Download Anesthesia for Robotic Repair of the Mitral Valve: A Report of Two

CARDIOVASCULAR ANESTHESIA
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SECTION EDITOR
KENNETH J. TUMAN
CASE REPORT
Anesthesia for Robotic Repair of the Mitral Valve:
A Report of Two Cases
Nutan Mehta, MD*, Sumeet Goswami,
and Berend Mets, MB, FRCA, PhD*
MD*,
Michael Argenziano,
MD†,
Craig R. Smith,
MD†,
Departments of *Anesthesiology and †Cardiothoracic Surgery, Columbia Presbyterian Medical Center, New York,
New York
R
obotic techniques are increasingly used in cardiac surgery because they allow precise tissue
handling and enable the endoscopic performance of cardiac surgical tasks that require a high
degree of dexterity (1). In addition, these techniques
can fulfill the main goals of minimally invasive cardiac surgery—namely, a discrete scar, patient comfort,
and fast rehabilitation (2). Thus, there is increased
impetus to use this emerging technology in cardiac
surgery, especially for mitral valve repair (1).
The da Vinci™ Surgical System (Intuitive Surgical,
Mountain View, CA) consists of a surgeon’s console
(Fig. 1), a patient-side cart, a high-performance vision
system, and instruments (Fig. 2). Using the da Vinci
Surgical System, the surgeon operates while seated
comfortably at a console viewing a three-dimensional
image of the surgical field. The surgeon’s fingers grasp
the instrument controls below the display, with wrists
naturally positioned relative to his or her eyes. The
robotic technology seamlessly translates the surgeon’s
movements into precise, real-time movements of the
surgical instruments inside the patient. The surgeon
uses a microphone speaker to direct another surgeon
positioned at the surgical field, directing the tasks of
positioning a sucker to maximize visibility.
Mitral valve surgeries with the robotic technique are
presently being performed in nine cardiac centers in
the United States. The anesthetic care of patients undergoing this procedure is a new challenge for cardiac
anesthesiologists and has not been described previously. We present two patients who had successful
mitral valve repair in our institution and highlight
some of the anesthetic and perioperative issues associated with this procedure.
Accepted for publication April 30, 2002.
Address correspondence and reprint requests to Dr. Berend Mets,
Associate Professor of Clinical Anesthesiology, Columbia Presbyterian Medical Center, 630 W. 168th St., P&S Box 46, New York, NY
10032-3784. Address e-mail to [email protected].
DOI: 10.1213/01.ANE.0000022363.86945.56
©2003 by the International Anesthesia Research Society
0003-2999/03
Case Report
Case 1
The patient, a 53-yr-old Caucasian man with severe mitral
regurgitation (MR), had a history of hypertension and was
treated with metoprolol, lisinopril, furosemide, and doxycycline. He was found to have cardiomegaly with bilateral
effusions on chest radiography, normal sinus rhythm with
left axis deviation, and left anterior fascicular block on electrocardiogram, whereas transthoracic echocardiography revealed normal left ventricular size and function, with a flail
posterior mitral valve and severe MR. Cardiac catheterization revealed severe MR and an absence of significant coronary artery disease.
The patient weighed 80 kg, had never experienced surgery, and was not known to be allergic to any medications.
Before the operation, his hematocrit was 45.8%, blood urea
nitrogen was 21 mg/dL, and plasma creatinine was 1.5 mg/
dL; coagulation values were within the reference range.
Case 2
The patient, a 58-yr-old Caucasian man with severe MR and
a history of mitral valve prolapse, hypertension, and gastrointestinal bleeding of unknown etiology, was being treated
with lisinopril. He was found to have an aberrant right
subclavian artery on computed axial tomogram of the chest,
sinus rhythm with first-degree atrioventricular block, and
left ventricular hypertrophy on electrocardiogram. Transesophageal echocardiogram (TEE) revealed severe MR from
prolapse and flail of the posterior mitral leaflet, with normal
left ventricular function. Cardiac catheterization revealed a
pulmonary artery pressure of 35/16 mm Hg and a cardiac
output of 6.4 L/min.
