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Robotic Aortic Valve Replacement with Concomitant Mitral Valve Repair and Bi-Atrial Cox Maze

Thursday, February 24, 2022

Badhwar V, Wei LM. Robotic Aortic Valve Replacement with Concomitant Mitral Valve Repair and Bi-Atrial Cox Maze. February 2022. doi:10.25373/ctsnet.19232997 

Surgical Technique 

Identical to the authors’ approach to robotic mitral valve surgery, robotic AVR—or RAVR—was developed utilizing a three robotic port technique accompanied by a fourth intercostal space 3 to 4cm mini lateral thoracotomy primary working incision at the level of the anterior axillary line (1,2). Peripheral cardiopulmonary bypass (CPB) with bicaval drainage is utilized in all patients. Transthoracic aortic clamping and antegrade 8:1 blood cardioplegia every twenty minutes is utilized to facilitate all cases.  


This robust seventy-six-year-old man presented with symptomatic severe aortic insufficiency without stenosis, moderate-severe primary mitral insufficiency because of a flail P2, persistent atrial fibrillation of ten months duration, a patent foramen ovale (PFO), congestive heart failure, an ejection fraction of 45 percent, trace tricuspid insufficiency, and normal coronary arteries. The patient had a calculated STS predicted risk of mortality for isolated AVR of 2.4 percent, which was likely underestimated given the need for concomitant procedures. This case was the twenty-second RAVR operation performed at the authors’ institution since commencement in January of 2020. It was their first such multiconcomitant procedure (1). 


Upon establishment of peripheral CPB and placement of an aortic root vent and right superior pulmonary vein left ventricular vent, transthoracic aortic cross-clamping was performed. An aortotomy then facilitated direct coronary ostial cardioplegia delivery to establish myocardial arrest. Under full robotic assistance, the left atriotomy was performed and the PFO was closed primarily. A complete biatrial Cox maze with cryoablation was performed, followed by left atrial appendage obliteration using established biatrial lesions (3). Mitral valve repair involved triangular resection of P2 supported by a 38mm posterior annuloplasty band.  

Finally, excellent exposure of the aortic valve leaflets facilitated resection, circumferential 2-0 braided annular suture placement, and implantation of a 25mm bioprosthesis, followed by aortotomy closure with 4-0 running monofilament suture in two layers to complete the RAVR.  

Times for the aortotomy, valvectomy, suture placement, suture tying, and aortic closure were one, one, twenty, eleven, and thirty-two minutes, respectively. Following antegrade warm cardioplegia, the patient was reanimated into normal sinus rhythm (NSR) and weaned from CPB without the need of inotropic support or transfusions, and he was extubated in the operating room. He was discharged home without narcotic use on postoperative day four on two weeks of oral furosemide, three months of oral amiodarone, and antiplatelet therapy without oral anticoagulation.  


At thirty-day follow-up, the patient was in NYHA Class I without residual valvular abnormality, NSR, and his ejection fraction had increased to 55 percent. At the one-year follow-up with a twenty-four-hour Holter continuous electrocardiogram and echocardiogram, the patient was in NSR without oral anticoagulation or antiarrhythmic drugs, trace to no residual mitral insufficiency, a normal functioning aortic valve prosthesis, and an ejection fraction of 60 percent. 


Surgical AVR utilizing full robotic assistance may be performed safely in a similar manner used for mitral operations. Incremental advancement of its application within increasing comorbidity and complexity may be possible to include concomitant valve and surgical ablation operations. At the authors’ institution, concomitant procedures to RAVR that are now performed include aortic root enlargement, mitral valve surgery, tricuspid valve repair, and surgical ablation.


  1. Badhwar V, Wei LM, Cook CC, Hayanga JWA, Daggubati R, Sengupta PP, Rankin JS. Robotic aortic valve replacement. J Thorac Cardiovasc Surg. 2021;161:1753-1759.
  2. Wei LM, Cook CC, Hayanga JWA, Rankin JS, Mascio CE, Badhwar V. Robotic Aortic Valve Replacement: First 50 Cases. Ann Thorac Surg. 2021 Sep 22:S0003-4975(21)01596-4. doi: 10.1016/j.athoracsur.2021.08.036. Online ahead of print.
  3. Badhwar V. Robotic-assisted biatrial Cox-maze ablation for atrial fibrillation. J Thorac Cardiovasc Surg. 2021 Oct 5:S0022-5223(21)01408-2. doi: 10.1016/j.jtcvs.2021.09.053. Online ahead of print.


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