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Mitral valve repair: Robotic and other minimally invasive approaches
Mitral Valve Repair: Robotic and Other Minimally Invasive Approaches Mateo Marin Cuartas, Hoda Javadikasgari, Bettina Pfannmueller, Joerg Seeburger, A. Marc Gillinov, Rakesh M. Suri, Michael A. Borger PII: DOI: Reference:
S0033-0620(17)30153-6 doi: 10.1016/j.pcad.2017.11.002 YPCAD 844
To appear in:
Progress in Cardiovascular Diseases
Received date: Accepted date:
6 November 2017 6 November 2017
Please cite this article as: Cuartas Mateo Marin, Javadikasgari Hoda, Pfannmueller Bettina, Seeburger Joerg, Gillinov A. Marc, Suri Rakesh M., Borger Michael A., Mitral Valve Repair: Robotic and Other Minimally Invasive Approaches, Progress in Cardiovascular Diseases (2017), doi: 10.1016/j.pcad.2017.11.002
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Mitral Valve Repair: Robotic and Other Minimally Invasive Approaches
Department of Cardiac Surgery, Leipzig Heart Center and University of Leipzig Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic
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Mateo Marin Cuartas MD,1 Hoda Javadikasgari MD,2 Bettina Pfannmueller MD,1 Joerg Seeburger MD PhD,1 A. Marc Gillinov MD,2 Rakesh M. Suri MD D. Phil,2 Michael A. Borger, MD PhD1
Key words: Minimally Invasive; Robotic surgery; Mitral valve; Repair
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Author disclosures: Dr. Gillinov is a consultant for CryoLife Technologies, Edwards Lifesciences, Medtronic, St. Jude Medical, Abbott Laboratories, and Atricure. He receives research funding from Abbott. Dr. Borger is a consultant for Edwards Lifesciences, Medtronic, LivaNova and CryoLife. No other author has a financial relationship with industry to report.
Word count: 6514
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Corresponding author:
Michael Borger, MD, PhD Director of Cardiac Surgery Leipzig Heart Center Struempellstrasse 39 04289 Leipzig, Germany Phone: +49-341-865-0 Fax: +49-341-865-1452 Email: [email protected]
ACCEPTED MANUSCRIPT Abbreviations 2D=Two-dimensional
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3D=Three-dimensional AF=Atrial fibrillation
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AML= Anterior mitral leaflet
ASD=Atrial septal defect CPB= Cardiopulmonary bypass
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ICS =Intercostal space
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AR =Aortic regurgitation
LV= Left ventricular
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LVEF= Left ventricular ejection fraction
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LVESD= Left ventricular end systolic dimension MR= Mitral regurgitation MV= Mitral valve PML= Posterior mitral leaflet PTFE= Polytetrafluorethylene SVC= Superior vena cava TEE= Transesophageal echocardiography
ACCEPTED MANUSCRIPT Abstract Robotic and minimally invasive mitral valve (MV) procedures have been
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performed with increasing frequency over time. These alternatives offer similar
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efficacy to that achieved via standard median sternotomy, particularly in large volume centers, along with low perioperative morbidity and mortality rates.
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Moreover, patient acceptance is oftentimes increased due to less postoperative pain and shorter recovery times, as well as superior cosmetic results. However,
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these techniques are technically complex and associated with a significant learning curve. The following review offers an overview of the most relevant aspects related to minimally invasive and robotic MV repair. Although these techniques are well established in referral centers, future innovations should
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concentrate on decreasing complexity and improving reproducibility of these
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procedures.
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Mitral valve (MV) repair surgery is indicated for patients with severe mitral
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regurgitation (MR) due to myxomatous disease. Current guidelines recommend
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surgical intervention for patients with symptomatic disease, as well as asymptomatic MR in the presence of left ventricular (LV) dysfunction (LV
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ejection fraction (LVEF) <60%) or dilation (LV end-systolic diameter (LVESD) >
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40-45 mm) (1,2). Over the past decade, there has been a growing body of data supporting early MV repair in patients with asymptomatic MR and preserved cardiac structure and function (3-7). Therefore, the most current guidelines also include a new recommendation (class IIa) for early correction of MR in patients
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with severe asymptomatic MR with LVEF>60% or LVESD <40-45 mm, if
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mortality risk is low (<1%) and likelihood of repair is high (>90%) (1,2). A broad spectrum of alternative surgical approaches to MV repair has been
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developed over the last decades. Modified cardiopulmonary bypass (CPB)
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techniques were introduced in 1995 and enabled safe and effective minimally invasive MV surgery.
Mohr and colleague introduced the voice-controlled
robotic camera and subsequently instituted large scale thoracoscopic minimal invasive and robotic MV repair programs (8). In 1998, Carpentier et al. performed the first completely robotic MV repair using robotic telemanipulation and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) (9) Soon afterward, Chitwood and colleagues carried out the first robotic MV repair in the United States as part of the initial Federal Drug Administration clinical trial (10). The principles of minimal invasive and robotic MV surgery consist of adhering to the same indications for MV repair as those for conventional sternotomy
ACCEPTED MANUSCRIPT surgery, achieving equivalent surgical dexterity and safety, accelerating patient recovery, and achieving superior cosmetic results (11). The current paper will
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review the surgical techniques and results of minimal invasive and robotic MV
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repair, and briefly address future perspectives.
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Definition
The term “minimally invasive MV surgery” has been traditionally defined as a
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reduced chest wall incision that does not include a full sternotomy (12). The term “robotic MV surgery” refers to a minimally invasive approach combined with the use of a robotic surgical system. To avoid misunderstanding, Chitwood and Rodriguez (13) adapted a classification for minimally invasive cardiac
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surgery originally described by Loulmet and Carpentier (14). It is based on four
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levels of technical complexity, as shown in Table 1.
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The most common minimally invasive approach to the MV is via a right minithoracotomy. Many other incisions such as lower mini-sternotomy and
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parasternotomy have also been described. A special set of surgical instruments along with careful operative planning are required for these techniques. Visualization is usually enhanced with port-access two –dimensional (2D) or three-dimensional (3D) thoracoscopic cameras. The remaining portion of the paper has been divided into minimal invasive MV techniques, followed by robotic MV surgery.
ACCEPTED MANUSCRIPT Minimal Invasive MV Repair
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Patient Selection
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Minimal invasive MV surgery via a right mini-thoracotomy can be performed in the vast majority of patients with indications for MV repair. Patients requiring
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atrial fibrillation (AF) ablative or right-sided procedures can also be operated on using this approach (see below). However, other concomitant procedures such
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as coronary bypass surgery or aortic valve or ascending aorta replacement require a median sternotomy approach. Other contraindications have been described (see Table 2) including:
due
to
pleural
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1. Prior right chest surgery or radiation. Such patients are at increased risk adhesions,
although
a
preoperative
Computed
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Tomographic scan may be used for evaluation.
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2. Severe peripheral atherosclerosis or chronic peripheral arterial occlusive disease. Peripheral cannulation for cardiopulmonary bypass (CPB) can
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be particularly challenging for these patients. 3. Descending
aorta
aneurysm,
aortic
dissection,
aortic
thrombus.
Retrograde CPB perfusion via the femoral arteries may be problematic in such patients. 4. Prominent ascending aorta calcifications or ascending aorta aneurysm / dilation (> 4.5 cm). Aortic clamping and antegrade cardioplegia administration are challenging in these patients. 5. Moderate to severe aortic regurgitation (AR) due to difficulties with cardioplegia administration.
ACCEPTED MANUSCRIPT 6. Significant chest wall deformity. Severe pectus excavatum, in particular, can be very problematic.
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7. Severe mitral annular calcification. Extensive decalcification of the mitral
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annulus and reconstruction with a pericardial patch is very challenging through a minimal invasive approach.
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Initially, less complex cases with a straightforward anatomy and pathology (eg.
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isolated P2 prolapse) should be considered for minimal invasive MV surgery. Once the learning curve has been overcome, more challenging cases may be performed. Holzhey et al (15) described reduced complication rates with increasing experience of the surgeon and the surgical team, with an optimal
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procedure rate of at least one procedure per week. The efficacy and safety of minimal invasive surgery have also been demonstrated in complex MV disease
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in experienced hands, comparable to the results achieved via conventional
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median sternotomy approaches (15-18)
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Higher risk patients such as reoperative, (18-21) elderly (22,23), and obese patients (24,25) may also benefit from less invasive MV surgery. However, surrounding pleural, right atrial and aortic adhesions due to previous operations or radiation may preclude safe dissection of the aorta for cross-clamping in some higher risk patients. Such procedures may, therefore, be performed during hypothermic ventricular fibrillation. However, more than trace AR is a contraindication to this approach because of poor visualization of the operative field.(26,27) MV endocarditis may also be treated in a minimally invasive technique (28), but patients with large peri-annular abscesses should be avoided.
