Robotic Endoscopic Intracardiac Surgery With Percutaneous Cannulation: A Merger Of Transcatheter And Minimally Invasive Skills
Woodrow J. Farrington, II, Nassrene Elmadhun, Diana Ramanujam, Meghann M. Fitzgerald, Arash Salemi, Thomas S. Guy.
Weill Cornell - New York Presbyterian, New York, NY, USA.
OBJECTIVE: Surgical robotics allows incision size to be dramatically reduced with expedited postoperative recovery. Percutaneous approaches to cannulation have reduced the morbidity of transcatheter procedures. We report our early experience performing totally endoscopic robotic cardiac surgery with percutaneous access. METHODS: From July 2018 through December 2018, 29 consecutive patients underwent totally endoscopic robotic cardiac surgery with percutaneous peripheral cannulation. The mean age was 62.3 years (34-80), 13 male, 16 female, and mean BMI 29.8 (19.6-58.1). Robotic procedures included mitral valve repair (17), mitral valve replacement (5), atrial septal defect closure (3), septal myectomy (2), and atrial mass resection (2). Thoracic access was comprised of four 8mm robotic ports. Additionally, there was one 12mm working port for the bedside assistant, except mitral valve replacement that requires a 35mm port. All percutaneous cannulation was achieved with surface ultrasound, transesophageal echocardiography, and fluoroscopic guidance. Percutaneous pulmonary artery vent and retrograde cardioplegia catheters are placed by anesthesia. The surgeon places a common femoral multistage venous canula, common femoral arterial canula, and internal jugular venous canula for superior vena cava drainage. A pre-close technique is used to facilitate decannulation. The aorta was occluded using an endoaortic balloon. Lower extremity perfusion is monitored continuously with tissue and pulse oximetry. At the conclusion of the case, vascular doppler ultrasound is used to confirm arterial flow. RESULTS: The mean hospital stay was 4.7 days (1-16). Aortic clamp and cardiopulmonary bypass times were 75.9 (29-108) and 119.1 (67-148) min respectively. No patient was converted to thoracotomy or sternotomy. There were no hospital or follow-up mortalities. There was one patient with acute limb ischemia following deployment of a percutaneous vascular closure device related to a posterior plaque. This was immediately diagnosed, and an endarterectomy was performed with good result. All patients have reported no pain at the site of cannulation and there have been no lymphoceles or other complications related to cannulation. CONCLUSIONS: Our experience with endoscopic robotic cardiac surgery with percutaneous cannulation suggests that this technique is both feasible and safe. To our knowledge these cases represent the smallest incision open heart surgery currently being performed in the world today. 
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