Table 3. Robotic mitral valve repair complications and management.
| Complication | Management |
|---|---|
| Injury to intercostal artery/vein | Immediate hemostasis with cautery, hemoclips, manual compression, or stitch |
| Injury to right intrathoracic artery | Immediate hemostasis with cautery, hemoclips, manual compression, or stitch |
| Diaphragm laceration | Prophylactic use of pledgeted retraction stitch, oversew with additional pledgeted stitches |
| Carotid artery puncture during CVC insertion | Do not withdrawal needle, assess with ultrasound, consider vascular surgery evaluation, angiogram, covered stent, cut-down and repair |
| Blood loss during right internal jugular SVC cannula insertion | Occlude distal aspect of SVC cannula with two [2] tubing clamps prior to insertion |
| Femoral cannulation site seroma, hematoma, infection, delayed healing | Prophylactically avoid complication with diligent closure of wound in multiple layers. Thorough evaluation of wound post operatively |
| Limb ischemia from femoral artery cannulation | Prophylactic use of distal perfusion cannula. Immediate placement of distal perfusion cannula when ischemia is identified intraoperatively |
| Compartment syndrome | Immediate release via fasciotomy and post-operative vascular surgery evaluation |
| PFO during femoral IVC cannula insertion with guidewire | Primary repair on CPB |
| Injury to right atrium during femoral IVC cannula insertion with guidewire | Primary repair on CPB |
| Iatrogenic injury to axillary artery during cannulation | Abort axillary cannulation. Primary repair, patch angioplasty, selective peripheral angiogram. Vascular surgery intervention if extensive |
| Blood loss during axillary artery cannulation | Control blood loss with vessel loops or vessel clamps |
| Phrenic nerve injury | Preventative: Identify phrenic nerve prior to pericardiotomy. Maintain generous distance with cautery and retraction sutures. Limit tension applied |
| Ventricular fibrillation and dysrhythmia when using cautery creating exposure | Discontinue use of cautery/robotic energy. Treat dysrhythmia per ACLS guidelines |
| Aortic injury (transverse sinus dissection or extending pericardiotomy superiorly) | Dependent upon extent of injury. Compression, primary repair with pledgeted suture, rapid CPB, convert to sternotomy, aortic repair |
| Pulmonary artery injury when creating exposure (when artery takes a more caudal course) | Dependent upon extent of injury. Compression, rapid CPB, convert to sternotomy, primary repair, patch angioplasty |
| Aortic hematoma, bruising, and bleeding during root vent placement | Preventative: placement of aortic root vent stay sutures prior to heparinization, excise all peri-aortic adipose tissue and redundant tissue in proximation of root vent insertion site, communicate to perfusion to lower systemic pressure when placing root vent. To manage, release hematoma, cautery, primary repair with pledgeted stitch |
| Air embolism | On CPB: defibrillate heart, turn all vents on high, increase systemic pressures by perfusionist or pharmacotherapy |
| Off CPB: defibrillate heart, manage per ACLS guidelines, increase systemic pressures with pharmacotherapy | |
| Aortic injury (disruption of aortic cross clamp by bedside assist or collision with robotic arm 1) | Evaluation of ascending aorta, aortic arch, and descending thoracic aorta with TEE. If dissection identified, abort operation, convert to sternotomy, repair per dissection type guidelines. If no dissection, manage aortic hematoma or bruising by releasing adventitia and reposition cross clamp |
| Iatrogenic endoballoon rupture | TEE inspection. Rapid extraction. Insertion of new endoballoon device |
| Iatrogenic aortic dissection from endoballoon aortic occlusion | Inspection with TEE. Abort procedure. Repair dissection per dissection type guidelines |
| Left atrial tear from lift retractor | Primary repair or patch repair at conclusion of case |
| Injury to atrioventricular septum with left atrial lift retractor | Small injury: primary closure with pledgeted mattress sutures |
| Large injury: patch repair | |
| LV perforation by LV vent | Convert to sternotomy. Management dependent on extent of injury. Primary repair, pledgeted mattress stitches, hemostatic agents, patch repair |
| Left circumflex artery injury | Re-establish CPB and identify etiology. Options include: replace annular sutures near P1 scallop, inotropic pharmacotherapy, IABP, ECMO, transfer to cardiac catheterization lab for coronary angiogram and PCI, direct injection of nitroglycerine, convert to sternotomy and perform coronary bypass |
| Posterior left atrial injury during decalcification | Re-establish CPB, re-arrest heart, repair injury from inside left atrium |
| Atrioventricular groove disruption | Re-establish CPB, re-arrest heart, convert to sternotomy, reopen left atrium, explant prosthesis, large patch repair with autologous or bovine pericardium |
| Aortic Insufficiency after separation from CPB | Inspect aortic valve with TEE. Re-establish CPB, re-arrest heart, re-enter left atrium and inspect mitral annular sutures. If anterior trigone stitches damage or fix the aortic cusp must be replaced. If unclear etiology under minimally invasive inspection, convert to sternotomy and evaluate via open approach |
| Systolic anterior motion | Re-establish CPB, re-arrest heart, re-enter left atrium, evaluate mitral repair with saline injection, re-repair MV |
| Difficulty weaning from CPB | TEE inspection to identify etiology. Wait and allow heart to recover. Ensure patient’s core temperature is normothermic. Placement of temporary pacing wire. Inotropic support. Increase systemic pressure (perfusionist or pharmacotherapy), insertion of IABP, ECMO, RV/LV support device, cardiac catheterization for diagnostic coronary angiogram, convert to sternotomy for further inspection, bail-out coronary bypass |
| Unilateral pulmonary edema | If extubated: intubate and support with mechanical ventilation. ECMO support. Inhaled nitric oxide |
CVC, central venous catheter; SVC, superior vena cava; PFO, patent foramen ovale; IVC, inferior vena cava; LV, left ventricle; CPB, cardiopulmonary bypass; ACLS, Advanced Cardiac Life Support; TEE, transesophageal echocardiogram; IABP, intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation; PCI, percutaneous coronary intervention; MV, mitral valve; RV, right ventricle.