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Surgical Considerations
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Peripheral femoro-femoral cannulation is the most commonly used approach for CPB in minimal invasive MV surgery. Some surgeons prefer direct aortic
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cannulation via the mini-thoracotomy incision, arguing that antegrade flow to the brain as well as avoidance of groin cannulation is beneficial. However, a larger
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thoracotomy incision is required for this approach. The choice between direct aortic clamping and balloon endoclamping varies from center to center. Direct aortic clamp proponents advocate the reduced rates of adverse neurological events in comparison with endoclamping. Nevertheless, Casselman et al.
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observed similar mortality and stroke rates using balloon endoclamping when
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compared to results from other centers (29).
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A wide variety of modified small sternal, parasternal, and mini-thoracotomy incisions have been described to access the cardiac valves. Our standard
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approach is via a right mini-thoracotomy, usually in the fourth intercostal space (ICS). Recently, a new type of approach known as the periareolar incision has been developed. It achieves very good aesthetic results and without significantly compromising surgical exposure (30,31). However, the periareolar technique requires well selected patients (Table 3). Other groups use a lower partial sternotomy approach to the MV. Briefly, a 6-8 cm skin incision is performed in the midline starting 3 cm under the angle of Louis and a partial sternotomy is performed from the xiphoid process to the second ICS, keeping the manubrium intact (32).
ACCEPTED MANUSCRIPT Further advances such as 3D video-assistance or even totally endoscopic surgery via port-access are being used on a more frequent basis. The term
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“totally endoscopic” usually refers to incisions no larger than 0.5- to 1.5 cm
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required for endoscope and instrument placement, and usually implies a robotic-assisted approach (33). However, some surgeons consider a small mini-
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thoracotomy without the use of rib spreading also as “totally endoscopic” (34). Despite the good results showed by Taylor and Vanermen using this technique,
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a 4 cm thoracotomy incision was still required (35). Leipzig Minimal Invasive MV Technique
We routinely use a right mini-thoracotomy approach with 2D or 3D video-
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assistance. (16) The patient is intubated with a single lumen endotracheal tube.
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The right side of the chest is elevated with a roll, and the right arm is positioned posteriorly (Figure 1). Cannulation of the femoral artery and vein for CPB is
fixed
to
the
skin
to
avoid
displacement.
Transesophageal
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then
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performed through a 2-3 cm oblique incision in the groin. The arterial cannula is
echocardiography (TEE) is used to confirm that the tip of the multiport venous cannula is positioned in the superior vena cava (SVC). For patients weighing more than 100 kg or those requiring a right-sided procedure, a second venous drainage cannula is inserted via the right internal jugular vein. Body temperature is maintained at 34℃ and vacuum-assisted venous drainage is used throughout the procedure. A 5-8 cm right lateral mini-thoracotomy incision is made just inferolateral to the nipple in men and in the submammary crease in women. The thorax is entered via the 4th ICS.
ACCEPTED MANUSCRIPT A dedicated instrument set designed for minimally invasive surgery is used to perform the operation. A soft tissue retractor with or without a small thoracic
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retractor is utilized to spread the ribs. The pericardium is opened 3-4 cm
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anterior and parallel to the right phrenic nerve, extending from the distal ascending aorta to the diaphragm. A video camera and a transthoracic
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Chitwood aortic cross-clamp are inserted via the 2nd and 3rd right ICS, respectively (Figure 2). Long-acting antegrade crystalloid cardioplegia is
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delivered directly into the aortic root through a long cardioplegia needle, allowing up to 90 minutes of safe ischemic time. The left atrium is accessed through a paraseptal incision (Sondergaard groove) and a left atrial retractor is
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used to expose the MV.
Our preferred method for MV repair of myxomatous disease has been the
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“respect rather than resect” strategy, which aims to create extensive coaptation and the posterior mitral leaflets (AML and PML,
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between the anterior
respectively). The AML acts like a mobile “door” and the PML like a fixed but
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smooth “doorframe” after this repair (36). The technique preserves leaflet mobility, increase surface of coaptation, maximizes effective orifice area, and avoids significant changes to annular geometry when compared to traditional leaflet resection techniques (37). We also find that leaflet preservation is technically easier to accomplish than leaflet resection via a right minithoracotomy approach. Leaflet prolapse is corrected by replacing the affected chordae tendinae from the prolapsing segment with polytetrafluorethylene (PTFE) neochordae. Von Oppell and Mohr originally described the “Loop technique”, which has been our procedure of choice for many years (38). Correct length of the PTFE loops is
ACCEPTED MANUSCRIPT determined using a caliper (Figure 3), and the loops are then attached to the papillary muscle and to the free edge of the prolapsing segment(s) (Figure 4). In
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patients with markedly elongated leaflets and redundant tissue (Barlow’s
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disease), other techniques including triangular leaflet resection and Alfieri’s edge-to-edge repair may be required (39).
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An annuloplasty ring (usually complete and semi-rigid) or annuloplasty band is
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implanted to support all MV repairs at our center. Functional MR is repaired by means of a downsized, complete, rigid annuloplasty ring with or without subvalvular procedures.
A water sealing probe test is used to confirm MV competency (Figure 5). The
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left atrium is closed and de-aired. The patient is temporarily weaned from CPB
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to assess the quality of the MV repair by TEE, as well as to assess for possible new regional wall motion abnormalities suggestive of circumflex artery
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compromise. CPB is then resumed, the cardioplegia needle vent is removed,
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haemostasis is ensured, and the pericardium and chest are closed. CPB is then weaned for the final time, protamine is administered, and the patient is decannulated.
Concomitant Procedures Minimal invasive approaches are also feasible in patients requiring concomitant right-sided procedures like tricuspid valve surgery, atrial septal defect (ASD) closures, heart tumor resection, and cryoablation for AF. Right-sided procedures
require
the
insertion
of
an
additional
venous
cannula
percutaneously through the right internal jugular vein into the SVC (16). Temporary occlusion of SVC and inferior vena cava is accomplished with
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requires separate right atrial access. Tricuspid valve surgery may be performed
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after releasing the aortic cross-clamp, thus shortening myocardial ischemic time
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Short- and Long-Term Results
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if desired (16).
Short- and long-term mortality are roughly equivalent between complete sternotomy and minimal invasive MV repair techniques. However, this
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observation is based on retrospective observational studies, since no wellpowered randomized controlled studies comparing both approaches have been
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performed. Large series have shown that 30-day mortality is similar to that
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achieved via median sternotomy, with a range from 0.2 to 2.6% (16,40,41). Similar studies have also demonstrated that long-term survival is equivalent to
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that achieved with conventional MV surgery (42,43). With regards to rates of MV repair for myxomatous MV disease, minimal invasive surgery is associated with a high rate of repair (over 90%) that is comparable to median sternotomy (16,40,41,44). In addition, recurrent MR and need for repeat MV surgery rates have also been found to be similar between the two approaches (41,45). Advantages and Disadvantages of Minimal Invasive MV Surgery An increasing proportion of patients are requesting minimally invasive surgery because of perceived advantages. Reduction in pain and faster return to normal
ACCEPTED MANUSCRIPT activity has been demonstrated in several studies (24, 46-48). Pain is usually equivalent to a full sternotomy approach for the first two postoperative days,
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with a significant reduction thereafter (46). Studies have also shown that in
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patients which underwent a minimally invasive approach as a reoperation, they felt that their recovery was more rapid and less painful than after their original
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sternotomy procedure (49) (50). Other reported benefits of a minimal invasive approach include less bleeding (although without a reduction in re-exploration
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for bleeding rates), decreased ventilation times, reduced atrial fibrillation, decreased wound infections, and shorter hospital stays (15,24,43,46,48-51). There are, however, drawbacks associated with a minimal invasive approach to
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the MV. Myocardial ischemic and CPB times are longer than those achieved with a conventional median sternotomy approach, due to increased technical
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demands of working through a confined space (51). In high volume centers,
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however, operating times approach those achieved with a conventional
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approach (52).
A previous meta-analysis reported that stroke rates may be increased with a minimal invasive approach, (53) presumably because of retrograde perfusion of the aorta during CPB or balloon migration during endoaortic clamping. This dreaded complication occurs in 1 to 2.6% of patients undergoing minimal invasive MV surgery (16) (41). In a more recently published meta-analysis, however, minimal invasive surgery was no longer associated with an increased risk of stroke (54). Another disadvantage associated with minimal invasive surgery is possible complications of peripheral cannulation (55). Groin seroma and superficial
ACCEPTED MANUSCRIPT infection are the most commonly reported complications, occurring between 1 and 7% of patients (29,55-59). Retrograde aortic dissection is a rare but life-
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threatening complication of peripheral cannulation.
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Another infrequent but potentially life-threatening complication observed with minimal invasive MV surgery is unilateral pulmonary edema (60). We believe
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this complication is related to selective lung ventilation, however, as we have
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performed such surgery without selective lung ventilation in over 6000 patients without experiencing this complication.
Finally, emergent conversion to median sternotomy (usually for bleeding) is another described complication of minimal invasive MV surgery, occurring in 0
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to 3.9% of patients (16,29,40,41,61).
