1. T OTALLY E NDOSCOPIC R OBOTIC T REATMENT OF H YPERTROPHIC O BSTRUCTIVE C ARDIOMYOPATHY WITH S EPTAL M YOMECTOMY AND A NTERIOR M ITRAL V ALVE L EAFLET A UGMENTATION. Thomas Kelley, Jr., T. Sloane Guy, Abul Kashem, Sheela Pai, Yanfu Shao, Yoshiya Toyoda, Mohamad Alkhouli, James McCarthy, Kaiser Larry R., Shiose Akira. Temple University School of Medicine, Philadelphia, PA, USA,

2. B ACKGROUND The common surgical treatment for hypertrophic cariomyopathy causing left ventricular outflow tract obstruction is a septal myomectomy developed by Morrow et al or mitral valve replacement. Current studies have demonstrated that in many cases, septal hypertrophy is not the sole cause of outflow obstruction, there is also concurrent mitral valve dysfunction. These two factors create obstruction of the Left Ventricular Outflow Tract (LVOT). With poor coaptation there can be systolic anterior wall motion causing further LVOT obstruction along with mitral regurgitation. The use of leaflet augmentation with myomectomy via a sternotomy was first demonstrated by Aubert et al. In this case report we demonstrate the feasibility of combining mitral valve augmentation and a minimal myomectomy while utilizing the minimally invasive advantages conferred by the Da Vinci Surgical System.

3. M ETHODS 2 patients with HOCM, SAM and LVOT gradients of greater than 50mm Hg consented to undergo robotic myomectomy and leaflet augmentation with the Da Vinci Robotic System. Ports were placed in the right chest (3 8mm ports, a 15mm working port and a 12 mm camera port) and bypass initiated through femoral cannulation and the heart was arrested with an endoclamp catheter. The anterior leaflet was detached at the base with a knife and a septal myomectomy performed through the hole created in the anterior mitral leaflet. A patch of CorMatrix ECM was then sutured into the leaflet hole to dramatically augment the anterior leaflet to bring it out of the LVOT.

4. I MAGING Preoperative TEEPostoperative TEE

5. R ESULTS Both patients had an immediate and dramatic reduction in the LVOT gradient (<10mm Hg). 2D echocardiogram demonstrated coaptation of the mitral leaflets to occur in a much more posterior location, thus taking the anterior leaflet out of the LVOT.

6. C ONCLUSIONS Enlargement of the LVOT can be done with totally endoscopic robotic techniques using both septal myomectomy and perhaps more importantly, anterior leaflet mitral valve augmentation. The leaflet augmentation removes the anterior leaflet from the outflow tract and dramatically decreases regurgitation without the requirement of total valve replacement. All the benefits of minimally invasive surgery are still conferred to the patient.

7. S OURCES F. Delahaye, O. Jegaden, G. De Gevigney, J. L. Genoud, M. Perinetti, P. Montagna, J. Delaye, and P. Mikaeloff Postoperative and long-term prognosis of myotomy-myomectomy for obstructive hypertrophic cardiomyopathy: influence of associated mitral valve replacement. Eur Heart J (1993) 14 (9): 1229- 1237 doi:10.1093/eurheartj/14.9.1229 Ruth K. Petrone, Heinrich G. Klues, Julio A. Panza, Elfriede E. Peterson, Barry J. Maron, Coexistence of mitral valve prolapse in a consecutive group of 528 patients with hypertrophic cardiomyopathy assessed with echocardiography, Journal of the American College of Cardiology, Volume 20, Issue 1, July 1992, Pages 55-61, ISSN 0735-1097. Stéphane Aubert, Erwan Flecher, Sylvain Rubin, Christophe Acar, Iradj Gandjbakhch, Anterior Mitral Leaflet Augmentation With Autologous Pericardium, The Annals of Thoracic Surgery, Volume 83, Issue 4, April 2007, Pages 1560-1561, ISSN 0003-4975. The Mitral Valve in Hypertrophic Cardiomyopathy: It's a Long StoryAnna Woo and Sean Jedrzkiewicz. Circulation. 2011;124:9-12, doi:10.1161/CIRCULATION AHA.111.035568