He weighed 91.6 kg, had had general anesthesia in the
past without complications, and was not known to be allergic to any medications. Before surgery his hematocrit was
40.8%, blood urea nitrogen was 19 mg/dL, and plasma
creatinine was 1.0 mg/dL, with a normal coagulation
profile.
After placement of standard monitors and a radial arterial
line, both patients were anesthetized with a combination of
midazolam, etomidate, fentanyl, and isoflurane and paralyzed with rocuronium for endotracheal intubation. To enable subsequent one-lung anesthesia, a left-sided doublelumen endotracheal tube was placed and its appropriate
position confirmed with a fiberoptic bronchoscope. A TEE
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Figure 2. Picture of a skeleton with applied robotic arms, printed
with permission from Intuitive Surgical, Inc., Mountain View, CA.
Figure 1. Picture of the da Vinci robotic module, showing the
surgeon’s console, printed with permission from Intuitive Surgical,
Inc., Mountain View, CA.
probe (M2424A Ultrasound system; Hewlett-Packard, Andover, MA) was placed to monitor valve repair and left
ventricular function and to guide later placement of the
superior vena cava (SVC) and inferior vena cava (IVC) cannulae and to confirm coronary sinus cannulation for retrograde cardioplegia administration (vide infra). Then a 9F
introducer was placed into the left internal jugular vein and
an 8F pulmonary artery catheter inserted.
A 17F Biomedicus (Eden Prairie, MN) cannula was then
placed into the SVC via the right internal jugular vein,
percutaneously, by the anesthesiologist, who used a
Seldinger technique. At the time of placement, the cannula
was flushed with 5000 U of heparin, and a continuous flush
with 5000 U of heparin in 1 L of normal saline was used to
ensure its patency. The cannula and tubing were then stabilized by anchoring to the patient’s head with a crepe
bandage. The TEE was used to image the right atrium (RA)
and the SVC to confirm initial appropriate location of the
Seldinger wire and subsequent placement of the cannula at
the SVC/RA junction (midesophageal bicaval view at 90°).
Next, the patients were positioned in a modified left lateral decubitus position, with their hips flat and the right arm
elevated on a padded support bar. Intraoperative TEE evaluation (Fig. 3) in Case 1 revealed severe MR (4⫹) with a flail
posterior leaflet and an eccentric jet over the abnormal leaflet and a mean pressure gradient (MPG) of 4.4 mm Hg. All
other valves were normal. The left ventricular ejection fraction was 60%, with no regional wall motion abnormality.
Intraoperative TEE of Case 2 revealed severe MR (4⫹), a
posterior leaflet prolapse with an eccentric jet, an ejection
fraction of 50%, and mild tricuspid regurgitation (1⫹). The
other valves were normal.
After the right femoral vessels were exposed and single
(left)-lung ventilation established, the chest cavity was entered and the heart exposed after opening of the pericardium by means of a 5-cm incision along the fifth rib, lateral
to the midclavicular line. The pericardium was then anchored to the chest wall by placement of stay sutures. Then,
after activated coagulation time-guided heparinization, the
femoral artery and vein were cannulated with a 24F Bard
cannula (C. R. Bard Inc., Haverhill, MA) and a 21F Biomedicus cannula, respectively. Appropriate location of the IVC
cannula was confirmed within the RA by using TEE
(midesophageal bicaval view at 90°). In addition, TEE visualization was used to guide and confirm retrograde coronary sinus cannula placement.
Cardiopulmonary bypass (CPB) was established, with venous drainage from both the femoral (IVC) and internal
jugular (SVC) cannulae and an anterograde cardioplegia
catheter. The transthoracic aortic cross-clamp (Cardiovasive
Chitwood Debakey clamp) was passed through a stab
wound in the right axilla and applied to the ascending aorta.
Cold blood (4:1) cardioplegia was given anterograde and
retrograde. Small (8-mm) incisions were made in the third
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CASE REPORT
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Figure 3. Transesophageal echocardiography (TEE) pictures for Case 1, taken before (A) and after (B) robotic mitral valve repair. Panel A
demonstrates severe mitral regurgitation, with an eccentric posterior jet caused by prolapse of the posterior leaflet. Panel B demonstrates TEE
evaluation by using color flow Doppler and continuous flow Doppler to assess the extent of the remaining mitral regurgitation (minimal) and
the presence of stenosis by assessing the mean gradient (4 mm Hg) across the repaired valve.
and fourth intercostal space, lateral to the minithoracotomy
incision. The right and left robotic arms (da Vinci robotic
system) (Fig. 2) were passed through the port sites, and the
robotic endoscopic camera was positioned in the medial
aspect of the minithoracotomy incision. In Cases 1 and 2,
mitral valvuloplasty (quadrangular resection, Cosgrove No.
30 ring) was performed with robotic assistance.
After completion of the repair, valvular function was
assessed to exclude significant regurgitation and then,
by using one-lung ventilation, the patients were weaned
from CPB after inotropic support was instituted with norepinephrine (both cases) and dobutamine infusion (0.5
␮g · kg⫺1 · min⫺1) (Case 1). Post-CPB arterial blood gases on
a fraction of inspired oxygen of 1.0 were the following for
Case 1: arterial pH, 7.30; Paco2, 49 mm Hg; Pao2, 138 mm
Hg; base excess, ⫺2 mEq/L; HCO3, 24 mEq/L; and oxygen
saturation, 99%. In Case 2 they were arterial pH, 7.28; Paco2,
49 mm Hg; Pao2, 408 mm Hg; base excess, ⫺3 mEq/L,
HCO3, 23 mEq/L; and oxygen saturation, 100%. Lungrecruitment maneuvers (temporarily inflating the nondependent lung) were needed to maintain adequate oxygen
saturation when coming off CPB in both cases. The total
bypass time was 4 h exactly and 4 h 42 min, whereas
cross-clamp time was 2 h 49 min and 3 h 7 min for Case 1
and 2, respectively.
After separation from CPB, TEE evaluation demonstrated
in Case 1 an absence of MR (Fig. 3), a normal MPG (4 mm
Hg), and no systolic anterior motion (SAM) of the anterior
mitral leaflet. In Case 2 we found no MR and an MPG of
4 mm Hg, with minor SAM that did not require intervention.
The 17F SVC cannula was removed after chest closure,
when activated coagulation time had been confirmed to be
back to baseline after protamine reversal. Digital pressure
was held at the cannulation site in both patients until hemostasis was secured. After this, a careful assessment of facial
edema was made as to the feasibility of replacing the
double-lumen tube (DLT) with a single-lumen endotracheal
tube. We then replaced the DLT by inserting a Cook airway
exchange catheter through the tracheal lumen and withdrawing the DLT and railroading a single-lumen tube with
an 8-mm internal diameter to ensure that we did not “lose”
the airway.
Both patients were tracheally extubated on postoperative
Day 1. The postoperative course of Case 1 was complicated
by the development of atrial fibrillation on postoperative
Day 2, and the patient was started on heparin initially and
was discharged on coumadin on postoperative Day 6. The
postoperative course of Case 2 was complicated by a small
pleural effusion. He was discharged on postoperative Day 5.
Discussion
The potential for performing cardiac surgical procedures using minimal access “closed-chest surgery”
became a reality with the introduction of the da Vinci
robotic surgical system (3). In these brief case reports,
we summarize anesthetic and perioperative concerns
and highlight their management as practiced in our
institution.
The patients selected for this procedure were in the
age group 18 – 80 years, had isolated MR without mitral stenosis, with MR, the result of posterior leaflet
pathology. The key issue that the anesthesiologist may
face in using this technique is maintaining stable hemodynamics and oxygenation in a patient with severe
MR (with possible cardiac decompensation) during
both the induction and maintenance of anesthesia as
well as during one-lung ventilation while preparing
the patient to go on CPB for the definitive mitral valve
repair. Further concerns are the need to separate from
CPB by using only single-lung ventilation after a potentially prolonged CPB time with possible pulmonary compromise (4).
