of the mass, a 1-cm defect was created in the anterior tricuspid leaflet and a 3- to 4-mm defect was created in the septal tricuspid leaflet (Figure 1B). The anterior leaflet defect was repaired with a 1.2-cm circular bovine pericardial patch. The small septal leaflet defect was repaired with a pair of 6-0 Prolene sutures. Valve competency was tested after repair and found satisfactory with mild regurgitation. The right atrium was closed. The patient was weaned off CPB, and the heart resumed spontaneous contraction. Transesophageal echocardiography (TEE) confirmed complete resection of the mass with normal tricuspid valve function and mild regurgitation. Total CPB and cross-clamp times were 114 and 74 minutes, respectively. The patient’s hospital length of stay was 7 days. Pathologic examination confirmed TVPFE. A 2-year follow-up visit showed no clinical issues. A 60-year-old woman presented with occasional chest pain and palpitations. TEE revealed mild tricuspid regurgitation and a 1.7-cm mass on the anterior leaflet of the tricuspid valve. Robot-assisted resection was performed as previously described. Intraoperatively, a 1.7 × 1.7 × 1.0-cm mass with a 5- to 6-mm attachment to the anterior leaflet o