Today’s Robotic Aortic Valve Replacement

This surgical video demonstrates the technical details of robotic aortic valve replacement in a sixty-eight-year-old man with bicuspid aortic valve and severe aortic insufficiency. 

The surgical set-up was the same as in robotic mitral surgery. First, right femoral arterial and venous cannulations were performed for cardiopulmonary bypass. A 3 cm access incision was made along the right fourth intercostal space just posterior to the lateral border of the pectoralis major muscle. An Alexis wound protector was placed to provide soft tissue retraction. The robotic arms one (left hand), two (30-degree camera) and four (right hand) were docked in the third, fourth, and sixth intercostal spaces along the right anterior axillary line, respectively. The robot arm three (fenestrated forceps) was docked in the fifth intercostal space lateral to the right internal mammary vessels to provide atrial retraction.

Next, the left ventricular vent was inserted via the Sondergaard’s groove under direct vision. The ascending aorta was then separated from the right pulmonary artery posteriorly. To avoid the potential risks of injury to the left appendage or the pulmonary artery, the positioning of the aortic clamp was placed just above right pulmonary artery. The aorta was cross-clamped and cold custodial cardioplegic solution was instilled slowly. After adequate venting, a transverse aortotomy was performed just distal to the sinotubular junction. Additional ostial cardioplegia was given to provide optimal myocardial protection via a soft cannula. Moderate hypothermia, 32°C, was maintained during the operation.

After that, the aortic valve was inspected. The leaflets were resected and the aortic annulus was completely decalcified. For annular sutures, 2-0 Ethibond Excel annular sutures without pledgets were used, starting from the commissure between the right coronary annulus and the left coronary annulus and going counter clockwise sequentially. Three pledgeted sutures were used below the nadirs of the aortic annulus to reduce the tension created by the sutures. The annulus was then sized. A 29 mm Inspiris Resilia tissue valve was selected. The annular sutures were then passed through the sewing ring of the valve. The sutures were clipped and cut. Next, the valve was parachuted down and the sutures were secured around the annulus with a Cor-Knot device. The aortotomy incision was closed with two layers of 4-0 Prolene sutures. 

After the procedure, the patient was decannulated from the CPB machine uneventfully. Hemostasis was carefully checked and protamine was given to reverse the heparin effect. Two 28 Fr soft drains were inserted. A postoperative transesophageal echocardiography showed normal ventricular function with no paravalvular leak.

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