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Robotic MV Repair
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Patient Selection
Robotic MV surgery is more technically challenging than standard minimal invasive MV surgery, but is suitable for degenerative and functional MV disease. Operative risks and mitral pathology should be considered when selecting patients for robotic MV repair. Patients should be screened for comorbidities that may preclude safe application of this technique (Table 2) (62,63). In addition, several relative contraindications should be taken into account, (Table 4) although most of these can be safely managed in experienced centers. Patient Setup
ACCEPTED MANUSCRIPT The patient is intubated with a double lumen endotracheal tube. A TEE probe is placed to identify detailed MV anatomy and pathology. Pulmonary artery vent
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and retrograde coronary sinus cardioplegia catheters (CardioVations; Ethicon
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Inc., Somerville, NJ) may be placed via the right internal jugular vein under TEE guidance. The patient is positioned at the right edge of the operating room table
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with a transverse roll under the chest. The right femoral artery and vein are
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exposed and assessed for appropriateness for cannulation. The endoscope camera port is placed in the 4 th ICS, 2 to 3 cm lateral to the nipple. In female patients, the breast is retracted superiorly and the incision is placed in the infra-mammary crease to enter the chest in the 4th or 5th ICS. The
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working port incision (for a 15-mm soft rubber retractor) is placed in the 4th ICS 4 cm lateral to the camera port.
The left instrument port is placed two
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interspaces above and approximately halfway between the shoulder and the
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camera port. The right instrument port is two interspaces below and near the anterior axillary line. The 4th robotic port for the atrial retractor instrument is
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placed in the 4th ICS medial to the camera port (Figure 6A). A purse-string suture is placed in the anterior surface of the femoral vein and then a guidewire is passed through the femoral vein into the SVC under TEE guidance. A 25 Fr CardioVations “Quickdraw” venous cannula is passed over the wire and positioned so that the tip is several centimeters up the IVC. The femoral artery is cannulated using open Seldinger’s technique (Figure 6B) and CPB is initiated. The pericardium is opened anterior to the phrenic nerve. The table is rotated all the way to the left and placed in reverse Trendelenburg. After docking the robot, the robotic arms and camera are positioned in the respective ports.
ACCEPTED MANUSCRIPT Aortic occlusion is achieved using the transthoracic clamp or endoaortic balloon occlusion, and cardioplegia is delivered antegrade and can be re-administered
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every 15-20 minutes throughout the cross-clamp time. A left atriotomy incision
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is made anterior to the right pulmonary veins. The atrial septum is elevated with the atrial retractor to expose the MV. A small suction vent is positioned in the
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left pulmonary veins to clear the surgical field of blood.
Robotic MV Repair Techniques
Triangular Resection: This technique is ideal for patients with PML prolapse. The extent of leaflet resection is identified by finding normal chordae on either
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side of the prolapsing portion. A triangular-shaped segment of tissue is excised
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with a curved scissor. Running 4-0 polypropylene suture with or without a ventricularization technique (64) is used to close the defect in the leaflet (Figure
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7).
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Quadrangular Resection with Dliding Repair: This technique is employed for management of
extensive,
redundant
PML
prolapse. The prolapsing,
excessively tall segment of posterior leaflet is excised and then the remaining portions of the PML are detached from the annulus and advanced centrally, “sliding” them over, to meet one another. The PML base is reattached to the annulus
with
running
4-0
polypropylene
and
the
leaflet
edges
are
reapproximated. Neochordae Implantation: PTFE Neochordae placement is facilitated by the robotic approach. A single-armed PTFE suture is prepared with a loose, pre-tied knot in the suture 4 cm from its end; this knot facilitates chordal measurement
ACCEPTED MANUSCRIPT and tying. The needle is passed once through the free edge of the prolapsing segment of the PML, and pulled through such that the pre-tied knot engages the
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leaflet edge. The needle is then passed once through the fibrous portion of the
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medial papillary muscle and then brought back up and passed two or three times through the leaflet edge, traveling a total distance of 1 cm at the leaflet
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edge. The chord is adjusted to an appropriate length, which is generally 1-2 cm, and then tied. A second PTFE suture is used to create a set of chords affixed to
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the lateral papillary muscle (Figure 8). This technique can be used for both AML and PML prolapse.
Annuloplasty: All repairs are completed using a flexible, standard-length annuloplasty band (63 or 65 mm). The band is first secured at the right (medial)
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trigone and additional sutures are placed from the medial to the lateral part of
(66)(Figure 9B).
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the annulus using either running (65) (Figure 9A) or interrupted technique
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Final Steps. All repairs are assessed using saline insufflation to fill and
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pressurize the LV before closure, de-airing, and cross-clamp removal.. Once the heart is beating and preliminary evaluation of the repair by TEE is satisfactory, the antegrade cardioplegia catheter is removed from the aorta and the puncture site is closed. The pericardium is loosely approximated with two sutures to prevent cardiac torsion (67). A 19-Fr Blake drain (Ethicon Inc) is inserted via the right instrument port. The instruments and ports are all removed and both lungs are ventilated. The patient is then separated from CPB and final evaluation of deairing and the integrity of the repair (i.e. ≤+1 residual MR) is evaluated by TEE. While protamine is administered, the cannulas are removed and the femoral vein and
ACCEPTED MANUSCRIPT artery are repaired. After protamine is administered, the right lung is deflated and the camera is reintroduced into the chest to examine the aortic cardioplegia
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site, as well as all port sites to ensure good hemostasis. All patients undergo
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transthoracic echocardiography before discharge from hospital and lifelong annual echocardiographic surveillance is recommended as for all MV repair
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operations (63) (66).
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Robotic MVR Outcomes
The goal of robotic MV repair is developing a procedure that is at least equal to the “gold-standard” sternotomy technique. Robotic MV repair is now routinely performed with or without concomitant tricuspid valve repair and AF ablation
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procedures. (64,68) This approach is safe, effective, and durable for complete correction of MV prolapse, regardless of complexity.
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Furthermore, the
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collective data from experienced centers reaffirms that this approach offers
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reduced blood loss, lower risk of incisional infection and AF, shorter hospital length of stay, quicker return to normal activities, and a superior cosmetic result
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(62,64,68 -74).
Future Perspectives Although minimal invasive and robotic MV surgery are technically complex, they should also be considered an opportunity for learning since the port-access visualization allows excellent visualization of the MV for the entire surgical team. In addition, several simulators exist for the practice of manual skills and familiarization with the special instruments required for these techniques. Further research and developments are required, however, in order to help
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Conclusions Minimal invasive and robotic MV repair techniques are safe and effective, and
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are being performed with increasing frequency over time. Early and long-term outcomes are very good and comparable to those achieved via conventional
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median sternotomy. Careful patient selection and surgical preparation are required in order to successfully perform these procedures. Current evidence is mostly based on observational studies, and therefore randomized trials may be required in order to definitively assess the advantages and disadvantages of
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these techniques. Future research should also focus on methods of simplifying
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these procedures and the development of surgical simulators in order to
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techniques.
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improve the utilization and reproducibility of these advanced surgical
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13. Chitwood WR, Rodriguez E. Minimally invasive and robotic mitral valve surgery. In: Cohn LH (ed). Cardiac Surgery in the Adult, 4th edn. New York: McGraw-Hill, 2008, 1080–100.
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14. Loulmet DF, Carpentier A, Cho PW, et al. Less invasive techniques for mitral valve surgery. J Thorac Cardiovasc Surg. 1998 Apr;115(4):772-9. 15. Holzhey DM, Seeburger J, Misfeld M, et al. Learning minimally invasivemitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation. 2013;128:483491.
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16. Davierwala PM, Seeburger J, Pfannmueller B, Garbade J, Misfeld M, Borger MA, Mohr FW. Minimally-invasive mitral valve surgery: “The Leipzig experience”. Ann Cardiothorac Surg 2013;2(6):744-750. .
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17. Mohr FW, Falk V, Diegeler A, et al. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 1998;115(3):567–574, discussion 574–576.
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18. Seeburger J, Borger MA, Falk V et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothorac Surg. 2008 Oct;34(4):760-5. doi: 10.1016/j.ejcts.2008.05.015. Epub 2008 Jun 30. 19. Ricci D, Pellegrini C, Aiello M, et al. Port-access surgery as elective approach for mitral valve operation in re-do procedures. Eur J Cardiothorac Surg. 2010;37:920-925. 20. Murzi M, Miceli A, Di Stefano G, et al. Minimally invasive right thoracotomy approach for mitral valve surgery in patients with previous sternotomy: a single institution experience with 173 patients. J Thorac Cardiovasc Surg. 2014;148:2763-2768. 21. Ghoneim A, Bouhout I, Mazine A, et al. Beating Heart Minimally Invasive Mitral Valve Surgery in Patients With Patent Coronary Bypass Grafts. Can J Cardiol. 2016;32:987 e981- 986.
ACCEPTED MANUSCRIPT 22. Moscarelli M, Fattouch K, Casula R, et al. What Is the Role of Minimally Invasive Mitral Valve Surgery in High-Risk Patients? A Meta-Analysis of Observational Studies. Ann Thorac Surg. 2016;101:981-989.
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23. Lamelas J, Sarria A, Santana O, et al. Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater. Ann Thorac Surg. 2011;91:79-84.
