Robot-Assisted Mitral Valve Repair With Posterior Leaflet Extension for Rheumatic Disease

Onan, Burak MD; Aydin, Unal MD; Kahraman, Zeynep MD; Erkanli, Korhan MD; Bakir, Ihsan MD

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: January/February 2017 - Volume 12 - Issue 1 - p 60–63
doi: 10.1097/IMI.0000000000000335
Case Reports

Abstract: Mitral valve repair has been one of the widely used applications of robotic surgery. Patients with rheumatic mitral disease usually present at an early age with thickening, retraction, or fusion of the leaflets and subvalvular apparatus. Robotic mitral repair can be feasible among this group of patients, rather than replacement. Herein, we describe a young woman who presented with rheumatic mitral valve insufficiency. A complex mitral repair with posterior leaflet extension with an autologous pericardial patch was successfully conducted using robot assistance.

From the Departments of *Cardiovascular Surgery and †Anesthesiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, Istanbul, Turkey.

Accepted for publication August 29, 2016.

A video clip is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Burak Onan, MD, Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, Turgut Ozal Bulvari, No: 11, Kucukcekmece, 34303-Istanbul, Turkey. E-mail:

Article Outline

Mitral valve repair has been one of the widely used applications of robotic surgery. Previous studies on robotic surgery have presented more than a thousand procedures that include valve replacement and valve repair for nonischemic degenerative mitral insufficiency.1–3 Rheumatic mitral valve disease has been described as an exclusion criterion for a robotic mitral repair. However, robotic mitral repair can be feasible with some complex techniques among this group of patients. Herein, we describe a complex valve repair of rheumatic mitral insufficiency with posterior leaflet extension with robot assistance.

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A 28-year-old woman was evaluated for progressive dyspnea and fatigue. The patient had a history of rheumatic fever. On admission, vital signs were stable. Physical examination revealed a grade 4/6 pansystolic murmur over the left sternal area. Chest roentgenogram showed an enlarged cardiac silhouette with increased pulmonary vascularity. An electrocardiogram showed sinus rhythm with a left axis deviation. A transthoracic echocardiogram showed a rheumatic mitral valve and severe insufficiency with an eccentric jet flow on systole (Fig. 1). The patients' preoperative mitral valve area was 1.4 cm2 and the mean mitral valve gradient was 5 mm Hg. It also revealed a trace tricuspid insufficiency with a tricuspid annulus of 33 mm, dilated left cardiac chambers, ejection fraction of 70%, and pulmonary artery pressure of 40 mm Hg.

The da Vinci SI robotic surgery system (Intuitive Surgical, Sunnyvale, CA USA) was used. The patient was intubated for single-lung ventilation and positioned with the right chest elevated approximately 30 degrees. After systemic heparinization and under transesophageal echocardiography guidance, the right internal jugular vein was cannulated percutaneously to drain the right superior vena cava using a 17 F cannula (DLP; Medtronic Inc, Minneapolis, MN USA). The right femoral vein was cannulated to drain the left inferior vena cava using a 24 F venous cannula (Medtronic Inc). The right femoral artery was used for arterial cannulation with a 19 F arterial cannula (Bio-Medicus; Medtronic Inc). A service port was opened through the fourth intercostal space in the anterior axillary line. A 30-degree endoscope was inserted into the pleural space through the fourth intercostal space in the midclavicular line. Two additional instrument ports in the third and fifth intercostal spaces were used. Atrial retractor was introduced through the fifth intercostal space anteriorly. The operative field was flooded with carbon dioxide.

After pericardiotomy incision and traction sutures, a purse suture was placed on the ascending aorta and a long-shafted cardioplegia cannula was inserted and fixed. A Chitwood aortic cross clamp (Scanlan International Inc, St. Paul, MN USA) was introduced through the fourth intercostal space in the midaxillary line. At moderate hypothermia, antegrade cold custodiol solution (HTK–Custodiol; Koehler Chemi, Alsbach-Haenlien, Germany) was administered, and cardiac arrest was confirmed. After left atriotomy incision, mitral valve was explored. There was a retracted posterior leaflet, commissural fusion, and thickening of subvalvular apparatus (Fig. 2, see Video, Supplemental Digital Content 1,, which demonstrates macroscopic examination of the mitral valve).

The initial step was to free the fused commissures and subvalvular apparatus by commissurotomy and splitting of the fused chords and papillary muscles (see Video, Supplemental Digital Content 2,, which demonstrates papillary muscle and chordae division). Secondary chords were cut to free the posterior leaflet further. Because the leaflet mobilization was not enough to compensate for tissue retraction, leaflet extension was decided to increase the surface area of the leaflet and to provide increased mobility for a better coaptation. Therefore, posterior leaflet tissue was divided away from the mitral annulus along the P2–P3 segments that were affected from fibrosis (Fig. 3, see Video, Supplemental Digital Content 3,, which demonstrates division of the posterior mitral leaflet). The height of the P1 segment was satisfactory. Posterior leaflet tissue was freely moving after divisions of secondary chordae and both papillary muscles. Then, a fresh autologous pericardial patch was harvested and prepared in a crescentic shape to enlarge the area of the posterior retracted leaflet. The size of the pericardial patch was made so that the newly augmented leaflet could fit the size of at least a 34-mm rigid 3D annuloplasty ring (Medtronic Inc). The patch was sutured using a continuous 5/0 Gore-Tex suture (W.L. Gore & Associates, Flagstaff, AZ USA; see Video, Supplemental Digital Content 4,, which demonstrates patch extension). The smooth surface of the pericardium was oriented toward the left atrial side to reduce the potential of thrombogenesis. At the end of leaflet extension, the height of the posterior leaflet was approximately 10 mm and that of coaptation surface was approximately 8 to 10 mm. The height ratio of anterior and reconstructed posterior leaflet was approximately 2/1. Repair procedure was completed with a ring annuloplasty (Fig. 4, see Video, Supplemental Digital Content 5,, which demonstrates mitral ring annuloplasty). The sutures were fixed using the Cor-Knot device (LSI SOLUTIONS, Inc, Victor, NY USA). After deairing, closure of the atrium and rewarming, the patient was weaned from bypass in sinus rhythm. Ventricular pacing wire and chest tubes were placed. Intraoperative transesophageal echocardiography demonstrated a mild residual insufficiency. There was no postoperative mitral valve gradient on echocardiography. Cardiopulmonary bypass and aortic clamping times were 135 and 86 minutes, respectively.

