Robotic Mitral Valve Surgery "The Chitwood Clamp"

Robotic Mitral Valve Surgery"The Chitwood Clamp"AATS Robotic Cardiac SurgeryMay 1, 2010Evelio Rodriguez, MD; L. Wiley Nifong, MD; andW. Randolph Chitwood, Jr., MDEast Carolina Heart InstituteGreenville, NC, USA

• Research Support• ATS Medical• Cardionet Inc.• Glaxo Smith-KlineDisclosures• Speaker• ATS Medical• Intuitive Surgical• Scientific Advisory Board• Cardionet Inc.

Overview1. Set-up options for robotic MV surgery1. Cannulation Techniques2. Review data from 555 cases performedat our institution3. Review literature comparing differentperfusion techniques

Port Placement

1-cm Fourth Arm1.2-cm Camera1-cm Left ArmTransthoracicAortic Clamp1-cm Right Arm

Cardiopulmonary Bypass Options• Arterial Cannulation‣ Femoral (unilateral or bilateral)‣ Aortic‣ Axillary• Venous Drainage‣ Two-staged femoral venous‣ Femoral venous and IJ/SVC drainage‣ PA Vent (Endovent)• Cardioplegia‣ Antegrade‣ Retrograde (via IJ or RA)‣ V-Fib Arrest

Peripheral Perfusion

Chitwood-Debakey Aortic Clamp

Advantages and Disadvantages“Chitwood Clamp”Endoclamp‣ Simple‣ Less Cost‣ Potential PA and LAAinjury‣ Interference with SVC‣ Interference withRobotic Arms‣ Have to Deal withAortic Cardiolegia Site‣ Learning Curve‣ Expensive‣ Peripheral AccessIssues‣ EndoballonObstruction of Lefttrigone Area‣ More Versatile• Redos• Aortic Insuffiency

Cardioplegia

Cardioplegia and Cross Clamp

2D and 3D TEE

Mitral Valve Repair

Robotic Mitral Repairs (N=555)77%Leaflet Rsn + Annuloplasty N=124 (22.3%)Leaflet Rsn + Sliding Plasty With/Without Chordal Proc + Annuloplasty N=108 (19.5%)Chordal Procedure (no leaflet resection) + Annuloplasty N=61 (10.9%)Leaflet Rsn + Chordal Procedure + Annuloplasty N=135 (24.3%)(Posterior Leaflet Shortening – “Haircut Procedure” N=71)Annuloplasty alone N=69 (12.4%)“Edge-to-Edge” (Alfieri) + Annuloplasty N=11 (1.9%)Leaflet Repair + Annuloplasty N=37 (6.6%)Other N=11 (2.1%)

HOURSIntraoperative Times (N=555)CPBXC

Complications (N=555)• Operative Deaths N = 1 (0.2%)• In-Hospital Deaths N = 15 (2.7%)• Return for Bleeding N = 15 (2.7%)• Myocardial Infarctions N = 4 (0.7%)• Strokes N = 3 (0.5%)• Infections N = 1 (wound)• Transfused 23.9%• Perfusion Complications N = 2 (0.4%)• Pleural Effusion N = 34 (6.1%)• Re-operations (band dehiscence) N = 6 (1.1%)• Re-operations (other, progression of disease) N = 10 (1.8%)• Re-operations (SAM) N = 2 (0.4%)

JTCVS, 133 (4); 1066-1070, 2007

Modi et al. JTCVS, 137 (6); 1481-1487, 2009

Conclusions• Minimally invasive and robotic assistedMV surgery is safe.• Arterial perfusion related complicationscould be significantly minimized withproper planning.• Surgeons should be familiar and proficientin using all cannulation andcadioplegic/fibrillatory techniques.

Thank You

Scalan Instruments

Conversions to Videoscopic• Device Complications N=3 (0.5%)• Poor Exposure N=4 (0.6%)• External Instrument Conflict N=1 (0.2%)• Changed to Replacement N=1 (0.2%)

Exposure

Exposure of Mitral Valve

Patient Set-UpMid ClavicularCameraLeft Atrial RetractorLeft PortWorking PortAnterior AxillaryRight PortMid AxillaryPosterior Axillary