Mitral Operation: Robotic Approach

HISTORICAL PERSPECTIVE

The history of robotic mitral valve surgery is relatively short, with the first robotic mitral valve operation performed in 1998 by Dr. Carpentier. This operation was prefaced by a movement in mitral valve surgery to become less invasive, starting with minimal access incisions in the right chest by Cohn and Cosgrove in the 1990s. Their operation, performed under direct visualization via a right posterolateral thoracotomy, allowed for arguably better visualization of the mitral valve due to the sagittal nature of the plane of the valve in the human body. Minimal access incisions were shortly followed by video-assisted mitral valve surgery, which allowed for even better visualization of the mitral valve; and, again, the first was reported by Dr. Carpentier, this time in 1998. These initial pioneering case series and reports showed that minimally invasive mitral valve surgery could be performed with acceptable short-term mortality rates.

Shortly following Dr. Carpentier’s work, the first robotic cardiac surgery was reported in the United States in 2000 by Dr. Chitwood. Again, this operation was a mitral valve repair for P2 prolapse involving a P2 resection and annuloplasty. Pivotal to the advancement of robotic mitral valve surgery were two trials in the early 2000s showing that the da Vinci surgical system (Intuitive Surgical, Inc., Mountain View, CA) was safe and effective for mitral valve repair. Furthermore, the system provided three-dimensional, magnified visualization and articulated wrist movements via seven degrees of freedom that enabled precise surgical manipulation in this complex surgery. ^, Over the past 20 years, the da Vinci surgical system has continued to evolve to optimize patient safety and surgeon experience.

INDICATIONS AND PREOPERATIVE ASSESSMENT

Indications for robotic mitral valve repair or replacement follow the American College of Cardiology (ACC) American Heart Association (AHA) guidelines for valvular heart disease, essentially the same as a sternotomy approach. Large series of concomitant mitral valve surgery with the Cox-Maze procedure or the modified Cox-Maze procedure or with concomitant tricuspid valve surgery have also been reported with excellent outcomes.

In the initial building of a robotic mitral valve surgery team, patient selection is key. More straight-forward repairs and replacement should be performed, and as experience increases so can the complexity of the operations.

Preoperative workup is fairly similar to patients undergoing cardiac surgery via sternotomy. All patients should have electrocardiography (ECG), chest x-ray, coronary angiogram if age appropriate, transthoracic echocardiogram, and pulmonary function tests. Transesophageal echocardiogram should be performed preoperatively if valve anatomy or pathology is unclear on transthoracic imaging. Specific to robotic mitral valve surgery, we recommended obtaining preoperative computed tomography (CT) angiogram of the chest, abdomen, and pelvis. This is an assessment of several factors: chest wall and intercostal anatomy; cardiac anatomy including aortic calcifications and left atrial size and orientation; lung pathology; peripheral arterial atherosclerotic disease; and central and peripheral venous anatomy.

CONTRAINDICATIONS

Absolute and relative contraindications are shown in Table 18.1 .