Robotic Mitral Valve Replacement in a Patient With Patent Bilateral Internal Mammary Grafts: A Case Video

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Objective 

Reoperative cardiac surgery is often viewed as a relative contraindication for robotic approaches. Here, the authors report a case of a robotic mitral valve replacement in a patient who underwent a prior coronary artery bypass grafting (CABG) procedure with patent bilateral internal mammary arteries. 

Case Video Summary 

The patient was a 74-year old male with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, carotid artery disease, and coronary artery disease. The patient had previously undergone CABG, including right internal mammary artery to left anterior descending artery (RIMA-LAD), left internal mammary artery to the second obtuse marginal artery (LIMA-OM2), saphenous vein graft to the first obtuse marginal artery (SVG-OM1), and saphenous vein graft to the left posterior descending artery (SVG-LPDA). The patient reported a one-year history of progressively worsening fatigue and dyspnea on exertion.  

Preoperative transesophageal echocardiography (TEE) demonstrated severe mitral regurgitation (MR) with a restricted posterior leaflet, no significant mitral stenosis, a left ventricular ejection fraction (LVEF) of 50-55 percent, and normal right ventricular function. Preoperative left heart catheterization (LHC) showed a patent in-situ LIMA-OM2 and RIMA-LAD. Computed tomography angiography (CTA) showed that the in-situ RIMA crossed the midline in close proximity to the posterior aspect of the sternum, complicating sternal reentry. As such, the decision was made to proceed with robotic mitral valve surgery.

The patient was prepped and draped in the usual sterile fashion. A limited fourth interspace anterolateral thoracotomy was performed and robotic ports were placed in the third, fourth, and sixth interspaces. The patient underwent peripheral cannulation for cardiopulmonary bypass and was cooled to 28 degrees Celsius. The robot allowed for careful dissection of the in-situ RIMA and exposure of the left atrium and Sondergaard’s groove. Following aortic occlusion and delivery of systemic potassium, the left atrium was entered through Sondergaard’s groove, and the mitral valve was exposed with a left atrial retractor. Valve analysis demonstrated a restricted posterior leaflet consistent with ischemic functional MR, so the decision was made to replace the valve.  

On postoperative TEE, the prosthetic valve appeared well seated, with normal gradients and mild intravalvular MR. The LVEF remained unchanged from baseline, and there was no evidence of aortic insufficiency (AI) or new regional wall motion abnormalities. The patient was discharged on postoperative day five with an uneventful hospital course. Over a nine-month follow-up period, the patient continues to do well. 
 
Conclusion 

By limiting possible complications associated with sternal reentry and allowing enhanced visualization and technical precision for careful dissection of cardiac structures, robotic mitral valve surgery is a safe and feasible approach for patients with a history of cardiac surgery. 

References

1. Meidan TG, Lanfear AT, Squiers JJ, et al. Robotic mitral valve surgery after prior sternotomy. JTCVS Tech. 2022;13:46-51. Published 2022 Feb 24. doi:10.1016/j.xjtc.2022.01.023

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