Robotically Controlled Video-Assisted Port-Access Mitral Valve Surgery

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Asian Cardiovascular and Thoracic Annals http://aan.sagepub.com/

Robotically Controlled Video-Assisted Port-Access Mitral Valve Surgery Naresh Trehan, Yugal K Mishra, Mitesh Sharma, Surinder Bazaz, Yatin Mehta, Krishan Kant Sharma and Sameer Shrivastava Asian Cardiovascular and Thoracic Annals 2002 10: 133 DOI: 10.1177/021849230201000209 The online version of this article can be found at: http://aan.sagepub.com/content/10/2/133

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Trehan ORIGINAL

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Robotic Mitral Valve Surgery

Robotically Controlled VideoAssisted Port-Access Mitral Valve Surgery Naresh Trehan, MD, Yugal K Mishra, PhD, Mitesh Sharma, MCh, Surinder Bazaz, MCh, Yatin Mehta, MD1, Krishan Kant Sharma, MD1, Sameer Shrivastava, DM2

INDIA

Department of Cardiovascular Surgery 1Department of Anaesthesiology 2Department of Cardiology Escorts Heart Institute and Research Centre New Delhi, India

ABSTRACT From 1997 to 2000, 221 patients underwent mitral valve surgery through a minithoracotomy, using a port-access endovascular cardiopulmonary bypass system in 38 and a transthoracic clamp in 183. In 120 patients, exposure of the mitral valve was facilitated by an endoscope attached to a voice-controlled robotic arm (AESOP 3000). The mitral valve was repaired in 26 patients and replaced in 195; 24 were redo cases. Operating time was 3.5 ± 1.2 hours, aortic crossclamp time was 58 ± 16 minutes, intensive care unit stay was 22 ± 7 hours, and hospital stay was 6.4 ± 1.2 days. Median postoperative blood loss was 332 ± 104 mL. There was 1 hospital death. On follow-up at 16.4 ± 12.2 months, there was no late death or reoperation. New York Heart Association functional class improved from 2.6 ± 0.5 to 1.4 ± 0.8. Use of video and robotic assistance minimized incision length and allowed visualization of the whole mitral valve apparatus. The transthoracic clamp facilitated aortic crossclamping and injection of cardioplegia. These findings indicate that the procedure is safe and effective and suggest advantages over conventional surgery in terms of cost, cosmesis, blood loss, postoperative discomfort, intensive care unit and hospital stay. (Asian Cardiovasc Thorac Ann 2002;10:133–6)

INTRODUCTION Less invasive cardiac surgery has emerged as a new and substantially different approach in various cardiovascular surgical procedures. The largest experience concerns coronary artery bypass grafting. However, minimally invasive valve surgery may prove even more promising than new coronary procedures because detailed vascular anastomosis is not required. Using a ministernotomy and parasternal incision, several groups have shown encouraging operative results with low surgical mortality.1–5 In early 1996, the Stanford group performed the first 4

minimally invasive mitral valve (MV) replacements using intraaortic balloon occlusion (port access) with cardioplegia.6 Later, Falk and colleagues7 at the University of Leipzig reported 24 successful MV operations using a similar technique. Video assistance appears to offer advantages over direct vision through tiny incisions. Carpentier and colleagues8 performed the first videoassisted MV repair through a minithoracotomy, using cold ventricular fibrillation. Chitwood’s group9,10 carried out the first video-assisted minimally invasive MV surgery in North America, with percutaneous crossclamping and

For reprint information contact: Yugal K Mishra, PhD Tel: 91 11 682 5000 Fax: 91 11 682 5013 email: [email protected] Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025, India. 2002, V OL . 10, N O . 2

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Robotic Mitral Valve Surgery cardioplegia. Subsequently, video assistance has been used extensively in Europe for MV surgery.11,12 The aim of this study was to evaluate the use of video-assisted minimally invasive MV surgery.

