Totally Endoscopic Resection Of Unsuspected Recurrent Pleural Tumor In Patient Undergoing Robotic Mitral And Tricuspid Repair
Neel K. Ranganath, Didier F. Loulmet, Hamza S. Sadhra, Travis C. Geraci, Robert G. Nampiaparampil, Robert J. Cerfolio, Aubrey C. Galloway, Eugene A. Grossi.
NYU Langone Health, New York, NY, USA.
A 75yo NYHA II woman presented with severe mitral and tricuspid regurgitation. Eight years prior, the patient underwent a large right thoracotomy for resection of a pleural tumor. We demonstrate a totally endoscopic resection of an unsuspected recurrent pleural tumor preceding concomitant mitral and tricuspid valve repair.
After initial positioning in left decubitus position via a postero-lateral approach, extensive adhesiolysis between the right lower lobe and diaphragm revealed a non-imaged 2-3cm right lower lobe mass. Limited parenchymal resection was performed.
The patient was repositioned supine. TEE confirmed severe MR with moderate-severe TR. Five lateral thoracic ports were placed for the DaVinciXi system. Cardiopulmonary bypass was instituted via femoral access with independent femoral and internal jugular venous lines. An endo-balloon clamp was positioned with fluorescent guidance and antegrade DelNido cardioplegia was administered. Sondergaard’s groove was opened and the left atrial appendage was oversewn with two layers of polytetrafluoroethylene (PTFE) suture.
The mitral valve was non-myxoid, inconsistent with Barlow’s disease. Inspection confirmed mild prolapse of the anterior leaflet, numerous hypertrophied and calcified secondary chordae, and restriction of the posterior leaflet. Secondary chordae were excised below A2-A3, P1-P2, and P2-P3 clefts. Small triangular excisions were performed at the A2-A3 and P1-P2 junctions, which were both reconstructed with a running PTFE suture. Hydrostatic testing revealed mild central insufficiency due to a lack of coaptation depth. Commissuroplasty was performed with a single PTFE suture, and the P2-P3 cleft was closed with a running PTFE suture. A 30mm annuloplasty band was placed. Final hydrostatic testing revealed excellent leaflet coaptation.
The cavae were occluded with snares and the tricuspid valve was exposed via right atriotomy. A reduction tricuspid annuloplasty with a 26mm band was performed. With the heart reperfused and aortic root and LV vented, the atriotomies were closed.
Postoperative TEE demonstrated preserved LV function with trace MR and TR. The patient was discharged on postoperative day 6. Final pathology confirmed a completely resected benign solitary fibrous tumor.
A totally endoscopic approach to mitral and tricuspid valve repair can be performed safely and effectively in patients with prior right thoracotomy.
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