Robotic Endoscopic Removal Of Failed Mitral Valve Clips With Complex Valve Repair Using Only 8-millimeter Port-site Incisions
Kyle W. Prochno, Jake L. Rosen, Colin C. Yost, Jenna L. Mandel, Regina E. Linganna, T. Sloane Guy.
Thomas Jefferson University, Philadelphia, PA, USA.
Objective: Mitral valve clip failure occurs at a rate of approximately 3.5%, and results in mortality in nearly one-third of patients and moderate-to-severe mitral valve regurgitation (MR) in almost one-half of patients. We present the first known case of mitral valve clip failure treated via robotic endoscopic removal of the clips—and subsequent complex mitral valve repair—using exclusively eight-millimeter skin incisions. Methods: A 79-year-old female with history of MR treated via mitral valve clip placement four years prior presented with significant increasing dyspnea. Transesophageal echocardiography revealed two mitral valve clips attached to A2/P2 and A3/P3, and mitral valve prolapse with severe MR and pulmonary vein flow reversal. Results: An eight-millimeter camera port was placed in the right fourth intercostal space, three additional eight-millimeter incisions were made for robotic arm ports, and an eight-millimeter incision for air-seal working port placement. Bypass cannulas were placed percutaneously in the femoral vessels, and an aortic endoballoon inserted via the femoral arterial cannula side port. After the mitral valve with clips was visualized through a left atriotomy, a 2-0 suture with needle was passed through the two small wire loops in the crotch of the first clip at P2, and traction assistance was provided manually via the working port while the clip was held and opened robotically. This enabled opening of the clip and detachment of the grippers, and removal of the clip itself, from the leaflet without significant damage; this was repeated for the A3/P3 clip. Static test of the valve revealed prominent prolapse, which was successfully repaired via the intracorporeal suturing in of two neochords and a 34-millimeter flexible band. The patient was discharged home on post-operative day three following an uncomplicated course. Conclusions: This represents the first known case of failed transcatheter mitral valve clips treated with robotic endoscopic mitral valve clip removal and subsequent mitral valve repair using only eight-millimeter incisions. With an experienced robotic surgeon and an appropriately selected patient, this appears to be an excellent treatment option compared to medical therapy for potentially increased survival, and compared to open surgery for potential reduction of post-operative pain and length of stay. 
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