PATIENTS AND METHODS Between September 1997 and September 2000, 221 patients underwent MV surgery through a right anterolateral minithoracotomy at the 4th intercostal space. A video-assisted technique was employed in 120 patients, using a voice-controlled robotic arm (AESOP 3000; Computer Motion, Inc., Santa Barbara, CA, USA). Surgery was carried out under direct vision in 101 patients. There were 78 males and 143 females, with a mean age of 36.4 ± 10.5 years. Most had rheumatic valvular pathology (Table 1), and 74 patients had involvement of the tricuspid valve. Patients were placed in a supine position with the right side of the chest slightly elevated. Standard anesthetic techniques for our institution were used. The right or left femoral artery and vein were surgically exposed through a 3- to 4-cm incision parallel to the inguinal skin fold. After systemic heparinization, a 21F Y-shaped arterial return cannula (Heartport, Inc., Redwood City, CA, USA) or a 21F straight cannula (DLP, Inc., Grand Rapids, MI, USA) was inserted into the femoral artery, depending on whether an endoaortic or transthoracic occlusion clamp was to be used. A 28F venous return cannula (Heartport) was placed in the femoral vein and advanced to the right atrium (RA) and then to the superior vena cava, guided by transesophageal echocardiography (TEE). A conventional cardiopulmonary bypass system with a roller pump and membrane oxygenator was used. In addition, a centrifugal pump (Sarns, Inc., Ann Arbor, MI, USA) was placed in the venous line to enhance drainage. A 5- to 8-cm incision was made anterolaterally over the 4th intercostal space on the right side. The pericardium was opened 3 cm above and parallel to the right phrenic nerve to expose the roof of the left atrium; exposure was enhanced by placing stay sutures on the pericardium, which were fixed to the chest wall. Cardiopulmonary bypass was instituted with temperature drift, without active cooling or warming, until the aortic crossclamp was in place. Before insertion of the endovascular aortic clamp, the aorta was examined by TEE for atheromatous plaque and thrombi, to avoid cerebral embolization during retrograde perfusion. Advancement of the guidewire could be visualized from the descending aorta to the aortic valve by TEE. Correct placement of the endovascular clamp (1 cm above the level of the sino-tubular junction) was controlled by fluoroscopy (Sieremobil 2000; Siemens, Erlangen, Germany) and multiplane TEE (SONOS 5500; Hewlett Packard, Inc., Andover, MA, USA). The balloon of the endovascular clamp was inflated to achieve endoluminal block of the ascending aorta while the heart was vented through the distal lumen of the endovascular A SIAN CARDIOVASCULAR & T HORACIC ANNALS

Table 1. Preoperative Characteristics of 221 Patients Variable Male/female ratio Mean age (years) NYHA functional class I II III Valvular pathology Rheumatic Degenerative Predominant mitral insufficiency Predominant mitral stenosis Ejection fraction (%) Tricuspid regurgitation Severe Mild to moderate Redo cases

No. of Patients 78/143 36.4 ± 10.5 9 66 146 188 33 144 77 45 ± 7 12 62 24

NYHA = New York Heart Association.

clamp in the aortic root. After clamping, the endovascular balloon pressure was continuously monitored and maintained between 250 and 340 mm Hg. Warm blood cardioplegic solution was delivered antegradely through the lumen of the endovascular clamp while maintaining aortic root pressure between 50 and 70 mm Hg. The endovascular clamp was used in the first 38 cases, but the transthoracic sliding-rod aortic clamp (Scanlan International, Inc., Minneapolis, MN, USA) was preferred in the next 183 cases; it was passed through the 3rd intercostal space at the midclavicular line through a 3-mm port. A DLP cardioplegia catheter was used for antegrade cardioplegia delivery, and a DLP catheter was also used for aortic root suction during deairing. After cardiac arrest was established, the left atrium was opened and the MV was exposed by a specially designed atrial retractor (Heartport) inserted through another 3-mm port at the 5th or 6th intercostal space parasternally. MV repair or replacement was performed under direct vision using a specially designed instrument (Heartport). The Starr-Edwards MV prosthesis (Baxter Healthcare Corp, Edwards CVS Division, Irvine, CA, USA) was chosen for valve replacement. After completion of the procedure, a left atrial vent was positioned across the MV and the left atrial incision was closed. In patients requiring concomitant tricuspid valve repair, the venous drainage cannula was withdrawn to the inferior vena cava after completion of MV surgery, and the RA was opened while the pump sucked out blood returning from the superior vena cava. The tricuspid valve was exposed with an insitu mitral retractor, and the repair was completed. The RA was closed and the venous drainage cannula was pushed back to the RA. Deairing was performed by inflation of the lungs and simultaneous reduction of venous drainage with the patient placed in the Trendelenburg