The postoperative courses were uneventful. The patient was discharged home on postoperative day 3 and was clinically well after 6 months with a mild insufficiency and no valve gradient on echocardiogram (Fig. 5).

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Rheumatic heart disease is still a major cause of mitral valve dysfunction in developing countries, where considerable numbers of adult cases are being diagnosed each year. The mechanism of mitral insufficiency in rheumatic disease is mainly associated with progressive fibrosis of the leaflets and subvalvular apparatus that causes decreased mobility and retraction of the leaflets. Posterior leaflet retraction occurs in almost in 60% of cases with rheumatic mitral disease, and this is the most common type of dysfunction that is classified as Carpentier type III leaflet restriction.4 In these patients, as an alternative to replacement, valve repair has been shown to provide satisfactory long-term results with 82% freedom from reoperation at 10 years, using suitable reconstruction techniques.5

In rheumatic mitral repair, the anterior or posterior leaflet can be extended in restrictive rheumatic disease.6–8 This technique provides complete mobilization of the retracted leaflet and an enlarged coaptation surface area. This is a challenging procedure, because the measurements of the height and coaptation surface of posterior leaflet are important for a successful repair. An excessive posterior leaflet tissue may cause systolic anterior motion of the anterior mitral leaflet and left ventricular outflow tract obstruction. The use of an annuloplasty ring is essential for correcting rheumatic mitral regurgitation, as done in other etiologies of mitral regurgitation.

Currently, robotic totally endoscopic mitral valve repair has been shown to be feasible especially in degenerative valve disease.1–3 However, rheumatic mitral valve disease and calcified annulus have been described as exclusion criteria for robotic mitral surgery.9 In such cases, mitral valve replacement has been the choice of procedure, rather than a complex repair. Although various repair techniques have been used in degenerative mitral disease in previous series on robotic mitral repair,1–3,9 this case showed that mitral repair with posterior leaflet extension in rheumatic disease could also be feasible and effective with robot assistance. According to our literature review, our case confirms the feasibility of robotic complex repair in rheumatic mitral disease in an adult.

In patients, who undergo mitral valve surgery for rheumatic disease, surgeons observe that the pathology frequently involves the mitral valve leaflet and its subvalvular apparatus. The use of dynamic atrial retractor provides enhanced exposure of these structures during commissurotomy, division of papillary muscle and primary chordae. Nevertheless, all these structures are fibrotic and thickened because of the pathological process. The division of papillary muscle or chordae and commissurotomy using robotic scissor can be difficult. Therefore, in some cases, we have used a number 11 blade instead of robotic curved scissor. Division of secondary chordae can also be challenging because two robotic arms (a forceps on the left hand and a scissor on the right hand) may not provide a good operative exposure and division at the same time. Therefore, patient-side surgeon helps the console surgeon using a hook retractor for the exposure of secondary chordae. Posterior leaflet extension is a feasible procedure after division of the posterior leaflet from the mitral annulus. The use of polytetrafluoroethylene suture and pericardial patch makes valve repair a feasible procedure and leads to a favorable outcome.

Robotic mitral valve replacement for rheumatic disease has previously been reported,9 but there is minimal discussion in the literature regarding robotic mitral valve repair for rheumatic disease. In rheumatic disease, we may speculate that leaflet calcifications can be a limitation for robotic mitral valve repair. In our clinical practice, we do not prefer the use of robotic approach to perform a valve repair or replacement in the presence of severe calcification, especially in the mitral valve annulus. We believe that these patients should be operated using conventional approaches. However, in some cases, calcifications are diagnosed on the edges of the mitral leaflets. If calcified tissue is minimal, repair can be feasible. In severe calcifications causing decreased valve mobility, failure of coaptation, and retraction, a valve replacement may be necessary.

Totally endoscopic robotic repair offers a less invasive alternative to traditional approaches. The other advantages of robotic surgery are superior three-dimensional endoscopic view and facilitated instrumentation, which provide an excellent manipulation within the left atrium. Endoscopically, robotic surgery allows superior exposure of the anatomical landmarks including pulmonary veins, atrioventricular valves, and cava-atrial junctions. Commissurotomy and divisions of chordae and papillary muscles are technically feasible with robot assistance.

In conclusion, this case shows the feasibility of robotic repair of rheumatic mitral repair with posterior leaflet extension in an adult. Although this case is anecdotal, robotic repair should be in the armamentarium of cardiac surgeons for suitable rheumatic mitral pathologies.

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1. Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012;94:38–42.
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8. Bakir I, Onan B, Onan IS, Gul M, Uslu N. Is rheumatic mitral valve repair still a feasible alternative?: indications, technique, and results. Tex Heart Inst J. 2013;40:163–169.
9. Senay S, Gullu AU, Kocyigit M, et al. Robotic mitral valve replacement for severe rheumatic mitral disease: perioperative technique, outcomes, and early results. Innovations. 2014;9:292–296.

Robotic surgery; Rheumatic disease; Mitral valve repair; Posterior leaflet extension

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©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery