Minimally invasive mitral valve surgery using three-dimensional video and robotic assistance

Different techniques have been developed for the common goal to minimize surgical trauma for mitral valve surgery. This article focuses on Port-Access (Heartport, Inc, Redwood City, CA) mitral valve replacement or repair (PAMVR) with emphasis on three-dimensional video and robotic assistance. PAMVR was undertaken using a small right anterior minithoracotomy using an endovascular cardiopulmonary bypass (CPB) system. A three-dimensional minicamera allowed visualization of the mitral valve apparatus during this limited access surgery. The three-dimensional (3D) image was displayed inside a helmet just above the real surgical image (VISTA system [Vista, Inc, Westborough, MA]). In addition, the camera was attached to a robotic arm (AESOP [Computer Motion, Inc, Goleta, CA]) that allows stabilization and voice-activated movement of the camera. Fifty patients (16 men, 34 women), aged 36 to 77 years (median, 61.5 years) underwent PAMVR. The underlying diseases were mitral valve insufficiency (n = 36) and combined mitral valve disease (n = 14). With optimal visualization, mitral valve repair was performed in 26 patients with quadrangular resection of the posterior leaflet (n = 26) and repair of the anterior leaflet (n = 3) together with insertion of a posterior or complete anuloplasty ring. The valve was replaced in 24 patients with a mechanical valve prosthesis. Intraoperative and postoperative mortality was 0%. One patient (2%) needed reoperation after a failed repair of an anterior leaflet prolaps. Three-month follow-up was complete in 40 patients, with 34 patients (85%) in New York Heart Association (NYHA) class I and 6 patients in class II. In conclusion, using 3D video and robotic assistance, it was possible to minimize the length of skin incision but at the same time to optimally visualize the whole mitral valve apparatus to perform true Port-Access mitral valve surgery, including complex repair techniques.