Cardiac robotics: repairing mitral and tricuspid valves after sternotomy

Robot-assisted mitral reintervention: overcoming the anterior sternotomy barrier

Mitral reintervention after median sternotomy represents a major technical challenge due to dense retrosternal adhesions, which expose the patient to an increased risk of cardiac and vascular injury during thoracic opening. Historically, a history of sternotomy was considered a relative contraindication to minimally invasive approaches, which are nevertheless preferred to limit operative trauma.

This case report details a robot-assisted mitral and tricuspid repair (da Vinci Xi system) in a 75-year-old female patient presenting with heart failure and a history of atrial septal defect closure via sternotomy 30 years ago. The objective is to evaluate the technical feasibility and safety of the right mini-thoracotomy approach in this specific reintervention context.

The underlying hypothesis is that rigorous preoperative imaging, coupled with limited adhesiolysis and optimized myocardial, cerebral, and pulmonary protection strategies, secures the robotic procedure while avoiding the risks associated with conventional resternotomy. This study analyzes the modalities of peripheral cardiopulmonary bypass setup, adhesion management, and preventive measures for re-expansion pulmonary edema to confirm the success of this therapeutic strategy.

Clinical case methodology

This study reports the surgical management of a single patient, illustrating the feasibility of robot-assisted valve repair after an anterior median sternotomy. The design is that of a clinical case report.

Population: A 75-year-old woman with congestive heart failure and a history of atrial septal defect closure via median sternotomy performed 30 years ago. Transthoracic echocardiography (TTE) revealed moderate mitral regurgitation and severe tricuspid regurgitation.

Surgical protocol:

• Access and cannulation: Use of the da Vinci Xi robotic system via a 5 cm incision in the third intercostal space. Peripheral cannulation under fluoroscopic guidance (internal jugular 17-Fr, femoral venous 21-Fr, femoral arterial 18-Fr).
• Myocardial protection: Antegrade cardioplegia after aortic clamping. Maintenance of body temperature at 30°C to prevent re-expansion pulmonary edema.
• Procedure: Mitral repair with a 28 mm Physio Flex ring and tricuspid repair with a 30 mm Tri-Ad ring, using Gore-Tex CV-4 suture.

Surgical parameters: The total surgical time was 291 minutes, with a cardiopulmonary bypass time of 197 minutes and an aortic cross-clamp time of 90 minutes. Postoperative evaluation was based on intraoperative transoesophageal echocardiography (TEE) and standard echocardiography before the patient's discharge on the 15th day.

Results of the robot-assisted procedure

The procedure was successfully performed in a 75-year-old patient presenting with moderate mitral regurgitation and severe tricuspid regurgitation. The procedure allowed for complete valve repair by annuloplasty without major intraoperative complications.

Key intraoperative data are detailed below:

Parameter	Value
Total operative time	291 minutes
Cardiopulmonary bypass time	197 minutes
Aortic cross-clamp time	90 minutes
Estimated blood loss	140 mL

Transfusion management required the administration of 6 units of packed red blood cells, 6 units of fresh frozen plasma, and 20 units of platelet concentrates. Intraoperative transoesophageal echocardiography confirmed the success of the repair, demonstrating residual mitral and tricuspid regurgitation described as "trivial".

Postoperative follow-up

• Ventilation: Total duration of 15 hours.
• Intensive care stay: 2 days.
• Echocardiographic results: Confirmation of mitral and tricuspid regurgitation below the "mild" threshold.
• Clinical result: Patient discharge on the 15th postoperative day without notable complication.

It should be noted that this single case study does not allow for comparative statistical analysis (p-values not applicable). However, the approach demonstrated its technical feasibility: despite the presence of mild intrathoracic adhesions, minimal dissection allowed for effective myocardial protection by maintaining hypothermia at 30°C, thus preventing re-expansion pulmonary edema.

Clinical analysis: The robot-assisted approach in reoperative surgery

This clinical case demonstrates the technical feasibility of robot-assisted mitral and tricuspid surgery in a 75-year-old patient with a history of median sternotomy. The use of the da Vinci Xi system allowed for the correction of severe valvular leaks via annuloplasty, with a CPB time of 197 minutes and an aortic cross-clamp time of 90 minutes. The favorable outcome, marked by discharge on postoperative day 15 without major complication, validates the right thoracotomy approach as a relevant alternative to avoid the risks inherent in resternotomy, particularly cardiac and vascular injuries related to retrosternal adhesions.

However, it is necessary to remain clear-sighted regarding the limitations of this report: it is a single observation (n=1). Although the safety of the procedure is demonstrated here, reproducibility on a larger scale intrinsically depends on rigorous candidate selection. The study highlights that preoperative imaging (CT angiography) is the cornerstone of this strategy: the absence of porcelain aorta and the feasibility of peripheral cannulation are sine qua non conditions for success.

Technically, this case confirms current trends favoring minimally invasive thoracotomy for reoperations, reinforcing the idea that the robot offers superior visualization allowing for minimal and safe dissection of adhesions. Managing body temperature at 30°C to prevent re-expansion pulmonary edema proves to be a key element of the perioperative protection documented here.

Clinical summary: robot-assisted mitral and tricuspid surgery after sternotomy

This case reports a double robot-assisted mitral and tricuspid repair (da Vinci Xi system) in a 75-year-old patient with a history of atrial septal defect closure via median sternotomy. The intervention, marked by a cardiopulmonary bypass time of 197 minutes and an aortic cross-clamp time of 90 minutes, allowed for complete repair without major complication, with discharge on the 15th postoperative day.

Concretely, for the practitioner:

• Rigorous selection: Preoperative CT angiography is essential to validate the feasibility of the right mini-thoracotomy approach and confirm the absence of contraindications to peripheral cannulation.
• Thermal management: Maintaining moderate hypothermia (30°C) during CPB is an effective strategy to prevent re-expansion pulmonary edema, a classic complication of this approach.
• Myocardial safety: Localized dissection of the distal ascending aorta and the use of robotic assistance allow for secure antegrade myocardial protection despite retrosternal adhesions.

{ "lexique": [ { "term": "Antegrade cardioplegia", "definition": "Myocardial protection technique administered into the aortic root after clamping, used here via a dedicated catheter to ensure effective cardiac arrest under robotic assistance." }, { "term": "Adhesiolysis", "definition": "Surgical action consisting of cutting adherent fibrous tissues, crucial in this context of reoperation to access the ascending aorta and cardiac structures after a historical median sternotomy." }, { "term": "Peripheral cannulation", "definition": "Vascular access technique, performed here via the femoral arteries and veins, allowing for the establishment of extracorporeal circulation without requiring a full sternotomy." }, { "term": "Re-expansion pulmonary edema", "definition": "Potential pulmonary complication related to surgical manipulation, prevented in this study by maintaining moderate hypothermia (30°C) during extracorporeal circulation." }, { "term": "Annuloplasty", "definition": "Valve repair procedure consisting of implanting a prosthetic ring (e.g., Physio Flex for the mitral valve or Tri-Ad for the tricuspid valve) to correct annular dilatation." }, { "term": "da Vinci Xi", "definition": "Robotic surgical system used to perform mitral and tricuspid valve repair via a right mini-thoracotomy, offering magnified visualization and increased precision of surgical maneuvers." } ] }

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