Native mitral valve endocarditis: Robotic cardiac surgical repair

Graphical Abstract

Operative view of robotic mitral valve reconstruction.

Central Message.

Mitral valve repair in native valve endocarditis is often a challenging procedure. Robotic cardiac surgery is a safe approach and can be an asset for valve reconstruction, especially in complex cases.

Mitral valve (MV) endocarditis is associated with a high mortality rate and the need for surgical treatment. When possible, MV repair (MVr) is preferable to replacement.^1,2 A robotic approach might prove to be a useful asset in cases requiring complex valve reconstruction.2, 3, 4

A previously healthy 31-year-old woman was admitted due to persistent fever and shortness of breath that began after a dental procedure. Transesophageal echocardiography (TEE) revealed a 10 mm vegetation in the MV. After initial unsuccessful antibiotic treatment with ceftriaxone and gentamicin, therapy was changed to daptomycin and meropenem. All cultures remained negative during the entire treatment course.

After 30 days, the new TEE showed severe MV regurgitation with thickening of the P2 segment and a ruptured chord in the P3 segment. There was also a large vegetation in the A3 segment. This was compatible with MV endocarditis. There were no signs of perivalvular complications. Biventricular systolic function and dimensions were preserved.

After multidisciplinary discussion by members of the endocarditis team, surgical treatment was indicated. The patient strongly wished for a minimally invasive approach. Because we are Latin America's first cardiac surgery service with more than 10 years' experience in robotic MVr, she was referred for our evaluation. Robotic-assisted cardiac surgery was deemed the best approach to facilitate MVr and provide a faster recovery.3, 4, 5 The patient was fully informed of all treatment options available, and a consent form for publication was signed under Research Ethics Committee Registry No. 11/1501–02/2011.

The patient was positioned for a standard robotic mitral valve repair (Video 1), and incision markings were made considering the presence of a breast prosthesis, as shown in Figure 1. After systemic heparinization, peripheral cannulation was performed guided by TEE, using the right common femoral artery and vein, and the right internal jugular vein. A 7Fr arterial distal shunt was placed, and limb perfusion was monitored with an INVOS system (Medtronic).

Figure 1.

Patient position with incision markings and the breast prosthesis. The left arm and work port sites remained in the standard sites for robotic mitral valve surgery, in the second and third intercostal spaces, respectively, at the level of the anterior axillary line. The right arm and left atrium retractor trocar sites were marked in the fourth intercostal space but were dislocated toward the inframammary breast crest.

With cardiopulmonary bypass (CPB) set up and selective left pulmonary ventilation, the microcamera was put in. Following right pleural space inspection, the remaining trocars were put in place, and the DaVinci robotic system (Intuitive Surgical) was docked. Continuous insufflation of carbon dioxide was started. After initiation of CPB and under 32 ^oC hypothermia, the aorta was crossclamped with a Chitwood transthoracic clamp (Fehling Instruments) placed through the second intercostal space. Custodiol HTK cardioplegic solution (Köhler Chemie) was administered in the ascending aorta with a 30 cm metal needle.

The left atriotomy was made anteriorly to the right pulmonary veins. A large vegetation was identified on the atrial surface of P3, as well as important leaflet thickening of the A2 segment (Figure 2, A).

Figure 2.

Identified vegetations on the posterior leaflet (A), with P3 resection (B), annular plication and leaflet reconstruction with a 5-0 polytetrafluoroethylene running suture (C). Exposure of the infected area of the anterior leaflet of the mitral valve before (D) and after the resection of the infected tissues (E), followed by reconstruction of the with a bovine pericardium patch (F).

The compromised segment of P3 was excised with a quadrangular resection with a 2-mm margin (Figure 2, B). Two U-shaped stitches were used for annular plication, and a 5–0 polytetrafluoroethylene (PFTE) running suture was used for P3 reconstruction (Figure 2, C). The infusion of saline solution for the static valve test showed adequate valve coaptation without regurgitation, and a number-32 prosthetic ring sizer properly fitted the valve.

The thickened portion of A2 (Figure 2, D) was removed with a wide circular resection, ensuring adequate margins (Figure 2, E). It was reconstructed using a bovine pericardium patch with a continuous 5–0 PTFE suture, which was then reattached to the native chord of the posteromedial papillary muscle (Figure 2, F).

Mitral annuloplasty was performed using a size-32 Memo 3D ring (Sorin Biomedica Cardio SrL). A small leak was detected in the posteromedial commissure and closed with a single 5–0 PTFE stitch. The final static saline test confirmed adequate mitral valve coaptation without regurgitation (Video 1).

The left atrium was closed, followed by thorough de-airing maneuvers, patient warming, CPB weaning, and decannulation. Heparinization was reversed with protamine administration. Aortic crossclamp and CPB times were 210 and 250 minutes, respectively. Intraoperative TEE confirmed a successful MVr. A 24Fr drain was positioned in the pericardial sac and right pleural cavity. The wounds were then closed and dressed.

The patient developed no complications. After 12 hours in the intensive care unit and 4 days in the cardiology ward, she was discharged home. Antibiotic treatment was completed in an outpatient setting. Six-year follow-up has been free of events, with excellent wound healing. An echocardiogram confirmed preserved mitral valve function (Video 1).

Conclusions

In this case of mitral infective endocarditis, robotic surgery facilitated a complex MVr while also allowing a fast recovery and excellent short- and midterm surgical results.

Conflict of Interest Statement

The 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 of this article have no conflicts of interest.

Supplementary Data

Video 1

Robotic mitral valve repair in native mitral valve endocarditis. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00471-6/fulltext.