Robotic Complex Congenital Cardiac Surgery—Partial Atrioventricular Canal Defect Repair

The use of robotic surgical platforms in mitral valve surgeries is an established technique with excellent outcomes (1). However, its use in congenital heart surgery currently is very limited. This video demonstrates a case of partial atrioventricular canal defect (PAVCD) repair using a DaVinci X surgical robot. 

The patient is a fifteen-year-old girl who presented with NYHA FC – II dyspnoea on exertion. On evaluation, she was diagnosed to have PAVCD. There was a moderate-sized ostium primum ASD. Both the mitral and tricuspid valves had clefts in their anterior leaflets leading to valvular regurgitation. There was moderate pulmonary arterial hypertension. 

Femoral-femoral cannulation was used for cardiopulmonary bypass. The internal jugular vein was also cannulated and connected to the venous circuit for better venous return. Surgery was performed under moderate hypothermia and custodial cardioplegia was used for myocardial protection. The access thoracotomy incision was placed in the fourth intercostal space between the anterior and midaxillary lines. A four-port strategy was used for routine robotic intracardiac surgeries. All ports are generally placed under camera guidance to prevent vascular injury. Once the patient was connected to a cardiopulmonary bypass, the robot was docked. The aorta was cross-clamped using a Chitwood clamp, which was placed via the second intercostal space in the midaxillary line. The mitral valve cleft was closed using a series of interrupted Prolene sutures and were secured using a knot pusher. Once the mitral valve repair was deemed satisfactory, the LV was inflated with saline against a competent mitral valve and the RV cavity was inspected to rule out any unidentified ventricular septal defect. The annular suture line was marked from commissure to commissure and the interrupted pledgeted sutures were used. A sized and treated autologous pericardium was used for ASD closure. The annular sutures were passed in the pericardium, the patch was lowered, and sutures were secured using a knot pusher. The remaining margins of the ASD were closed using CV-5 Gore-Tex suture in a running fashion (2). The cleft in the TV leaflet was closed using a Prolene suture. The rest of the surgery was completed in a standard fashion. The patient had an uneventful recovery and was discharged on postoperative day 4. She was able to resume high school within two weeks. Her follow-up echocardiogram at three months shows satisfactory repair—no residual ASD or valvular regurgitation (MR/TR) and she is in FC – I. 

Conclusion 

This is one of the earliest attempts at using a surgical robot to treat complex congenital heart disease. With more experience, the authors are very confident that they will be able to expand the boundaries of robotic cardiac surgery. 

References

1. Rao A, Tauber K, Szeto WY, Hargrove WC, Atluri P, Acker M, Crawford T, Ibrahim ME. Robotic and endoscopic mitral valve repair for degenerative disease. Ann Cardiothorac Surg. 2022 Nov;11(6):614-621. doi: 10.21037/acs-2022-rmvs-28. PMID: 36483610; PMCID: PMC9723529.
2. Manning, P. B. (2004). Repair of primum ASD with cleft mitral valve. Operative Techniques in Thoracic and Cardiovascular Surgery, 9(3), 240-246. https://doi.org/10.1053/j.optechstcvs.2004.08.001

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