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24. Santana O, Reyna J, Grana R, et al. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011 Feb;91(2):406-10. doi: 10.1016/j.athoracsur.2010.09.039.
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25. Reser D, Sündermann S, Grünenfelder J, et al. Obesity should not deter a surgeon from selecting a minimally invasive approach for mitral valve surgery. Innovations (Phila).8:225- 229. 26. Arcidi Jr JM, Rodriguez E, Elbeery JR, et al. Fifteen-year experience with minimally invasive approach for reoperations involving the mitral valve. J Thorac Cardiovasc Surg. 2012;143:1062–8.
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27. Petracek MR, LeaccheM, Solenkova N, et al. Minimally invasive mitral valve surgery expands the surgical options for highrisks patients. Ann Surg. 2011;254:606–11.
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28. Folkmann S, Seeburger J, Garbade J, et al. Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis. Thorac Cardiovasc Surg. 2017 Jul 27. doi: 10.1055/s-0037-1604206.
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29. Casselman F, Aramendi J, Bentala M, et al. Endoaortic Clamping Does Not Increase the Risk of Stroke in Minimal Access Mitral Valve Surgery: A Multicenter Experience. Ann Thorac Surg. 2015;100:1334-1339. 30. Poffo R, Pope RB, Toschi AP, Mokross CA. Video-assisted minimally invasive mitral valve repair: periareolar approach.Rev Bras Cir Cardiovasc. 2009 Jul-Sep;24(3):425-7. 31. Poffo R, Pope RB, Selbach RA, et al. Video-assisted cardiac surgery: results from a pioneer project in Brazil. Rev Bras Cir Cardiovasc. 2009 JulSep;24(3):318-26. 32. Bouhout I, Morgant MC, Denis B. Minimally invasive heart valve surgery, Canadian Journal of Cardiology (2017), doi: 10.1016/j.cjca.2017.05.014. 33. Glower DD. Surgical approaches to mitral regurgitation. J Am Coll Cardiol 2012;60:1315–22.
ACCEPTED MANUSCRIPT 34. Glauber M, Miceli A. State of the art for approaching the mitral valve: sternotomy, minimally invasive or total endoscopic robotic? Eur J Cardiothorac Surg 2015;48:639–41.
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35. Taylor BS, Vanermen H. Totally endoscopic mitral valve surgery. Oper Tech Thorac Cardiovasc Surg 2007;12:226–34.
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36. Melnitchouk SI, Dal-Bianco JP, Borger MA. Minimally Invasive Mitral Valve Surgery via Mini-Thoracotomy: Current Update. Curr Treat Options Cardiovasc Med. 2015 Nov;17(11):48. doi: 10.1007/s11936-015-0406-x.
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37. Seeburger J, Falk V, Borger MA, et al. Chordae replacement versus resection for repair of isolated posterior mitral leaflet prolapse: a egalite. Ann Thorac Surg. 2009;87:1715–20. 38. Von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg 2000;70(6):2166–2168.
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39. Borger MA, Kaeding AF, Seeburger J. Minimally invasive mitral valve repair in Barlow's disease: early and long-term results. J Thorac Cardiovasc Surg. 2014 Oct;148(4):1379-85. doi: 10.1016/j.jtcvs.2013.11.030. Epub 2014 Jan 10.
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40. Glauber M, Miceli A, Canarutto D, et al. Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients. J Cardiothorac Surg. 2015;10:181.
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41. McClure RS, Athanasopoulos LV, McGurk S, et al. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up. J Thorac Cardiovasc Surg. 2013;145:1199-1206. 42. Lange R, Voss B, Kehl V, et al. Right Minithoracotomy Versus Full Sternotomy for Mitral Valve Repair: A Propensity Matched Comparison. Ann Thorac Surg. 2016. 43. Goldstone AB, Atluri P, Szeto WY, et al. Minimally invasive approach provides at least equivalent results for surgical correction of mitral regurgitation: a propensity-matched comparison. J Thorac Cardiovasc Surg. 2013;145:748756. 44. Reser D, van Hemelrijck M, Pavicevic J, et al. Repair rate and durability of video assisted minimally invasive mitral valve surgery. J Card Surg. 2014;29:766-771. 45. Galloway AC, Schwartz CF, Ribakove GH, et al. A decade of minimally invasive mitral repair:long-term outcomes. Ann Thorac Surg. 2009;88:11801184.
ACCEPTED MANUSCRIPT 46. Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997; 226:421–6. pp. 421–428.
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47. Yamada T, Ochiai R,Takeda J,et al. Comparison of early postoperative quality of life in minimally invasive versus conventional valve surgery. J Anesth. 2003;17(3):171-6.
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48. Glower DD, Landolfo KP, Clements et al F. Mitral valve operation via Port Access versus median sternotomy. Eur J Cardiothorac Surg. 1998 Oct;14 Suppl 1:S143-7.
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49. Casselman FP, Van Slycke S, Wellens F et al. Mitral valve surgery can now routinely be performed endoscopically. Circulation. 2003 Sep 9;108 Suppl 1:II48-54. 50. Felger JE, Chitwood WR, Nifong LW, Holbert D. Evolution of mitral valve surgery: toward a totally endoscopic approach. Ann Thorac Surg. 2001 Oct;72(4):1203-8; discussion 1208-9.
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51. Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2010 Nov;90(5):1401-8, 1410.e1; discussion 1408-10. doi: 10.1016/j.athoracsur.2010.05.055.
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52. Iribarne A, Easterwood R, Russo MJ et al. A minimally invasive approach is more cost-effective than a traditional sternotomy approach for mitral valve surgery. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1507-14. doi: 10.1016/j.jtcvs.2011.04.038. Epub 2011 Jun 14. 53. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review. Innovations (Phila). 2011;6:84-103. 54. Cao C, Gupta S, Chandrakumar D. A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease. Ann Cardiothorac Surg. 2013 Nov;2(6):693-703. doi: 10.3978/j.issn.2225-319X.2013.11.08. 55. Krapf C, Wohlrab P, Häußinger S, et al. Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate? Eur J Cardiothorac Surg. 2013;44:898-904. 56. Lamelas J, Williams RF, Mawad M, LaPietra A. Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery.Ann
ACCEPTED MANUSCRIPT Thorac Surg. 2017 Jun; 22., 103(6):1927-1932. 10.1016/j.athoracsur.2016.09.098. Epub 2016 Dec.
doi:
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57. Akowuah E, Burdett C, Khan K, et al. Early and Late Outcomes After Minimally Invasive Mitral Valve Repair Surgery. J Heart Valve Dis. 2015;24:470477.
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58. Reser D, Walser R, van Hemelrijk M, et al. Long-Term Outcomes after Minimally Invasive Aortic Valve Surgery through Right Anterior Minithoracotomy. Thorac Cardiovasc Surg. 2016.
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59. Aybek T, Dogan S, Risteski PS, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg. 2006;81:1618-1624. 60. Tutschka MP, Bainbridge D, Chu MW, et al. Unilateral postoperative pulmonary edema after minimally invasive cardiac surgical procedures: a casecontrol study. Ann Thorac Surg. 2015 Jan;99(1):115-22. doi: 10.1016/j.athoracsur.2014.07.067. Epub 2014 Nov 14.
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61. Vollroth M, Seeburger J, Garbade J, et al. Conversion rate and contraindications for minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2:853-854.
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62. Suri RM, Dearani JA, Mihaljevic T, et al. Mitral valve repair using robotic technology: Safe, effective, and durable. J Thorac Cardiovasc Surg. 2016;151:1450-1454.
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63. Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early Results of Robotically Assisted Mitral Valve Surgery: Analysis of the First 1,000 Cases. J Thorac Cardiovasc Surg. 2017. 64. Suri RM, Burkhart HM, Schaff HV. A novel method of leaflet reconstruction after triangular resection for posterior mitral valve prolapse.Ann Thorac Surg. 2010;89:e53-e56. 65. Mihaljevic T, Jarrett CM, Gillinov AM, Blackstone EH. A novel running annuloplasty suture technique for robotically assisted mitral valve repair. J Thorac Cardiovasc Surg. 2010;139:1343-1344. 66. Javadikasgari H, Suri RM, Tappuni B, et al. Robotic mitral valve repair for degenerative posterior leaflet prolapse. Ann Cardiothorac Surg. 2017;6:27. 67. Suri RM, Javadikasgari H, Mihaljevic T, et al. Don't miss the obvious: The dangers of lateral pericardial defects. J Thorac Cardiovasc Surg. 2016 Oct 1;152(4):e83-4.
ACCEPTED MANUSCRIPT 68. Nifong LW, Rodriguez E, Chitwood WR. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012;94:38-43.
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69. Suri RM, Taggarse A, Burkhart HM, et al. Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Mid-Term Clinical and Echocardiographic Quality Outcomes. Circulation. 2015:CIRCULATIONAHA. 115.017792.
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70. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized.J Thorac Cardiovasc Surg. 2011;141:72-80. e74.