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position. Air in the aorta was removed by suction through the distal lumen of the endovascular clamp or cardioplegia catheter (depending on which was in place). The endovascular aortic clamp was deflated and the catheter was left in place for further venting until deairing was complete. If necessary, defibrillation was performed using external defibrillation pads. A temporary pacing wire was placed in the right ventricular epicardium before the aortic crossclamp was removed. After appropriate reperfusion, the arterial and venous cannulae were removed and the femoral vessels were repaired. The chest wound was closed after inserting a drainage tube into the pleural space. Postoperatively, the patients were followed up by echocardiography at 3 months, 6 months, and then annually. Data were prospectively collected using a prescribed form and stored in a database.

RESULTS In all patients, the MV was easily accessed through the right anterolateral minithoracotomy. The average length of the incision was 6.8 ± 1.8 cm (range, 5 to 8 cm). There Table 2. Operative Procedures in 221 Patients Procedure MVR MVR + TV repair MV repair + ASD closure MVR + ASD closure MV repair + TV repair MV repair Post-MVR paravalvular leak closure

No. of Patients 178 12 1 4 3 22 1

ASD = atrial septal defect, MV = mitral valve, MVR = mitral valve replacement, TV = tricuspid valve.

Table 3. Follow-up Findings in 220 Survivors Variable Mean follow-up (months) Late death Reoperation Anticoagulant-related complications Echocardiographic results Mitral valve repair Residual stenosis Preoperative MR (graded 0–4) Postoperative MR (graded 0–4) Mitral valve replacement Paravalvular leak SABE vegetation on prosthetic valve NYHA functional class Preoperative (1–4) Postoperative (1–4)

The findings at follow-up are listed in Table 3. Functional status was found to have improved by one class in all except 5 patients who had longstanding mitral regurgitation with high pulmonary artery pressures. One patient had an anticoagulant-related complication: she was readmitted with bleeding from the gums and swelling at the femoral cannulation site; her prothrombin time was found to be very prolonged due to a high dose of anticoagulation. She was managed with a fresh frozen plasma transfusion that stopped the bleeding from the gums, and the groin swelling began to regress. When her prothrombin time was controlled, the residual groin swelling was aspirated; it revealed collected altered blood.

No. of Patients

DISCUSSION

16.4 ± 12.2 0 0 1

0 3.2 ± 0.4 0.6 ± 0.7 0 1 2.6 ± 0.5 1.4 ± 0.8

MR = mitral regurgitation, NYHA = New York Heart Association, SABE = subacute bacterial endocarditis.

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were no conversions to sternotomy. Operative procedures are outlined in Table 2. The MV was repaired by a combination of techniques including commissurotomy, sliding plasty, and ring annuloplasty. Successful repair was achieved in all 26 cases, as demonstrated by intraoperative TEE. In patients undergoing MV replacement, the posterior mitral leaflet could be preserved in all except 25 with heavily calcified valves. The mean operating time was 3.5 ± 1.2 hours, and crossclamp time was 58 ± 16 minutes. Among the patients who underwent transthoracic sliding-rod aortic crossclamping, there was no clamp-related injury or aortic dissection. The mean duration of intensive care was 22 ± 7 hours, and hospital stay was 6.4 ± 1.2 days. Median postoperative blood loss was 332 ± 104 mL. Four patients developed lymphorrhea from groin wounds, requiring surgical intervention to ligate cut lymphatics. One patient developed left hemiparesis after extubation on the 1st postoperative day, and had recovered fully by the 3rd postoperative day. There were 3 cases of chest wound complications. One death occurred on the 12th postoperative day due to massive upper gastrointestinal bleeding in an 85-year-old man with a bioprosthesis operated on for degenerative mitral regurgitation. On discharge, all patients had normal MV function with trivial or no regurgitation.

