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J Thorac Cardiovasc Surg 2006;131:468-469
© 2006 The American Association for Thoracic Surgery

Brief Communication

Robotic endoscopic excision of accessory mitral leaflet

^a Department of Cardiothoracic Surgery, Saint Joseph's Hospital of Atlanta, Atlanta, Ga
^b Department of Anesthesiology, Saint Joseph's Hospital of Atlanta, Atlanta, Ga
^c Department of Cardiology, Saint Joseph's Hospital of Atlanta, Atlanta, Ga

Received for publication August 25, 2005; accepted for publication August 31, 2005.

^_* Address for reprints: Douglas A. Murphy, MD, Department of Cardiothoracic Surgery, Saint Joseph's Hospital of Atlanta, 5665 Peachtree Dunwoody Rd, Atlanta, GA 30342 (Email: dmurphy407{at}aol.com).

Accessory mitral valve is an uncommon cause of left ventricular outflow tract obstruction in the adult patient. ¹ Excisional therapy has traditionally been performed through the proximal aorta by using a median sternotomy. We report the excision of an obstructive accessory mitral leaflet through the left atrium using a right chest endoscopic approach with the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, Calif).

Clinical Summary

A 43-year-old man presented with dyspnea on exertion of 1 years' duration. Examination revealed a body mass index of 36.7 kg/m² and a systolic cardiac murmur. Transesophageal echocardiography demonstrated a membranous structure in the left ventricular outflow tract with a parachute action during systole. Chordal attachment suggested this membranous structure was an accessory mitral leaflet. Peak systolic gradient across the membrane measured 45 mm Hg. Right and left cardiac catheterization confirmed the echocardiographic findings and showed normal coronary arteries. Surgical excision was undertaken to relieve symptoms.

At the time of the operation, the heart was approached endoscopically through 4 ports in the third, fourth, and sixth intercostal spaces of the right lateral chest (Figure 1). Intermittent insufflation with carbon dioxide was used to create working space for pericardiotomy and traction sutures. Cardiopulmonary bypass, endoaortic balloon occlusion, and antegrade cardioplegia were achieved through the femoral vessels, and pulmonary artery venting and retrograde cardioplegia administration were achieved through the right internal jugular vein by using the Port Access System (Cardiovations, Somerville, NJ). The left atrium was entered immediately anterior to the right pulmonary veins, and the atrial septum was retracted anteriorly to expose the mitral valve. The anterior mitral leaflet was partially detached to visualize the left ventricular outflow tract. An accessory mitral leaflet with chordal tissue attachment was then excised with the robotic instruments, assisted by a handheld shafted forceps inserted through the service port (Figure 2). The anterior mitral leaflet was patched with glutaraldehyde-treated autologous pericardium to prevent leaflet shortening with repair. A vent through the closed left atriotomy and across the mitral valve was used to ensure air removal. Aortic occlusion time was 77 minutes. Postoperative echocardiography demonstrated a peak systolic left ventricular gradient of less than 7 mm Hg and normal mitral valve function. The patient was discharged on postoperative day 3 after an uncomplicated recovery and is in New York Heart Association class 1 at 6 weeks after the operation.

View larger version (109K): [in this window] [in a new window]   Figure 1. Endoscopic ports. R, Robotic right arm; L, robotic left arm; E, robotic endoscope; S, service port.

View larger version (83K): [in this window] [in a new window]   Figure 2. Excision of accessory mitral leaflet (AML) with assistance of handheld shafted instrument (HSI).

Endoscopic approach to the left ventricular outflow tract through the right chest has been previously described for septal myomectomy and fibroelastoma of the aortic valve by using 2-dimensional videoscopy and handheld shafted instruments. ^2,3 Excellent visualization of this area is afforded by partial detachment of the anterior mitral leaflet, leaving the commissural attachments intact to maintain proper orientation. Reconstruction of the anterior leaflet with autologous pericardium is supported by experience with rheumatic valve repair. ⁴ Although an endoscopic technique is the least invasive surgical method to approach intracardiac lesions, such as the accessory mitral valve described here, it can be technically challenging. The use of the da Vinci system offers a stable instrument platform coupled with stereoscopic vision at surgical sites deep within the thorax. Surgical manipulations with the mechanical robotic instruments are facilitated by handheld shafted instruments inserted by the patient-side assistant through an adjacent service port. Placing the service port between the instrument arms and lateral to the endoscope port allows both the patient-side assistant and the console surgeon to work simultaneously at the intracardiac operative site. The da Vinci Robotic System might facilitate an endoscopic approach to lesions of the left ventricular outflow tract.

References

1. Aoka Y, Ishizuka N, Sakomura Y, Nagashima H, Kawana M, Kawai A, et al. Accessory mitral valve tissue causing severe left ventricular outflow tract obstruction in an adult. Ann Thorac Surg 2004;77:713-715.[Abstract/Free Full Text]
   
2. Casselman F, Vanermen H. Idiopathic hypertrophic subaortic stenosis can be treated endoscopically. J Thorac Cardiovascular Surg 2002;124:1248-1249.[Free Full Text]
   
3. Schroeyers P, Coddens J, Vermeulen Y, Vanermen H. Video-assisted Port-Access aortic valve exploration through left atriotomy. Eur J Cardiothorac Surg 2001;20:1032.[Free Full Text]
   
4. Chauvaud S, Fuzellier J, Berrebi A, Deloche A, Fabiani J, Carpentier A. Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency. Circulation 2001;104(suppl I):12-15.[Abstract/Free Full Text]
   

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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): Douglas A. Murphy John J. Byrne Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Murphy, D. A. Articles by Malave, H. A. Search for Related Content PubMed PubMed Citation Articles by Murphy, D. A. Articles by Malave, H. A. Related Collections Congenital - acyanotic Minimally invasive surgery Valve disease