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71. Paul S, Isaacs AJ, Jalbert J, et al. A Population-Based Analysis of Robotic-Assisted Mitral Valve Repair. Ann Thorac Surg. 2015;99:1546-1553. 72. Ramzy D, Trento A, Cheng W, et al. Three hundred robotic-assisted mitral valve repairs: the Cedars-Sinai experience. J Thorac Cardiovasc Surg. 2014;147:228-235.
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73. Murphy DA, Moss E, Binongo J, et al. The Expanding Role of Endoscopic Robotics in Mitral Valve Surgery: 1,257 Consecutive Procedures.Ann Thorac Surg. 2015;100:1675-1682.
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74. Trento A, Ramzy D, De Robertis M, et al. Ten Years With Robotic Assisted Mitral Valve Repair: One Center’s Experience. ICCAD. Florence, Italy2015.
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75. Neely RC, Borger MA. Myxomatous Mitral Valve Repair: Loop Neochord Technique. Operative Techniques in Thoracic and Cardiovasculary Surgery 20:106-123.2015
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Level 2
Direct vision / video assisted with mini
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Level 1
incisions (4–6 cm)
Video directed and robot assisted
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Level 3
with micro incisions (1.5–4 cm) Robotic (computer telemanipulation)
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Level 4
and totally endoscopic port incisions
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(<1.5 cm)
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aortic
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aortic
Moderate or regurgitation
severe
aortic
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Significant dilatation
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Right ventricular dysfunction generalized
peripheral
arterial
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Severe disease
Calcification of the aortic root/ascending aorta
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Mitral annular calcification
Coronary artery disease requiring CABG
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Severe pulmonary dysfunction
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Symptomatic cerebrovascular disease or recent stroke Severe liver dysfunction Significant bleeding disorder
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Fixed pulmonary hypertension (> 60 mmHg)
CABG – coronary artery bypass grafting
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Feasible for both genders
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Areolar diameter At least 3 cm Should not extend over 180 degrees
Obese patients
Not contraindicated. Breast flattens around the areolar region after patient is positioned on the surgical table.
Breast implants
Not contraindicated. The breast prosthesis should be kept within saline solution with diluted antibiotics during the procedure.
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Incision
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Contraindications History of breast irradiation or surgery for cancer with reconstructive breast surgery (mastopexy)
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Adapted from references (30,31)
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Mild aortic stenosis or regurgitation
pulmonary
hypertension
Limited peripheral arterial disease Chest deformity (pectus/scoliosis)
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Asymptomatic, mild coronary disease Moderate pulmonary dysfunction
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EF - ejection fraction
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(>50
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Reduced left ventricular function (EF <50%)
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Figure Legends
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permission from Neely RC and Borger MA (Ref 75).
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Figure 1. Patient positioning for minimally invasive MV repair. Reproduced with
Figure 2. Incisions and access/instrumentation for minimally invasive MV
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repair. Reproduced with permission from Neely RC and Borger MA (Ref 75).
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Figure 3. Loop length determination using a caliper.
Figure 4. Loop technique: Attachment of the PTFE suture to the papillary muscle and to the free edge of the prolapsing leaflet segment(s). Reproduced
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with permission from Neely RC and Borger MA (Ref 75).
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Figure 5. Sealing probe test after minimally invasive MV repair.
vessels.
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Figure 6. Patient setup. A: Port placement; B: Cannulation of the femoral
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Figure 7. Mitral valve repair techniques. A: Triangular resection of the posterior leaflet; B: Posterior leaflet repair using running technique; C: Repair of the posterior leaflet using ventricularization technique; D: Running closure of the posterior defect; E: Final stitch next to the annulus. Figure 8. Repair of the mitral valve using artificial chordae. Figure 9. Band annuloplasty. A: interrupted stitch; B: running stitch.
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Disclosures: : Dr. Gillinov is a consultant for CryoLife Technologies, Edwards Lifesciences, Medtronic, St. Jude Medical, Abbott Laboratories, and Atricure. He receives research funding from Abbott. Dr. Borger is a consultant for Edwards Lifesciences, Medtronic, LivaNova and CryoLife. No other author has a financial relationship with industry to report.
S0033-0620(17)30153-6 doi: 10.1016/j.pcad.2017.11.002 YPCAD 844
To appear in:
Progress in Cardiovascular Diseases
Received date: Accepted date:
6 November 2017 6 November 2017
Please cite this article as: Cuartas Mateo Marin, Javadikasgari Hoda, Pfannmueller Bettina, Seeburger Joerg, Gillinov A. Marc, Suri Rakesh M., Borger Michael A., Mitral Valve Repair: Robotic and Other Minimally Invasive Approaches, Progress in Cardiovascular Diseases (2017), doi: 10.1016/j.pcad.2017.11.002
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Mitral Valve Repair: Robotic and Other Minimally Invasive Approaches
Department of Cardiac Surgery, Leipzig Heart Center and University of Leipzig Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic
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Mateo Marin Cuartas MD,1 Hoda Javadikasgari MD,2 Bettina Pfannmueller MD,1 Joerg Seeburger MD PhD,1 A. Marc Gillinov MD,2 Rakesh M. Suri MD D. Phil,2 Michael A. Borger, MD PhD1
Key words: Minimally Invasive; Robotic surgery; Mitral valve; Repair
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Author disclosures: Dr. Gillinov is a consultant for CryoLife Technologies, Edwards Lifesciences, Medtronic, St. Jude Medical, Abbott Laboratories, and Atricure. He receives research funding from Abbott. Dr. Borger is a consultant for Edwards Lifesciences, Medtronic, LivaNova and CryoLife. No other author has a financial relationship with industry to report.
Word count: 6514
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Corresponding author:
Michael Borger, MD, PhD Director of Cardiac Surgery Leipzig Heart Center Struempellstrasse 39 04289 Leipzig, Germany Phone: +49-341-865-0 Fax: +49-341-865-1452 Email: [email protected]
ACCEPTED MANUSCRIPT Abbreviations 2D=Two-dimensional
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3D=Three-dimensional AF=Atrial fibrillation
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AML= Anterior mitral leaflet
ASD=Atrial septal defect CPB= Cardiopulmonary bypass
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ICS =Intercostal space
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AR =Aortic regurgitation
LV= Left ventricular
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LVEF= Left ventricular ejection fraction
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LVESD= Left ventricular end systolic dimension MR= Mitral regurgitation MV= Mitral valve PML= Posterior mitral leaflet PTFE= Polytetrafluorethylene SVC= Superior vena cava TEE= Transesophageal echocardiography
ACCEPTED MANUSCRIPT Abstract Robotic and minimally invasive mitral valve (MV) procedures have been
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performed with increasing frequency over time. These alternatives offer similar
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efficacy to that achieved via standard median sternotomy, particularly in large volume centers, along with low perioperative morbidity and mortality rates.
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Moreover, patient acceptance is oftentimes increased due to less postoperative pain and shorter recovery times, as well as superior cosmetic results. However,
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these techniques are technically complex and associated with a significant learning curve. The following review offers an overview of the most relevant aspects related to minimally invasive and robotic MV repair. Although these techniques are well established in referral centers, future innovations should
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concentrate on decreasing complexity and improving reproducibility of these
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procedures.
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Mitral valve (MV) repair surgery is indicated for patients with severe mitral
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regurgitation (MR) due to myxomatous disease. Current guidelines recommend
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surgical intervention for patients with symptomatic disease, as well as asymptomatic MR in the presence of left ventricular (LV) dysfunction (LV
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ejection fraction (LVEF) <60%) or dilation (LV end-systolic diameter (LVESD) >
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40-45 mm) (1,2). Over the past decade, there has been a growing body of data supporting early MV repair in patients with asymptomatic MR and preserved cardiac structure and function (3-7). Therefore, the most current guidelines also include a new recommendation (class IIa) for early correction of MR in patients
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with severe asymptomatic MR with LVEF>60% or LVESD <40-45 mm, if
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mortality risk is low (<1%) and likelihood of repair is high (>90%) (1,2). A broad spectrum of alternative surgical approaches to MV repair has been
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developed over the last decades. Modified cardiopulmonary bypass (CPB)
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techniques were introduced in 1995 and enabled safe and effective minimally invasive MV surgery.
Mohr and colleague introduced the voice-controlled
robotic camera and subsequently instituted large scale thoracoscopic minimal invasive and robotic MV repair programs (8). In 1998, Carpentier et al. performed the first completely robotic MV repair using robotic telemanipulation and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) (9) Soon afterward, Chitwood and colleagues carried out the first robotic MV repair in the United States as part of the initial Federal Drug Administration clinical trial (10). The principles of minimal invasive and robotic MV surgery consist of adhering to the same indications for MV repair as those for conventional sternotomy
ACCEPTED MANUSCRIPT surgery, achieving equivalent surgical dexterity and safety, accelerating patient recovery, and achieving superior cosmetic results (11). The current paper will
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review the surgical techniques and results of minimal invasive and robotic MV
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repair, and briefly address future perspectives.
