International Society For Minimally Invasive Cardiothoracic Surgery

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The Evolution Of Robotic Totally Endoscopic Aortic Valve Replacement: Development Of A State Of The Art Technique And Future Steps
Bob Kiaii1, Husam H. Balkhy2, Hubert Stein3, Marco Vola4.
1London Health Sciences Center, London, ON, Canada, 2University of Chicago, Chicago, IL, USA, 3Intuitive Surgical, Sunnyvale, CA, USA, 4University of Lyon, Lyon, France.

Objective: As the treatment of Aortic Valve Disease continues to become Catheter-based, we need to improve the treatment of patients with aortic valve disease who are not candidates for catheter based intervention. Hence in the quest of developing a minimally invasive endoscopic aortic valve replacement, we embarked on developing a Robotic totally endoscopic aortic valve replacement (TEAVR) Methods: A total of 4 cadavers were utilized. Several locations for the endoscopic ports over the anterior chest wall were investigated. The endoscopic ports were all adapted to the da Vinci Robotic system (Intuitive Surgical, Sunnyvale, CA). The goal was to identify the most ideal location for port placement to perform robotic TEAVR. All steps of the procedure, including aortotomy, visualization of the aortic valve, valve debridement, placement of sutures and then closing the aorta, were performed. Results: The most ideal location for the endoscopic ports included Camera port in the 2ndspace (4 cm from sternal edge), Right robotic arm in the 3rdinterspace 2 cm lateral from midclavicular line (MCL), and the left robotic arm in the 1st space at the MCL. The working port in the 2ndspace, 2-3 cm lateral from camera port between the right and left arm port. The procedural steps include removal of pericardial fat, opening of pericardium, placement of pericardial traction sutures. The aorta should be dissected as high as possible from the pulmonary artery to enable cross-clamping of the aorta. Robotic assistance facilitated insertion of the purse string suture over the right superior pulmonary vein for insertion of the left ventricular vent. In one cadaver who actually had aortic valve stenosis we discovered that the robotic instruments were not adequate for valve debridement and annular decalcification. Using this approach, our group successfully completed several robotic TEAVR at two different institutions. Conclusion: The utilization of robotics in TEAVR further enhances the procedure by providing a 3-dimentional visualization and better dexterity in manipulating and suturing the aorta and the aortic annulus. The sutureless or rapid deployment valve technology further facilitates this procedure. Robotic TEAVR is feasible but for it to get more widespread adoption there needs to be improvement and development of instrumentation such as valve sizers and robotic instruments to enable better debridement of the calcium from the aortic annulus.

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