International Society For Minimally Invasive Cardiothoracic Surgery

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Automated Suturing Technology For Minimally Invasive Mitral Valve Replacement
Victor Costache, MD1, Peter Knight, MD2, Andreea Costache, MD3, Crina Solomon1, Tatiana Melnic1, Jude Sauer, MD4, Grayson Wheatley, III, MD5.
1NextCARDIO Research Institute, Sibiu, Romania, 2University of Rochester Medical Center, Rochester, NY, USA, 3NextCardio Research Institute, Sibiu, Romania, 4Josephs Hospital, Syracuse, NY, USA, 5Siragusa Vascular, Nashville, TN, USA.

OBJECTIVE: Automated suturing technology has been shown to facilitate minimally invasive aortic valve replacements performed through a right thoracotomy. We present the first-in-man use of a novel automated suturing technology for placement of annular sutures during a minimally invasive mitral valve replacement performed using a right lateral mini-thoracotomy approach.
METHODS: A patient with severe rheumatic mitral valve stenosis underwent mitral valve surgery. After induction of general anesthesia, cardiopulmonary bypass was instituted via transfemoral arterial and venous cannulation using transesophageal echocardiography (TEE) guidance. A 5cm right lateral thoracotomy was made in the 4th intercostal space 10 cm lateral to the right sternal border. A soft tissue retractor was placed, followed by placement of an intercostal retractor to provide maximal exposure through the primary access incision. A longitudinal pericardiotomy from the right pericardial reflection to the diaphragm was performed anterior to the phrenic nerve. Pericardial stay sutures were placed.
RESULTS: Antegrade cold-blood cardioplegia was administered after cross-clamping the aorta. A left atrial retractor was delivered through a separate incision medial to the primary access incision. A 10mm videoscope was inserted through a mid-axillary line port. The mitral valve leaflets were excised while preserving elements of the posterior valve apparatus. Pledgeted annular sutures were placed using the RAM (LSI Solutions, Victor, NY) automated suturing device along with hand-placed sutures. Needle caps were loaded into SEW-EASY cassettes (LSI Solutions, Victor, NY). Once all the annular sutures were placed, they were sequentially passed through the sewing-cuff of a 29mm bioprosthetic mitral valve prosthesis using a SEW-EASY automated suturing device. The prosthesis was secured into the supra-annular position using a COR-KNOT (LSI Solutions, Victor, NY) automated titanium fastener. The left atriotomy was closed. The left atrium, left ventricle, and ascending aorta are deaired, the aortic cross clamp was removed, and cardiopulmonary bypass was discontinued.
CONCLUSIONS: Annular suture placement using a novel automated suturing technology during minimally invasive mitral valve surgery is feasible. Additional study is needed to determine whether use of automated suturing technology in minimally invasive mitral valve surgeries could positively affect patient outcomes by helping reduce the technical challenges associated with this approach.

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