Robotic Mitral Valve Repair: The Potential in a Case with Challenging Thoracic Anatomy

Objectives: To demonstrate the value or robotically assisted mitral surgery in cases with challenging thoracic anatomy leading to extremely limited exposure of the mitral valve when using conventional access through median sternotomy.

Methods: Seventy-one-year-old female patient with severe symptomatic mitral valve regurgitation, due to annular dilatation, and paroxysmal atrial fibrillation. Clinical examination revealed severe pectus excavatum. CT-Scan showed the severely deformed anterior chest wall with only 7.5 cm internal distance between the sternum and the vertebral column. Moreover, CT-scan showed right-sided aortic arch, right-sided thoracic descending aorta and persistent left superior vena cava. A robotic mitral valve repair through right anterolateral minithoracotomy with percutaneous femoral cannulation and transthoracic aortic clamping was performed combined with left atrial Cryoablation and occlusion of the left atrial appendage.

Results: Using the robotic assistance in this case enabled an optimal visualization of the left atrial structures and provided an advanced level of freedom during suturing without excessive tissue manipulation due to the confined space. The mitral repair was performed using implantation of rigid annuloplasty ring. The left atrial appendage closure was performed using suturing for the endocardial side. The aortic cross clamping was 90 minute. The intraoperative transesophageal echocardiography showed no residual mitral regurgitation and complete closure of the left atrial appendage. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day.

Conclusion: In such cases with multiple thoracic anomalies the conventional approach using sternotomy is known to be cumbersome in terms of sternal spreading, aortic cannulation and cross-clamping and exposure of left atrial structures. Robotic assisted surgery may the best choice due to the optimal visualization, dexterity and precision.