Current Status of Endoscopic and Robotic Mitral Valve Surgery

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Current Status of Endoscopic and Robotic Mitral Valve Surgery W. Randolph Chitwood, MD The Annals of Thoracic Surgery Volume 79, Issue 6, Pages S2248-S2253 (June 2005) DOI: 10.1016/j.athoracsur.2005.02.079 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Doctor C. Walton Lillehei (1954) in front of a display showing how his innovative cross circulation, incorporating a “biologic oxygenator,” was used to perform early congenital heart operations 50 years earlier. The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Doctors Richard DeWall and Lillehei developed the helical bubble oxygenator, improving on the Gibbon device, and first used in patients in 1955. Here Dr DeWall is demonstrating his invention at the 2004 Lillehei symposium nearly 50 years after the innovative first use. (Photograph by Dr Chitwood.) The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 An early cardiac operation at Duke University. Doctors Will Sealy and Glen Young are using the DeWall helical bubble oxygenator and “finger” pump in 1957 to perform a cardiac operation. They added the “Brown” heat exchanger to the circuit. The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 The surgeon is shown directing a voice-activated robotic camera and repairing a mitral valve through a 5-cm minithoracotomy using long endoscopic instruments and assisted vision. The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 A two-dimensional image of an endoscopic complex mitral repair. Chordae tendineae have been transferred from P2 of the posterior leaflet to the mid-anterior leaflet at A2 to reduce anterior leaflet prolapse in a Barlow’s valve. P1 will be approximated to P3 using a leaflet-reducing sliding plasty. (Carpentier Classification.) The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 The operating surgeon is positioned at a console and remains immersed in the operative landscape via the three-dimensional camera. He or she is telemanipulating mitral valve tissues using various instrument tips, each having a full range of motion. The patient-side assistant is responsible for instrument exchanges as well as suture delivery and needle retrieval. The assistant currently relies on two-dimensional images for operative reference. The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 The 1-cm robotic instrument arms are placed through the chest wall as described in Table 3. A transthoracic retractor arm elevates the interatrial septum toward the sternum. The three-dimensional camera is placed through the 4-cm incision, which will serve also as a working port for the assistant. The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 In a robotic mitral repair, ports with right and left instrument arms are shown as described in Table 3. The aortic clamp is placed posterior and slightly cephalad to the left arm, and the three-dimensional camera is inserted through the 4-cm working incision, which is the only access for the assistant surgeon. The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Robotic mitral repair: (A) P1 is the most anterior or lateral posterior leaflet scallop and P2 is the redundant mid-scallop that is being resected. (Ant. Leaflet = anterior mitral leaflet.) (B) P1, P2, and P3 of the posterior leaflet are shown. P2 will be resected. P3 has been elevated radially from the mitral annulus and will be displaced toward P2 for the sliding plasty. (AC= anterior commissure; PC = posterior commissure; * = left fibrous trigone.) The Annals of Thoracic Surgery 2005 79, S2248-S2253DOI: (10.1016/j.athoracsur.2005.02.079) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions