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J Thorac Cardiovasc Surg 2000;120:1171-1172
© 2000 The American Association for Thoracic Surgery

Evolving Technology

Robotic mitral valve repair: Trapezoidal resection and prosthetic annuloplasty with the da Vinci Surgical System

From the Center for Robotic and Minimally Invasive Surgery, University Health Systems–Pitt Memorial Hospital, Brody School of Medicine at East Carolina University, Greenville, NC.

Address for reprints: W. Randolph Chitwood, Jr, MD, Professor and Chairman, Department of Surgery, Brody School of Medicine, East Carolina University, 600 Moye Blvd, Greenville, NC 27858 (E-mail: chitwoodw{at}mail.ecu.edu).

Reconstructive mitral valve procedures require access, vision, and dexterity. Despite meteoric technical advances, surgeons remain reluctant to perform minimally invasive cardiac operations. Two-dimensional vision remains the major impediment to endoscopic cardiac operations. Additionally, small incisions result in a rotational axis for longer instruments, increasing tremor and diminishing accuracy. Robotic surgical instruments emulate the 7 degrees of freedom in the human wrist. In Europe, robotic devices have been used to repair mitral valves and perform coronary surgery safely. ^1,2 Herein, we describe a complex mitral valve repair done in North America, with the use of an articulated "wrist" robot.

Patient preparation and perfusion methods

After institutional review board and Food and Drug Administration– Investigational Device Exemption protocol (#G000023) approval, informed consent was obtained from a 69-year-old woman with severe mitral insufficiency (class IV of the New York Heart Association). She had a 1.5-month history of atrial fibrillation. A transesophageal echocardiogram showed severe mitral insufficiency and a large P₂ prolapse, secondary to ruptured/redundant chordae. The left ventricular ejection fraction was 55%, and the coronary arteries were normal.

Assisted bicaval venous drainage was accomplished with a percutaneous internal jugular 17F and a 23F femoral venous Bio-Medicus cannula (Medtronic Bio-Medicus, Eden Prairie, Minn). Arterial inflow was established via a transverse 2-cm groin incision. A 5-cm right inframammary incision in the fourth intercostal space was used. The pericardium was incised ventral to the phrenic nerve. A transthoracic aortic clamp (Scanlan International, Minneapolis, Minn) was placed through the third intercostal space. We have performed more than 120 manual videoscopic mitral valve operations safely by similar methods. ³

Robotic mitral repair technique and results

After cardiac arrest and valve exposure, trocars were placed in the third and fifth intercostal spaces to deliver intra-atrial mechanical wrists containing needle holders, scissors, or tissue graspers. The 1-cm 3-dimensional camera was placed through the incision. The primary surgeon moved to the operative console 10 feet away (Fig 1). A second surgeon remained as the patient-side assistant. The limits of the flail segment were determined. By master console telemanipulation of robotic scissors, the flail segment with abnormal chordae was extirpated trapezoidally. Annular closure, intraleaflet, and annuloplasty sutures were placed by means of the da Vinci Surgical System (Intuitive Surgical, Inc, Mountain View, Calif). Annular compression sutures decreased the defect length, which was approximated by means of 2 "figure-of-8" 2-0 braided sutures. The leaflet defect was closed with 6 monofilament 4-0 sutures. Leaflet edges of P₁ and P₃ were reduced to the normal annular plane (Fig 2). A 28-mm Cosgrove Annuloplasty Band (Edwards Lifesciences LCC, Irvine, Calif) was lowered into the atrium with 7 sutures pre-threaded and stabilized by a "tip-embedding" technique. Sutures were detached serially, passed through the anulus, and redirected through the band. Resection of the valve segment required 4.2 minutes. Band suture placement with knot tying took 3.9 ± 1.4 minutes each (mean ± standard deviation). Total valve repair time was 2 hours 35 minutes. The woman was discharged on the fifth postoperative day without complications. Postoperative transesophageal echocardiography showed no mitral insufficiency.

View larger version (99K): [in this window] [in a new window]   Fig. 1. The da Vinci Surgical System: surgeon's console.

View larger version (83K): [in this window] [in a new window]   Fig. 2. Valve repair. Prolapsing segment resection using micro-scissors and valve forceps.

In May of 1997, Carpentier and Mohr independently performed the first mitral valve repairs using a prototype of this robotic device. The "micro-wrist" permits intracardiac instrument articulation with the 7 degrees of freedom offered by the human wrist. The surgeon operates from a master console using 3-dimensional vision. Filtered and scaled movements are effected in a robotic slave that drives intracardiac articulated instruments. Recently, Lange in Munich completed a totally endoscopic mitral valve repair using the da Vinci Surgical System. Moreover, Mohr ⁴ reported over 100 mitral and coronary operations with a low operative mortality and excellent results. Grossi and coworkers recently performed a partial mitral repair using ZEUS robotic technology (Computer Motion, Inc, Goleta, Calif). This article reports a complex repair with annuloplasty ring insertion and the first use of the da Vinci Surgical System in the United States for mitral surgery. The operative times were longer than with conventional sternotomy. However, with evolution of our past videoscopic mitral operations, operative and arrest times fell markedly. ³ We believe that a similar path will follow with progressive implementation of this robotic surgical technology. This technology may represent the final step in the evolution toward an endoscopic mitral operation. Future refinements in these devices are needed to apply this new technology widely.

Acknowledgments

We express our appreciation to the surgical team: operating room nurses, Renee Grainger and Cindy Mallol; perfusionist, Bill Hodges; and anesthesiologist, Michael Biggerstaff, MD. We also appreciate the support from Jeff Smith and the staff of Intuitive Surgical, Inc, Goleta, California.

References

1. Falk V, Autschbach R, Krakor R, Walther T, Diegler A, Onnasch JF, et al. Computer enhanced mitral valve surgery: toward a total endoscopic procedure. Semin Thorac Surg 1999;11:244-9.
   
2. Loulmet D, Carpentier A, d'Attelis N, Berrebi A, Cardon C, Ponzio O, et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 1999;118:4-10.[Abstract/Free Full Text]
   
3. Chitwood WR Jr. Video assisted and robotic mitral valve surgery: toward an endoscopic surgery. Semin Thorac Surg 1999;11:194-205.
   
4. Mohr FW, Falk V, Diegeler A, Krakor R, Gummert JF, Walther T, et al. Computer enhanced "robotic" cardiac surgery—first clinical results in 100 patients. American Association for Thoracic Surgery Program, Eightieth Annual Meeting; 2000. p. 170.
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph E. Elbeery James A. Young Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chitwood, W. R. Articles by Young, J. A. Search for Related Content PubMed PubMed Citation Articles by Chitwood, W. R., Jr Articles by Young, J. A.