Robotic trans-atrial and trans-mitral ventricular septal resection

Abstract

Localized ventricular septal hypertrophy, also known as idiopathic hypertrophic subaortic stenosis or idiopathic hypertrophic subaortic septal obstruction (IHSS), can create severe ventricular outflow obstruction. This often results in a high sub-aortic pressure gradient with potentially lethal symptoms. In 1960, Braunwald described the hemodynamic characteristics of IHSS, and thereafter, Morrow developed a trans-aortic approach to resect a large part of the ventricular septum, enlarging the outflow tract. The Morrow operation has remained the gold standard for surgically treating this pathology. However, in patients with a small aortic annulus, a severely hypertrophied septum, and a long anterior mitral leaflet, the trans-aortic approach may be more difficult, resulting in an inadequate resection and/or systolic anterior leaflet motion. The latter usually increases the obstruction and can cause mitral regurgitation. Herein, we describe a minimally invasive trans-left atrial robotic approach to treat IHSS. First, the anterior mitral leaflet is incised radially to reveal the aortic outflow tract and ventricular septum, which are located posteriorly.Thereafter, a deep "block" of septum is excised, beginning at the right valve cusp nadir and continued counterclockwise toward the left fibrous trigone. This excision is extended to the anterior papillary muscle base, where any septal connections must be divided. Subsequently, the anterior leaflet is re-suspended and the repair is completed with a flexible annuloplasty band. If necessary, the anterior leaflet can be augmented with a pericardial patch. The "wristed" robotic instruments and magnified 3-D vision definitely facilitate an adequate septal resection and anterior papillary muscle mobilization. Moreover, it is possible that this fine control helps to reduce complications, such as heart block or a ventricular septal defect.

Assisted Da Vinci robotic surgery combined with 3D printing technology applied in septal myectomy

“…However, some particularly anatomical alterations and lesions, especially within the limited surgical field, are not indicated for the traditional incision including smaller aortic annulus, severe septal hypertrophy and prolonged anterior mitral valve, which may lead to, through median sternal incision, inadequate resection, SAM and even damaging of aortic valve [ 3 , 4 ]. Although some modifications in minimal invasive surgery system including endoscopic and robotic surgery have been applied as the surgical attempts for septal myectomy, due to actual diversities of clinical interventions, the outcomes of patients are highly depended on the surgical ability and experience of surgeons [ 5 , 6 ].…”

Robotic Trans-Mitral Septal Myectomy and Papillary muscle reorientation for HOCM combined with or without Mitral valve repair: Technical aspects – How we do it

“…Introduced by Dr. Chitwood, robotic assisted septal myectomy has proven itself as an alternate approach for myectomies 3,4 . From our extensive experience in both robotic mitral repairs and trans-aortic myectomies, we found it appealing to approach patients needing both myectomies and primary mitral valve repairs robotically.…”

“…Surgical septal myectomy for HOCM is the standard of care and is routinely performed through a median sternotomy. Septal myectomy has also been performed using the trans-atrial, trans-mitral approach either directly 1, 2 or with robotic assistance 3,4 . In cases with severe LVOT obstruction in the setting of only mild to moderate proximal septal hypertrophy, intrinsic problems with the mitral valve contribute.…”

Robotic trans‐mitral septal myectomy and papillary muscle reorientation for HOCM combined with or without mitral valve repair: Technical aspects – How we do it

“…Introduced by Dr. Chitwood, robotic assisted septal myectomy has proven itself as an alternate approach for myectomies. 5,6 In the…”

“…Introduced by Dr. Chitwood, robotic assisted septal myectomy has proven itself as an alternate approach for myectomies. 5,6 In the Cleveland Clinic, we have as of today performed close to 2000 HOCM surgeries which were almost all have been done via…”