Early Clinical Experiences of Robotic Assisted Aortic Valve Replacement for Aortic Valve Stenosis with Sutureless Aortic Valve

Abstract

<jats:p> Robotic assisted aortic valve surgery is still challenging and debatable. We retrospectively reviewed our cases of robotic assisted aortic valve replacement utilizing sutureless aortic valve with following surgical technique: 3 ports, 1 for endoscope and 2 for the robotic arms were inserted in the right chest and da Vinci Si robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was adapted to these ports. Cardiopulmonary bypass was initiated through peripheral cannulations. A vent cannula was placed through the right superior pulmonary vein and a cardioplegia cannula in the ascending aorta. After cardioplegic arrest following aortic cross-clamp, the aortic valve was exposed through a clam shell aortotomy. Valvectomy along with decalcification was performed. Next using 3 guiding sutures the Perceval S valve (LivaNova, London, UK) was parachuted down and deployed. After confirming valve position, the aortotomy was closed. There were no major complications during the procedures and no conversion to sternotomy. Exposure of aortic valve was of high quality. Valvectomy required assistance with long scissors by the bedside surgeon for excision of the severely calcified valve cusps and effective decalcification of annulus. Postoperative convalescence was uncomplicated except for postoperative atrial fibrillation in 1 patient. Robotic assistance in aortic valve procedure enabled excellent exposure of the aortic valve and improved manipulation and suturing of the aortic annulus and aorta. There needs to be improvement of instrumentation for valve debridement and removal of calcium from the annulus. In addition, the sutureless valve technology contributes to the feasibility and the efficacy of this procedure. </jats:p>

Robotic aortic valve replacement

“…In an effort focused on learning curve quality improvement, times were recorded in a protocolized manner by the operative team for each of the following robotic operative segments: aortotomy, valvectomy, annular suture placement, suture tying, and aortotomy closure. For the entire cohort, the median time (range) in minutes for each segment was 1 (1-2), 4 (1-10), 19 (15-40), 7.5 (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21), and 28 (23-45), respectively.…”

“…The minimally invasive RAT approach was first used to explore 5 cases of rAVR 14 but is now commonly used to facilitate direct-vision sutureless valve implantation, including a few recent cases performed with robotic assistance. 17,18 The RAT approach provides excellent exposure to the aorta and root. This involves an anteromedial chest incision, often in the second or third intercostal space and midclavicular line, commonly performed by dividing or splitting pectoralis muscle fibers, dividing the right internal thoracic artery, and possibly shingling a rib, with the subsequent need for rib stabilization.…”

“…The procedure was largely abandoned, however, until recent reports of using the RAT approach to robotically facilitate initial cases of sutureless valve implantation. [13][14][15][16][17][18] A robotic approach to mitral valve surgery via a 3-cm minimally invasive lateral thoracotomy at the level of the anterior axillary line has been established as a reproducible approach with an excellent safety profile and longitudinal outcomes. 19 In this report, we introduce the first human experience with an entirely robotic surgical aortic valve replacement (rAVR) using conventional prostheses performed via a minimally invasive lateral thoracotomy working incision.…”

Totally Endoscopic Uniportal Surgical Aortic Valve Replacement via Transcervical Approach: How to Do It

“…Use of the da Vinci robot for surgical aortic valve replacement through endoscopic approach has also been described by Balkhy and others. [11][12][13] These authors have provided proof of concept for robot assisted excision of non-calcified aortic valve leaflets and closure of the aortotomy. These specific tasks are very easily done using conventional MIS instruments.…”

Outcomes in minimally invasive double valve surgery

“…Given the complexity associated with robotics, careful patient selection is important and requires a high degree of operator experience for a successful outcome 19 . However, the initial capital investment along with the maintenance cost has limited its uptake 20 and research is sparse for double valve pathology, with a greater focus on single valve only 21,22 . Ranganath et al 23 conducted mitral valve (MV) surgery with the assistance of robotics, noting several cases requiring concomitant tricuspid repair with overall positive outcomes.…”