Robotic surgery allows incredible visualization of the mitral valve and great dexterity even in very complex mitral disease.
Cardiac surgeons at the Penn Heart and Vascular Center are performing minimally invasive endoscopic robotic mitral valve repairs incorporating a non-thoracotomy non-rib spreading approach for severe mitral valve regurgitation.
Robotic minimally invasive heart surgeries at Penn Medicine include mitral valve repair as well as tricuspid and full Cox Maze IV procedures and approaches to limited cancers of the heart. Mitral valve repair is a complex surgical procedure. To ensure best outcomes, Penn Heart and Vascular maintains a high volume of cases of varying complexity for a skilled robotic surgery team that includes cardiac surgeons, anesthetists, and nursing and support staff. Moreover, in support of the robotics program, research at the Penn Cardiovascular Institute has demonstrated the equivalence of short- and medium-term outcomes in robotic and traditional endoscopic procedures for mitral valve degeneration. [1]
About Robotic Non-Thoracotomy Mitral Valve Repair
The robotic non-thoracotomy approach places a 1cm skin incision at the 4th intercostal space and employs soft tissue retractors to eliminate rib spread during surgery. Although the approach has advantages from a surgical perspective (including a superior view of the mitral valve in its natural position and greater instrument versatility), its principal benefit is to patients.
The intercostal spaces are home to the respiratory muscles and the nervous and vascular supply of the thoracic wall. Pain occurs in approximately 50% of patients having standard thoracotomy. However, in 5% of patients the pain is severe and disabling. In some patients, chronic post-thoracotomy pain (described as continuous dysesthetic burning and aching in the general area of the incision) persists for two or more months after surgery. Uncontrolled post-operative pain is associated with increased morbidity and mortality, the risk for opioid addiction, reduced health-related quality of life, and increased costs of care.
Because the incision and portal site are smaller and the need for rib separation avoided, non-thoracotomy robotic surgery avoids much of the trauma, bleeding, pain, and post-operative complications of standard thoracotomy, including wound infection and atrial fibrillation. Most importantly, the approach results in excellent valve repairs.
Reference
- Rao A, Tauber K, Szeto WY, Hargrove WC, Atluri P, Acker M, Crawford T, Ibrahim ME. Robotic and endoscopic mitral valve repair for degenerative disease. Ann Cardiothorac Surg 2022;11(6):614-621.
Case Study
Mr. G, a 69 y.o. male with severe mitral regurgitation (MR) was referred to Penn Cardiovascular Surgery for evaluation and care. Mr. G's recent medical history included a hospitalization for severe MR requiring intubation. Imaging showed a complex mitral pathology with severe degeneration of the mitral valve and severe mitral regurgitation.
At the Penn Heart and Vascular Center, Mr. G met with surgeon Michael Ibrahim, MD, PhD, to discuss the options for care, including minimally invasive robotic mitral valve repair. After a thorough discussion of the risks and benefits of this approach, Mr. G offered his informed consent to proceed.
A small incision was made at the right groin to expose the femoral artery, while a 1cm interspace incision was established at the 4th intercostal space. Robotic ports were then placed at this space, as well as the 3rd and 6th rib spaces. Following heparinization, cardiopulmonary bypass was instituted with direct femoral venous return via femoral arterial cannulation and a superior vena cava (SVC) cannula. The Da Vinci Robot was then docked.
The SVC, with the femoral arterial and venous cannulas and endoclamp balloon were passed under continuous TEE guidance.
The Procedure
The mitral valve was exposed and examined via the interatrial groove, revealing severe degeneration of the anterior mitral leaflet, and several torn chordae. The middle (A2) section was then reinforced with 4 pairs of neochordae, and annuloplasty sutures placed along the posterior annulus from trigone to trigone. An annuloplasty device was secured, and the left atrium closed with running prolene sutures.
At this point, Mr. G was weaned from cardiopulmonary bypass in sinus rhythm without difficulty. Post-operative TEE revealed unchanged left and right ventricular function, with a left ventricular ejection fraction of 60%. The valve was then examined to confirm a structurally sound repair, and found to be functioning perfectly resulting in normal blood flow in the pulmonary veins and no residual mitral regurgitation.
Mr. G did well, was extubated in the operating room, and went home three days after surgery.
About Robotic Cardiac Surgery at Penn Heart and Vascular
The Penn Heart and Vascular Center performs the most heart valve surgeries in Pennsylvania, New Jersey and Delaware, delivering high success and low complication rates in every age group. The Penn Heart Surgery Program is recognized for its expertise in surgeries for aortic disease, arrhythmias, congenital and inherited heart disease, heart valve disorders, and transplantation, as well as for innovations in cardiac surgery.
About Michael Ibrahim, MD, PhD
A graduate of the University of Cambridge and Imperial College, where he earned both his MD and PhD degrees, Dr. Ibrahim performs the full spectrum of adult cardiac surgery at the Penn Heart and Vascular Center, including robotic mitral valve surgery. After training in cardiac surgery, Dr. Ibrahim underwent additional specialist training in mitral and robotic cardiac surgery with world leaders in this area.
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Penn Cardiovascular Surgery Penn Presbyterian
Penn Presbyterian Medical Center
Heart & Vascular Pavilion, 2nd Floor
51 N. 39th Street
Philadelphia, PA 19104
A facility of Penn Presbyterian Medical Center