The right anterolateral minithoracotomy is appropriate for minimally invasive MV surgery because the incision gives a direct view of the left atrium with minimal patient discomfort. Nearly two-thirds of our patients were young women, and this incision provides good cosmesis as it is hidden below the breast. Using video and a voicecontrolled robotic arm, it was possible to limit the length of the incision while achieving good visualization of the whole mitral apparatus. We now routinely use the transthoracic aortic clamp instead of the endovascular clamp, because this technique is safe and requires few additional resources or disposable supplies. The transthoracic clamp technique shortens the time of surgery, facilitates complete aortic crossclamping, provides good myocardial protection via antegrade cardioplegia, and reduces cost. The endovascular clamp provides similar

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Robotic Mitral Valve Surgery intraluminal aortic occlusion and antegrade cardioplegia capabilities, but it is more expensive. In this series, there was no aortic dissection with use of the endovascular clamp as reported by Mohr and colleagues,11 which may be because of the younger age of our patients. There were no complications related to femoral artery cannulation as reported previously, for the same reason.11,13

3.

Konertz W, Waldenberger F, Schmutzler M, Ritter J, Liu J. Minimal access valve surgery through superior partial sternotomy: a preliminary study. J Heart Valve Dis 1996; 5:638–40.

4.

Arom KM, Emery RW. Minimally invasive mitral operations [letter]. Ann Thorac Surg 1997;63:1219a–20a.

5.

Navia JL, Cosgrove DM III. Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542–4.

This study included 24 patients who had undergone previous operations: aortic valve replacement in 5, coronary bypass grafting in 8, closed mitral commissurotomy in 10, and one had a paravalvular leak after MV replacement one year earlier. In all redo cases except previous closed mitral commissurotomies, the endovascular clamp was used as it avoids the need for extensive dissection to clear the aorta for external clamping. The right minithoracotomy is an excellent approach for MV procedures in patients who have had previous cardiac surgery through a median sternotomy.

6.

Pompili MF, Stevens JH, Burdon TA, Siegel LC, Peters WS, Ribakove GH, et al. Port-access mitral valve replacement in dogs. J Thorac Cardiovasc Surg 1996; 112:1268–74.

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Falk V, Walther T, Diegeler A, Wendler R, Autschbach R, van Son JA, et al. Echocardiographic monitoring of minimally invasive mitral valve surgery using an endoaortic clamp. J Heart Valve Dis 1996;5:630–7.

8.

Carpentier A, Loulmet D, Carpentier A, Le Bret E, Haugades B, Dassier P, et al. Open heart operation under videosurgery and minithoracotomy. First case (mitral valvuloplasty) operated with success [French]. C R Acad Sci III 1996;319:219–23.

9.

Chitwood WR Jr, Elbeery JR, Chapman WHH, Moran JM, Lust RL, Wooden WA, et al. Video-assisted minimally invasive mitral valve surgery: the “micro-mitral” operation. J Thorac Cardiovasc Surg 1997;113:413–4.

In addition to cost effectiveness and good cosmesis, the limited postoperative blood loss, low mortality (0.45%), and excellent early echocardiographic results attest to the safety and efficacy of this approach, and were similar to the results of conventional surgery. However, the minimally invasive technique required a slightly longer operating time, which is attributed to the additional technical maneuvers to enhance exposure and ensure proper deairing under TEE control. A prospective study is currently underway to evaluate the additional benefits of this technique over conventional MV surgery, in terms of blood transfusion requirements, postoperative discomfort, intensive care unit and hospital stay.

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Cosgrove DM III, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62: 596–7. Cosgrove DM III, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg 1998;65:1535–8.

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10. Felger JE, Chitwood WR Jr, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach. Ann Thorac Surg 2001;72:1203–9. 11.

Mohr FW, Falk V, Diegeler A, Walther T, van Son JAM, Autschbach R, et al. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 1998;115: 567–71.

12. Reichenspurner H, Boehm DH, Gulbins H, Schulze C, Wildhirt S, Welz A, et al. Three-dimensional video and robot-assisted port-access mitral valve operation. Ann Thorac Surg 2000;69:1176–81. 13. Aklog L, Adams DH, Couper GS, Gobezie R, Sears S, Cohn LH. Techniques and results of direct-access minimally invasive mitral valve surgery: a paradigm for the future. J Thorac Cardiovasc Surg 1998;116:705–15.

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