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.