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Definition
The term “minimally invasive MV surgery” has been traditionally defined as a
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reduced chest wall incision that does not include a full sternotomy (12). The term “robotic MV surgery” refers to a minimally invasive approach combined with the use of a robotic surgical system. To avoid misunderstanding, Chitwood and Rodriguez (13) adapted a classification for minimally invasive cardiac
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surgery originally described by Loulmet and Carpentier (14). It is based on four
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levels of technical complexity, as shown in Table 1.
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The most common minimally invasive approach to the MV is via a right minithoracotomy. Many other incisions such as lower mini-sternotomy and
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parasternotomy have also been described. A special set of surgical instruments along with careful operative planning are required for these techniques. Visualization is usually enhanced with port-access two –dimensional (2D) or three-dimensional (3D) thoracoscopic cameras. The remaining portion of the paper has been divided into minimal invasive MV techniques, followed by robotic MV surgery.
ACCEPTED MANUSCRIPT Minimal Invasive MV Repair
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Patient Selection
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Minimal invasive MV surgery via a right mini-thoracotomy can be performed in the vast majority of patients with indications for MV repair. Patients requiring
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atrial fibrillation (AF) ablative or right-sided procedures can also be operated on using this approach (see below). However, other concomitant procedures such
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as coronary bypass surgery or aortic valve or ascending aorta replacement require a median sternotomy approach. Other contraindications have been described (see Table 2) including:
due
to
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1. Prior right chest surgery or radiation. Such patients are at increased risk adhesions,
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Tomographic scan may be used for evaluation.
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2. Severe peripheral atherosclerosis or chronic peripheral arterial occlusive disease. Peripheral cannulation for cardiopulmonary bypass (CPB) can
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be particularly challenging for these patients. 3. Descending
aorta
aneurysm,
aortic
dissection,
aortic
thrombus.
Retrograde CPB perfusion via the femoral arteries may be problematic in such patients. 4. Prominent ascending aorta calcifications or ascending aorta aneurysm / dilation (> 4.5 cm). Aortic clamping and antegrade cardioplegia administration are challenging in these patients. 5. Moderate to severe aortic regurgitation (AR) due to difficulties with cardioplegia administration.
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annulus and reconstruction with a pericardial patch is very challenging through a minimal invasive approach.
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Initially, less complex cases with a straightforward anatomy and pathology (eg.
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isolated P2 prolapse) should be considered for minimal invasive MV surgery. Once the learning curve has been overcome, more challenging cases may be performed. Holzhey et al (15) described reduced complication rates with increasing experience of the surgeon and the surgical team, with an optimal
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procedure rate of at least one procedure per week. The efficacy and safety of minimal invasive surgery have also been demonstrated in complex MV disease
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in experienced hands, comparable to the results achieved via conventional
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median sternotomy approaches (15-18)
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Higher risk patients such as reoperative, (18-21) elderly (22,23), and obese patients (24,25) may also benefit from less invasive MV surgery. However, surrounding pleural, right atrial and aortic adhesions due to previous operations or radiation may preclude safe dissection of the aorta for cross-clamping in some higher risk patients. Such procedures may, therefore, be performed during hypothermic ventricular fibrillation. However, more than trace AR is a contraindication to this approach because of poor visualization of the operative field.(26,27) MV endocarditis may also be treated in a minimally invasive technique (28), but patients with large peri-annular abscesses should be avoided.
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Surgical Considerations
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Peripheral femoro-femoral cannulation is the most commonly used approach for CPB in minimal invasive MV surgery. Some surgeons prefer direct aortic
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cannulation via the mini-thoracotomy incision, arguing that antegrade flow to the brain as well as avoidance of groin cannulation is beneficial. However, a larger
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thoracotomy incision is required for this approach. The choice between direct aortic clamping and balloon endoclamping varies from center to center. Direct aortic clamp proponents advocate the reduced rates of adverse neurological events in comparison with endoclamping. Nevertheless, Casselman et al.
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A wide variety of modified small sternal, parasternal, and mini-thoracotomy incisions have been described to access the cardiac valves. Our standard
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approach is via a right mini-thoracotomy, usually in the fourth intercostal space (ICS). Recently, a new type of approach known as the periareolar incision has been developed. It achieves very good aesthetic results and without significantly compromising surgical exposure (30,31). However, the periareolar technique requires well selected patients (Table 3). Other groups use a lower partial sternotomy approach to the MV. Briefly, a 6-8 cm skin incision is performed in the midline starting 3 cm under the angle of Louis and a partial sternotomy is performed from the xiphoid process to the second ICS, keeping the manubrium intact (32).
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thoracotomy without the use of rib spreading also as “totally endoscopic” (34). Despite the good results showed by Taylor and Vanermen using this technique,
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a 4 cm thoracotomy incision was still required (35). Leipzig Minimal Invasive MV Technique
We routinely use a right mini-thoracotomy approach with 2D or 3D video-
ED
assistance. (16) The patient is intubated with a single lumen endotracheal tube.
PT
The right side of the chest is elevated with a roll, and the right arm is positioned posteriorly (Figure 1). Cannulation of the femoral artery and vein for CPB is
fixed
to
the
skin
to
avoid
displacement.
Transesophageal
AC
then
CE
performed through a 2-3 cm oblique incision in the groin. The arterial cannula is
echocardiography (TEE) is used to confirm that the tip of the multiport venous cannula is positioned in the superior vena cava (SVC). For patients weighing more than 100 kg or those requiring a right-sided procedure, a second venous drainage cannula is inserted via the right internal jugular vein. Body temperature is maintained at 34℃ and vacuum-assisted venous drainage is used throughout the procedure. A 5-8 cm right lateral mini-thoracotomy incision is made just inferolateral to the nipple in men and in the submammary crease in women. The thorax is entered via the 4th ICS.
ACCEPTED MANUSCRIPT A dedicated instrument set designed for minimally invasive surgery is used to perform the operation. A soft tissue retractor with or without a small thoracic
T
retractor is utilized to spread the ribs. The pericardium is opened 3-4 cm
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anterior and parallel to the right phrenic nerve, extending from the distal ascending aorta to the diaphragm. A video camera and a transthoracic
SC
Chitwood aortic cross-clamp are inserted via the 2nd and 3rd right ICS, respectively (Figure 2). Long-acting antegrade crystalloid cardioplegia is
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delivered directly into the aortic root through a long cardioplegia needle, allowing up to 90 minutes of safe ischemic time. The left atrium is accessed through a paraseptal incision (Sondergaard groove) and a left atrial retractor is
ED
used to expose the MV.
Our preferred method for MV repair of myxomatous disease has been the
PT
“respect rather than resect” strategy, which aims to create extensive coaptation and the posterior mitral leaflets (AML and PML,
CE
between the anterior
respectively). The AML acts like a mobile “door” and the PML like a fixed but
AC
smooth “doorframe” after this repair (36). The technique preserves leaflet mobility, increase surface of coaptation, maximizes effective orifice area, and avoids significant changes to annular geometry when compared to traditional leaflet resection techniques (37). We also find that leaflet preservation is technically easier to accomplish than leaflet resection via a right minithoracotomy approach. Leaflet prolapse is corrected by replacing the affected chordae tendinae from the prolapsing segment with polytetrafluorethylene (PTFE) neochordae. Von Oppell and Mohr originally described the “Loop technique”, which has been our procedure of choice for many years (38). Correct length of the PTFE loops is
ACCEPTED MANUSCRIPT determined using a caliper (Figure 3), and the loops are then attached to the papillary muscle and to the free edge of the prolapsing segment(s) (Figure 4). In
T
patients with markedly elongated leaflets and redundant tissue (Barlow’s
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disease), other techniques including triangular leaflet resection and Alfieri’s edge-to-edge repair may be required (39).
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An annuloplasty ring (usually complete and semi-rigid) or annuloplasty band is
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implanted to support all MV repairs at our center. Functional MR is repaired by means of a downsized, complete, rigid annuloplasty ring with or without subvalvular procedures.
A water sealing probe test is used to confirm MV competency (Figure 5). The
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left atrium is closed and de-aired. The patient is temporarily weaned from CPB
PT
to assess the quality of the MV repair by TEE, as well as to assess for possible new regional wall motion abnormalities suggestive of circumflex artery
CE
compromise. CPB is then resumed, the cardioplegia needle vent is removed,
AC
haemostasis is ensured, and the pericardium and chest are closed. CPB is then weaned for the final time, protamine is administered, and the patient is decannulated.
Concomitant Procedures Minimal invasive approaches are also feasible in patients requiring concomitant right-sided procedures like tricuspid valve surgery, atrial septal defect (ASD) closures, heart tumor resection, and cryoablation for AF. Right-sided procedures
require
the
insertion
of
an
additional
venous
cannula
percutaneously through the right internal jugular vein into the SVC (16). Temporary occlusion of SVC and inferior vena cava is accomplished with
ACCEPTED MANUSCRIPT tourniquets or large bulldog clamps. Direct closure of a patent foramen ovale can be easily performed through the left atriotomy, but ASD closure usually
T
requires separate right atrial access. Tricuspid valve surgery may be performed
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after releasing the aortic cross-clamp, thus shortening myocardial ischemic time
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Short- and Long-Term Results
SC
if desired (16).
Short- and long-term mortality are roughly equivalent between complete sternotomy and minimal invasive MV repair techniques. However, this
ED
observation is based on retrospective observational studies, since no wellpowered randomized controlled studies comparing both approaches have been
PT
performed. Large series have shown that 30-day mortality is similar to that
CE
achieved via median sternotomy, with a range from 0.2 to 2.6% (16,40,41). Similar studies have also demonstrated that long-term survival is equivalent to
AC
that achieved with conventional MV surgery (42,43). With regards to rates of MV repair for myxomatous MV disease, minimal invasive surgery is associated with a high rate of repair (over 90%) that is comparable to median sternotomy (16,40,41,44). In addition, recurrent MR and need for repeat MV surgery rates have also been found to be similar between the two approaches (41,45). Advantages and Disadvantages of Minimal Invasive MV Surgery An increasing proportion of patients are requesting minimally invasive surgery because of perceived advantages. Reduction in pain and faster return to normal
ACCEPTED MANUSCRIPT activity has been demonstrated in several studies (24, 46-48). Pain is usually equivalent to a full sternotomy approach for the first two postoperative days,
T
with a significant reduction thereafter (46). Studies have also shown that in
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patients which underwent a minimally invasive approach as a reoperation, they felt that their recovery was more rapid and less painful than after their original
SC
sternotomy procedure (49) (50). Other reported benefits of a minimal invasive approach include less bleeding (although without a reduction in re-exploration
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for bleeding rates), decreased ventilation times, reduced atrial fibrillation, decreased wound infections, and shorter hospital stays (15,24,43,46,48-51). There are, however, drawbacks associated with a minimal invasive approach to
ED
the MV. Myocardial ischemic and CPB times are longer than those achieved with a conventional median sternotomy approach, due to increased technical
PT
demands of working through a confined space (51). In high volume centers,
CE
however, operating times approach those achieved with a conventional
AC
approach (52).
A previous meta-analysis reported that stroke rates may be increased with a minimal invasive approach, (53) presumably because of retrograde perfusion of the aorta during CPB or balloon migration during endoaortic clamping. This dreaded complication occurs in 1 to 2.6% of patients undergoing minimal invasive MV surgery (16) (41). In a more recently published meta-analysis, however, minimal invasive surgery was no longer associated with an increased risk of stroke (54). Another disadvantage associated with minimal invasive surgery is possible complications of peripheral cannulation (55). Groin seroma and superficial
ACCEPTED MANUSCRIPT infection are the most commonly reported complications, occurring between 1 and 7% of patients (29,55-59). Retrograde aortic dissection is a rare but life-
T
threatening complication of peripheral cannulation.
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Another infrequent but potentially life-threatening complication observed with minimal invasive MV surgery is unilateral pulmonary edema (60). We believe
SC
this complication is related to selective lung ventilation, however, as we have
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performed such surgery without selective lung ventilation in over 6000 patients without experiencing this complication.
Finally, emergent conversion to median sternotomy (usually for bleeding) is another described complication of minimal invasive MV surgery, occurring in 0
PT
ED
to 3.9% of patients (16,29,40,41,61).
CE
Robotic MV Repair
AC
Patient Selection
Robotic MV surgery is more technically challenging than standard minimal invasive MV surgery, but is suitable for degenerative and functional MV disease. Operative risks and mitral pathology should be considered when selecting patients for robotic MV repair. Patients should be screened for comorbidities that may preclude safe application of this technique (Table 2) (62,63). In addition, several relative contraindications should be taken into account, (Table 4) although most of these can be safely managed in experienced centers. Patient Setup
ACCEPTED MANUSCRIPT The patient is intubated with a double lumen endotracheal tube. A TEE probe is placed to identify detailed MV anatomy and pathology. Pulmonary artery vent
T
and retrograde coronary sinus cardioplegia catheters (CardioVations; Ethicon
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Inc., Somerville, NJ) may be placed via the right internal jugular vein under TEE guidance. The patient is positioned at the right edge of the operating room table
SC
with a transverse roll under the chest. The right femoral artery and vein are
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exposed and assessed for appropriateness for cannulation. The endoscope camera port is placed in the 4 th ICS, 2 to 3 cm lateral to the nipple. In female patients, the breast is retracted superiorly and the incision is placed in the infra-mammary crease to enter the chest in the 4th or 5th ICS. The
ED
working port incision (for a 15-mm soft rubber retractor) is placed in the 4th ICS 4 cm lateral to the camera port.
The left instrument port is placed two
PT
interspaces above and approximately halfway between the shoulder and the
CE
camera port. The right instrument port is two interspaces below and near the anterior axillary line. The 4th robotic port for the atrial retractor instrument is
AC
placed in the 4th ICS medial to the camera port (Figure 6A). A purse-string suture is placed in the anterior surface of the femoral vein and then a guidewire is passed through the femoral vein into the SVC under TEE guidance. A 25 Fr CardioVations “Quickdraw” venous cannula is passed over the wire and positioned so that the tip is several centimeters up the IVC. The femoral artery is cannulated using open Seldinger’s technique (Figure 6B) and CPB is initiated. The pericardium is opened anterior to the phrenic nerve. The table is rotated all the way to the left and placed in reverse Trendelenburg. After docking the robot, the robotic arms and camera are positioned in the respective ports.
ACCEPTED MANUSCRIPT Aortic occlusion is achieved using the transthoracic clamp or endoaortic balloon occlusion, and cardioplegia is delivered antegrade and can be re-administered
T
every 15-20 minutes throughout the cross-clamp time. A left atriotomy incision
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is made anterior to the right pulmonary veins. The atrial septum is elevated with the atrial retractor to expose the MV. A small suction vent is positioned in the
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left pulmonary veins to clear the surgical field of blood.
Robotic MV Repair Techniques
Triangular Resection: This technique is ideal for patients with PML prolapse. The extent of leaflet resection is identified by finding normal chordae on either
ED
side of the prolapsing portion. A triangular-shaped segment of tissue is excised
PT
with a curved scissor. Running 4-0 polypropylene suture with or without a ventricularization technique (64) is used to close the defect in the leaflet (Figure
CE
7).
AC
Quadrangular Resection with Dliding Repair: This technique is employed for management of
extensive,
redundant
PML
prolapse. The prolapsing,
excessively tall segment of posterior leaflet is excised and then the remaining portions of the PML are detached from the annulus and advanced centrally, “sliding” them over, to meet one another. The PML base is reattached to the annulus
with
running
4-0
polypropylene
and
the
leaflet
edges
are
reapproximated. Neochordae Implantation: PTFE Neochordae placement is facilitated by the robotic approach. A single-armed PTFE suture is prepared with a loose, pre-tied knot in the suture 4 cm from its end; this knot facilitates chordal measurement
ACCEPTED MANUSCRIPT and tying. The needle is passed once through the free edge of the prolapsing segment of the PML, and pulled through such that the pre-tied knot engages the
T
leaflet edge. The needle is then passed once through the fibrous portion of the
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medial papillary muscle and then brought back up and passed two or three times through the leaflet edge, traveling a total distance of 1 cm at the leaflet
SC
edge. The chord is adjusted to an appropriate length, which is generally 1-2 cm, and then tied. A second PTFE suture is used to create a set of chords affixed to
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the lateral papillary muscle (Figure 8). This technique can be used for both AML and PML prolapse.
Annuloplasty: All repairs are completed using a flexible, standard-length annuloplasty band (63 or 65 mm). The band is first secured at the right (medial)
ED
trigone and additional sutures are placed from the medial to the lateral part of
(66)(Figure 9B).
PT
the annulus using either running (65) (Figure 9A) or interrupted technique
CE
Final Steps. All repairs are assessed using saline insufflation to fill and
AC
pressurize the LV before closure, de-airing, and cross-clamp removal.. Once the heart is beating and preliminary evaluation of the repair by TEE is satisfactory, the antegrade cardioplegia catheter is removed from the aorta and the puncture site is closed. The pericardium is loosely approximated with two sutures to prevent cardiac torsion (67). A 19-Fr Blake drain (Ethicon Inc) is inserted via the right instrument port. The instruments and ports are all removed and both lungs are ventilated. The patient is then separated from CPB and final evaluation of deairing and the integrity of the repair (i.e. ≤+1 residual MR) is evaluated by TEE. While protamine is administered, the cannulas are removed and the femoral vein and
ACCEPTED MANUSCRIPT artery are repaired. After protamine is administered, the right lung is deflated and the camera is reintroduced into the chest to examine the aortic cardioplegia
T
site, as well as all port sites to ensure good hemostasis. All patients undergo
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transthoracic echocardiography before discharge from hospital and lifelong annual echocardiographic surveillance is recommended as for all MV repair
SC
operations (63) (66).
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Robotic MVR Outcomes
The goal of robotic MV repair is developing a procedure that is at least equal to the “gold-standard” sternotomy technique. Robotic MV repair is now routinely performed with or without concomitant tricuspid valve repair and AF ablation
ED
procedures. (64,68) This approach is safe, effective, and durable for complete correction of MV prolapse, regardless of complexity.
