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How I Do It: Robotic Endoscopic Mitral Valve Repair Video
Caroline M. Komlo, BS1, Brigitte Anderson, BS1, Nkosi H. Alvarez, MD1, Regina E. Linganna, MD2, Jordan E. Goldhammer, MD2, T. Sloane Guy, MD, MBA1.
1Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 2Department of Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

BACKGROUND: The use of cryoanesthesia for intercostal nerve block, the utility of V-lock sutures, and percutaneous cannulation for robotic total endoscopic mitral valve repair using an 8 mm working port incision are introduced in this video.
METHODS: A 61 year-old male with asymptomatic, severe, non-rheumatic mitral regurgitation with severe P2 prolapse underwent robotic endoscopic mitral valve repair. 8 mm incisions were made for the robotic camera, left and right arm, and the working port. Three 14-gauge long Angiocatheters were placed in the right chest wall for suture exteriorization. Under ultrasound guidance, a 5-French micro-puncture followed by 6-French sheath were used for femoral vessel cannulation. Pro-glide sutures were placed for eventual percutaneous closure. Percutaneous femoral venous cannulation of the SVC, percutaneous arterial cannulation, and an aortic endoballoon were placed under fluoroscopic and TEE guidance. A right diaphragmatic retraction suture was placed and exteriorized. Cryoablation of right chest intercostal nerves (T3-T8) was performed. Pericardial retraction sutures were exteriorized. After arrest, 2-0 Ethibond sutures and a left atrial retractor exposed the posterior annulus.The LAA and PFO were closed with non-resorbable 3-0 V-lock sutures. Two Neochords from the anterolateral papillary muscle to the left-sided P2 and from the right posterior medial papillary muscle to the right-sided P2 were placed and dynamically assessed. A 32-MM Cosgrove flexible band was secured with non-resorbable 3-0 V-lock sutures. Static testing showed a competent valve with posterior coaptation. Non-resorbable V-lock sutures were used for left atrial closure. The Pro-glide sutures were tightened, cut, and removed to percutaneously close the femoral vessels during decannulation without complication.
RESULTS: CPB and cross clamp times were 120 and 61 minutes. Postoperative TEE showed 60% EF and no mitral regurgitation or SAM. No blood products were required. Extubation occurred in the OR. Narcotics were used for pain management only once and patient was discharged on postoperative day 2 without narcotic prescription.
CONCLUSIONS: An 8 mm working port incision and cryoanesthesia decreased postoperative narcotic usage and facilitated early discharge. V-lock sutures eliminated bedside knot-tying and can abbreviate cross clamp time intraoperatively. Percutaneous cannulation may reduce complications by eliminating groin cut-down.

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