Robotic Endoscopic Septal Myectomy And Complex Mitral Valve Repair Using Only 8-millimeter Port-site Incisions
Kyle W. Prochno1, Caroline M. Komlo2, Jake L. Rosen1, Colin C. Yost1, Jenna L. Mandel1, Regina E. Linganna1, Jordan E. Goldhammer1, T. Sloane Guy1.
1Thomas Jefferson University, Philadelphia, PA, USA, 2Yale University, New Haven, CT, USA.
Objective: Symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) are often invasive septal reduction therapy candidates. We present the first case, to our knowledge, of a minimally invasive approach to robotic endoscopic trans-mitral septal myectomy—with concomitant complex mitral valve repair using a patch, and patent foramen ovale (PFO) and left atrial appendage (LAA) closures—using exclusively eight-millimeter skin incisions. Methods: A 55-year-old male with HOCM presented via referral for surgical evaluation. One year prior, he received placement of a primary prophylactic implantable cardioverter-defibrillator, and upon evaluation was NYHA Functional Class III and found to have a left ventricular outflow tract (LVOT) gradient with Valsalva following exertion of 90 mmHg. Results: An eight-millimeter camera port was placed in the right fourth intercostal space, and three additional eight-millimeter incisions were made for robotic arm ports, as well as 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 cardiopulmonary bypass initiation, the PFO and LAA were closed and the anterior mitral leaflet was detached from commissure to commissure, enabling LVOT visualization. Three vertical incisions were made in the septum, at a depth of 10 millimeters, from trigone to trigone; the septum was excised from just below the aortic valve to below the papillary muscles, using traction sutures in the intervening muscle segments. Finally, a bovine pericardium patch with a width equal to the intra-commissure distance was trimmed and intracorporeally sewn into the anterior leaflet defect, increasing the anterior-to-posterior ratio. Total cardiopulmonary bypass and cross-clamp times were 128 minutes and 94 minutes, respectively. The patient was extubated in the operating room and discharged home on post-operative day two following an uncomplicated course.Conclusions: This report presents a case of HOCM treated with robotic endoscopic trans-mitral septal myectomy using the smallest known incisions for robotic arm and working port access. With an experienced robotic surgeon and an appropriately selected patient, this appears to be an excellent treatment option compared to traditional sternotomy, thoracotomy, and endoscopic approaches for the potential to reduce post-operative pain and length of stay. 
LEGEND: Figure 1. Pre-operative (left) and post-operative (right) long-axis TEE showing LVOT
Back to 2022 Display Posters