Robotic Mitral Respectful Resection For Repair Of Diffuse Degenerative Posterior Leaflet Disease
Harold G. Roberts, M.D., Lawrence M. Wei, M.D., Christopher C. Cook, M.D., Takashi Murashita, M.D., J. Scott Rankin, M.D., Vinay Badhwar, M.D..
West Virginia University, Morgantown, WV, USA.
OBJECTIVE: Non-resection and resection techniques are equally accepted methods to repair myxomatous degeneration. In cases at elevated risk of systolic anterior motion (SAM), strategies are needed to reduce posterior leaflet height while preserving leaflet motion. A simplified technique of limited resection merged with neochordal support is presented.
METHODS: From June 2016 to June 2017, 12 cases with high risk echocardiographic predictors of SAM were managed robotically with a limited triangular posterior leaflet resection followed by a single polytetrafluroethylene (PTFE) suture used both for chordal support to the papillary muscle as well as leaflet re-approximation. Patients were followed with intraoperative as well as 30-day and 1 year echocardiography.
RESULTS: The video case is a 55 year old male with symptomatic severe mitral valve disease with preserved left ventricular function. His echocardiographic findings included a severe anteriorly directed jet of regurgitation combined with an acute aorto-mitral angle, a reduced coaptation point to outflow tract septal distance, a long anterior leaflet and a tall posterior leaflet with diffuse myxomatous change. Along with an annular dimension of 34 mm, the pathoanatomy was predictive of SAM. Therefore, instead of a sliding valvuloplasty or multiple PTFE neochords, a generous but focal posterior triangular resection was completed with a simple 4-0 PTFE suture placed in the posterior papillary muscle used to complete the double layer valvular anastomosis. This was followed by a 38 mm posterior band. Intraoperative and 30 day echocardiogram revealed no residual regurgitation and no SAM. The other 11 cases in this series had identical echocardiographic results.
CONCLUSIONS: A technique of "respectful resection" imparts the principles of leaflet motion preservation known with PTFE techniques along with the posterior height reduction from resection methods. In this early experience, this technique appears to be a feasible solution for patients at risk for SAM and readily applicable to a robotic approach.
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