Intraoperative image after mitral valve repair.
Central Message.
Totally endoscopic, robotic-assisted mitral valve repair in patients who had previously undergone transcatheter aortic valve replacement poses additional technical challenges.
Moderate-to-severe mitral regurgitation (MR) affects approximately 25% of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).1 Although MR may improve after TAVR in up to 50% due to left ventricular reverse remodeling,1 persistent MR is associated with increased morbidity and hospitalization for heart failure.2 The best modality for the treatment of severe MR after TAVR remains debated.
We present the case of an acutely decompensated, frail, 86-year-old patient with severe aortic stenosis and moderate-to-severe MR (due to anterolateral commissural prolapse) with multiple comorbidities (Figure 1), with symptomatic MR after TAVR with the Evolut R (Medtronic). The patient was denied conventional mitral surgery (due to high-risk status), transcatheter mitral valve replacement (not meeting the inclusion criteria for the APOLLO trial), and MitraClip (Abbott) (due to location of the prolapse at the anterolateral commissure). We offered a totally endoscopic, robotic-assisted approach for mitral valve repair (Video 1), which was performed 12 days after TAVR (institutional review board No. 2000020356; October 19, 2021, Informed written consent for publication of study data was obtained). Ports were placed in our standard fashion,3 and cardiopulmonary bypass was achieved by percutaneous femoral cannulation.4 Aortic crossclamp and cardioplegia delivery were provided using the endoaortic balloon occlusion device (EABO), which was filled with indocyanine green5 and carefully placed in the ascending aorta. Of note, optimal and safe positioning of the EABO (well above the frame of the Evolut R aortic valve prosthesis and below the brachiocephalic trunk) was achieved by leveraging preoperative computed tomography angiography imaging (which allowed us to carefully evaluate the peripheral vascular as well as the ascending aortic anatomy of the patient), intraoperative transesophageal echocardiography imaging, bilateral upper extremities arterial pressure monitoring, and intraoperative visualization of the indocyanine green inside the EABO via the Firefly mode offered by the robotic platform. Additionally, multiple checks of the positioning of the EABO were carried out throughout the procedure. After entering the left atrium via the interatrial groove, we exposed the mitral valve while avoiding TAVR valve dislocation via careful maneuvering of the atrial retractor. The mitral valve had myxomatous degenerative changes, with flailed P1 (which explained the failed improvement after) and anterolateral commissural prolapse. We repaired the valve with commissural plication and placement of a 30-mm Physioflex annuloplasty band (Edwards Lifesciences). Cardiopulmonary bypass time and aortic crossclamp time were 115 minutes and 77 minutes, respectively. At the end of the procedure, transesophageal echocardiography revealed trace MR with a mean gradient of 4 mm Hg, and a still properly positioned and well-functioning Evolut R prosthesis. The patient experienced a transient ischemic attack on postoperative day 2, but remained neurologically intact and asymptomatic thereafter.
Figure 1.
Case summary and timeline.
In conclusion, using a totally endoscopic, robotic-assisted approach is safe and effective for the treatment of persistent severe MR after TAVR in selected patients.
Conflict of Interest Statement
Dr Amabile receives consulting fees from JOMDD/Sanamedi. Mr LaLonde receives consulting fees from Edwards Lifesciences and Intuitive Surgical. Dr Krane is a physician proctor and a member of the medical advisory board for JOMDD/Sanamedi, a physician proctor for Peter Duschek, is a medical consultant for EVOTEC and Moderna, and has received speakers’ honoraria from Medtronic and Terumo. Dr Geirsson receives consulting fees for being a member of the Medtronic Strategic Surgical Advisory Board and from Edwards Lifesciences. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers f this article have no conflicts of interest.
Footnotes
Read at the American Association for Thoracic Surgery Mitral Conclave 2023, New York, New York, May 4-5, 2023.
Contributor Information
Arnar Geirsson, Email: ag4877@cumc.columbia.edu.
Markus Krane, Email: markus.krane@yale.edu.
Supplementary Data
Narrated case video. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00308-5/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Narrated case video. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00308-5/fulltext.