19
Furthermore, the
PT
collective data from experienced centers reaffirms that this approach offers
CE
reduced blood loss, lower risk of incisional infection and AF, shorter hospital length of stay, quicker return to normal activities, and a superior cosmetic result
AC
(62,64,68 -74).
Future Perspectives Although minimal invasive and robotic MV surgery are technically complex, they should also be considered an opportunity for learning since the port-access visualization allows excellent visualization of the MV for the entire surgical team. In addition, several simulators exist for the practice of manual skills and familiarization with the special instruments required for these techniques. Further research and developments are required, however, in order to help
ACCEPTED MANUSCRIPT surgeons overcome the learning curves associated with these procedures and to improve the reproducibility of these operations.
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Conclusions Minimal invasive and robotic MV repair techniques are safe and effective, and
SC
are being performed with increasing frequency over time. Early and long-term outcomes are very good and comparable to those achieved via conventional
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median sternotomy. Careful patient selection and surgical preparation are required in order to successfully perform these procedures. Current evidence is mostly based on observational studies, and therefore randomized trials may be required in order to definitively assess the advantages and disadvantages of
ED
these techniques. Future research should also focus on methods of simplifying
PT
these procedures and the development of surgical simulators in order to
AC
techniques.
CE
improve the utilization and reproducibility of these advanced surgical
ACCEPTED MANUSCRIPT References
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24. Santana O, Reyna J, Grana R, et al. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011 Feb;91(2):406-10. doi: 10.1016/j.athoracsur.2010.09.039.
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ACCEPTED MANUSCRIPT 34. Glauber M, Miceli A. State of the art for approaching the mitral valve: sternotomy, minimally invasive or total endoscopic robotic? Eur J Cardiothorac Surg 2015;48:639–41.
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39. Borger MA, Kaeding AF, Seeburger J. Minimally invasive mitral valve repair in Barlow's disease: early and long-term results. J Thorac Cardiovasc Surg. 2014 Oct;148(4):1379-85. doi: 10.1016/j.jtcvs.2013.11.030. Epub 2014 Jan 10.
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ACCEPTED MANUSCRIPT 46. Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997; 226:421–6. pp. 421–428.
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47. Yamada T, Ochiai R,Takeda J,et al. Comparison of early postoperative quality of life in minimally invasive versus conventional valve surgery. J Anesth. 2003;17(3):171-6.
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51. Gammie JS, Zhao Y, Peterson ED, et al. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2010 Nov;90(5):1401-8, 1410.e1; discussion 1408-10. doi: 10.1016/j.athoracsur.2010.05.055.
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52. Iribarne A, Easterwood R, Russo MJ et al. A minimally invasive approach is more cost-effective than a traditional sternotomy approach for mitral valve surgery. J Thorac Cardiovasc Surg. 2011 Dec;142(6):1507-14. doi: 10.1016/j.jtcvs.2011.04.038. Epub 2011 Jun 14. 53. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review. Innovations (Phila). 2011;6:84-103. 54. Cao C, Gupta S, Chandrakumar D. A meta-analysis of minimally invasive versus conventional mitral valve repair for patients with degenerative mitral disease. Ann Cardiothorac Surg. 2013 Nov;2(6):693-703. doi: 10.3978/j.issn.2225-319X.2013.11.08. 55. Krapf C, Wohlrab P, Häußinger S, et al. Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate? Eur J Cardiothorac Surg. 2013;44:898-904. 56. Lamelas J, Williams RF, Mawad M, LaPietra A. Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery.Ann
ACCEPTED MANUSCRIPT Thorac Surg. 2017 Jun; 22., 103(6):1927-1932. 10.1016/j.athoracsur.2016.09.098. Epub 2016 Dec.
doi:
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57. Akowuah E, Burdett C, Khan K, et al. Early and Late Outcomes After Minimally Invasive Mitral Valve Repair Surgery. J Heart Valve Dis. 2015;24:470477.
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58. Reser D, Walser R, van Hemelrijk M, et al. Long-Term Outcomes after Minimally Invasive Aortic Valve Surgery through Right Anterior Minithoracotomy. Thorac Cardiovasc Surg. 2016.
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59. Aybek T, Dogan S, Risteski PS, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg. 2006;81:1618-1624. 60. Tutschka MP, Bainbridge D, Chu MW, et al. Unilateral postoperative pulmonary edema after minimally invasive cardiac surgical procedures: a casecontrol study. Ann Thorac Surg. 2015 Jan;99(1):115-22. doi: 10.1016/j.athoracsur.2014.07.067. Epub 2014 Nov 14.
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61. Vollroth M, Seeburger J, Garbade J, et al. Conversion rate and contraindications for minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2:853-854.
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62. Suri RM, Dearani JA, Mihaljevic T, et al. Mitral valve repair using robotic technology: Safe, effective, and durable. J Thorac Cardiovasc Surg. 2016;151:1450-1454.
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63. Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early Results of Robotically Assisted Mitral Valve Surgery: Analysis of the First 1,000 Cases. J Thorac Cardiovasc Surg. 2017. 64. Suri RM, Burkhart HM, Schaff HV. A novel method of leaflet reconstruction after triangular resection for posterior mitral valve prolapse.Ann Thorac Surg. 2010;89:e53-e56. 65. Mihaljevic T, Jarrett CM, Gillinov AM, Blackstone EH. A novel running annuloplasty suture technique for robotically assisted mitral valve repair. J Thorac Cardiovasc Surg. 2010;139:1343-1344. 66. Javadikasgari H, Suri RM, Tappuni B, et al. Robotic mitral valve repair for degenerative posterior leaflet prolapse. Ann Cardiothorac Surg. 2017;6:27. 67. Suri RM, Javadikasgari H, Mihaljevic T, et al. Don't miss the obvious: The dangers of lateral pericardial defects. J Thorac Cardiovasc Surg. 2016 Oct 1;152(4):e83-4.
ACCEPTED MANUSCRIPT 68. Nifong LW, Rodriguez E, Chitwood WR. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012;94:38-43.
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69. Suri RM, Taggarse A, Burkhart HM, et al. Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Mid-Term Clinical and Echocardiographic Quality Outcomes. Circulation. 2015:CIRCULATIONAHA. 115.017792.
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70. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized.J Thorac Cardiovasc Surg. 2011;141:72-80. e74.
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71. Paul S, Isaacs AJ, Jalbert J, et al. A Population-Based Analysis of Robotic-Assisted Mitral Valve Repair. Ann Thorac Surg. 2015;99:1546-1553. 72. Ramzy D, Trento A, Cheng W, et al. Three hundred robotic-assisted mitral valve repairs: the Cedars-Sinai experience. J Thorac Cardiovasc Surg. 2014;147:228-235.
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73. Murphy DA, Moss E, Binongo J, et al. The Expanding Role of Endoscopic Robotics in Mitral Valve Surgery: 1,257 Consecutive Procedures.Ann Thorac Surg. 2015;100:1675-1682.
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74. Trento A, Ramzy D, De Robertis M, et al. Ten Years With Robotic Assisted Mitral Valve Repair: One Center’s Experience. ICCAD. Florence, Italy2015.
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75. Neely RC, Borger MA. Myxomatous Mitral Valve Repair: Loop Neochord Technique. Operative Techniques in Thoracic and Cardiovasculary Surgery 20:106-123.2015
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Level 2
Direct vision / video assisted with mini
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Level 1
incisions (4–6 cm)
Video directed and robot assisted
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Level 3
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and totally endoscopic port incisions
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aortic
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aortic
Moderate or regurgitation
severe
aortic
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Significant dilatation
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Right ventricular dysfunction generalized
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Severe disease
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CABG – coronary artery bypass grafting
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Breast implants
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Contraindications History of breast irradiation or surgery for cancer with reconstructive breast surgery (mastopexy)
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EF - ejection fraction
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Figure Legends
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Figure 1. Patient positioning for minimally invasive MV repair. Reproduced with
Figure 2. Incisions and access/instrumentation for minimally invasive MV
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Figure 3. Loop length determination using a caliper.
Figure 4. Loop technique: Attachment of the PTFE suture to the papillary muscle and to the free edge of the prolapsing leaflet segment(s). Reproduced
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Figure 5. Sealing probe test after minimally invasive MV repair.
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Figure 6. Patient setup. A: Port placement; B: Cannulation of the femoral
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Figure 7. Mitral valve repair techniques. A: Triangular resection of the posterior leaflet; B: Posterior leaflet repair using running technique; C: Repair of the posterior leaflet using ventricularization technique; D: Running closure of the posterior defect; E: Final stitch next to the annulus. Figure 8. Repair of the mitral valve using artificial chordae. Figure 9. Band annuloplasty. A: interrupted stitch; B: running stitch.
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Disclosures: : Dr. Gillinov is a consultant for CryoLife Technologies, Edwards Lifesciences, Medtronic, St. Jude Medical, Abbott Laboratories, and Atricure. He receives research funding from Abbott. Dr. Borger is a consultant for Edwards Lifesciences, Medtronic, LivaNova and CryoLife. No other author has a financial relationship with industry to report.