Robotic Transmitral Septal Myectomy And Secondary Chord Resection For Hypertrophic Obstructive Cardiomyopathy
Hiroto Kitahara, Kaitlin Grady, Dinesh Kurian, Husam Balkhy.
The University of Chicago, Chicago, IL, USA.
A 59-year-old woman with hypertrophic obstructive cardiomyopathy presented with shortness of breath. Transthoracic echocardiography revealed severe left ventricular outflow tract (LVOT) obstruction with max gradient of 83-mmHg and severe mitral regurgitation. Interventricular septal thickness was 1.6 cm. Thick secondary chords of the anterior mitral leaflet (AML) played a primary role to tether the AML toward the LVOT resulting in severe LVOT obstruction. Severe mitral regurgitation was caused by systolic anterior motion of the AML and posterior mitral leaflet prolapse. A robotic endoscopic trans-mitral approach was chosen. The Da Vinci Xi robot was docked with 8-mm working ports after femoral cardiopulmonary bypass was established. Cardiac arrest was achieved using a Chitwood clamp and Del Nido antegrade cardioplegia via a long percutaneous 14 F angiocath. The mitral valve was exposed via left atriotomy. The AML was detached from commissure to commissure using sharp scissors, leaving a small cuff attached to the annulus. The fibrotic secondary chordae were carefully identified and excised as much as possible. The interventricular septum was carefully exposed through this plane using the dynamic atrial retractor, and hypertrophied septal muscle was resected sharply. The AML was primarily reattached to the annulus using 5-0 prolene suture. The height of the posterior leaflet was shortened using CV-4 PTFE NeoChords, and a size 32-mm semirigid partial annuloplasty ring was placed. Postoperative transesophageal echocardiography showed max gradient across the LVOT was 8-mmHg and trivial mitral regurgitation. The patient was discharged on postoperative day 2 and returned to full activity in 14 days.
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