One-lung ventilation is necessary because the pericardium is tethered to the chest wall with stay sutures,
and ventilation of the corresponding nondependent
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lung would cause lung laceration by the stay sutures
as the lung inflates. Furthermore, one-lung ventilation
also helps to provide the surgeons a clear view of the
operative field while the patient comes off CPB, because at this point it is imperative to identify and
control any bleeding. To ensure adequate oxygenation
before and immediately after CPB, we use intermittent
insufflation of the nondependent lung, sufficient to
maintain oxygen saturation of 95%–100%, but do not
inflate this lung to the extent that the lung will be
damaged by the stay sutures.
Thus, we believe that lung isolation is best assured
by using a DLT, even though a Univent tube (Fuji
Systems Co., Tokyo, Japan) or temporary isolation of
one lung by using a bronchial blocker would avoid the
need to change to a single-lumen tube at the end of the
operation. This is because neither the Univent tube nor
a bronchial blocker technique allows intermittent nondependent lung inflation to combat desaturation.
Thus, the use of a DLT appears most appropriate in
these patients (5). Nevertheless, replacing the DLT
with a single-lumen tube at the end of surgery to
facilitate intensive care unit management may be complicated by the profound facial and upper-airway
edema that is often present. We facilitated the endotracheal tube changeover with the use of a Cook catheter. However, occasionally we do leave the DLT in
place, especially when we anticipate that the patient
will be extubated very early in the intensive care unit.
TEE is crucial for the continuous monitoring of cardiac function and is key to proper placement of the
femoral (IVC) and internal jugular (SVC) cannulae. At
a later stage, the TEE is important for the insertion of
the coronary sinus catheter, because the surgeon is
blind to the continued appropriate positioning of
these cannulae because of the limited surgical access.
Finally, it is essential to assess the quality of the mitral
valve repair and to exclude significant repair-induced
mitral stenosis or the development of SAM of the
mitral valve. In these patients, a pulmonary artery
catheter is placed via the left internal jugular vein,
because the right internal jugular vein is needed for
placement of the Biomedicus SVC cannula.
The 17F Biomedicus arterial cannula is placed into
the SVC via the right internal jugular vein by the
Seldinger technique with TEE guidance. The SVC cannula is required to allow for venous drainage from the
upper part of the body and stents the SVC during
manipulation of the heart. The cannula used is preheparinized with 5000 U of heparin and a continuous
flushing device attached to infuse a heparin saline
infusion (2 U/mL) to avoid clot formation in the cannula. During CPB, the central venous pressure should
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2003;96:7–10
be read from the sheath catheter rather than intracardiac (central venous pressure) to allow for early detection of venous congestion in the upper part of the
body.
Patient positioning involves a modified left lateral
decubitus position, with the lower part of the body flat
and the right arm elevated on a padded support bar;
hence, left radial arterial monitoring appears appropriate. Maintenance of anesthesia for these procedures
is guided by the fact that early extubation after these
nonsternotomy procedures would appear to be desirable and readily achievable with minor tailoring of the
traditional cardiac anesthetic (6,7). Maintenance usually consists of isoflurane or another inhaled drug in a
small dose, a nondepolarizing muscle relaxant of moderate duration, and anesthesia adjuncts as needed.
In summary, we have presented two patients who
had successful mitral valve repair with use of robotic
surgical techniques. Anesthetic management of these
patients may be challenging because these patients
may be hemodynamically compromised yet require
prolonged periods of one-lung ventilation before and
when coming off CPB. Further, percutaneous SVC
cannulation for venous drainage to achieve CPB is
performed (by the anesthesiologist) and TEE used to
ascertain appropriate placement of this and other cannulae for CPB. TEE evaluation of the mitral valve
repair, as well as for the absence of significant stenosis
and SAM, is crucial during this procedure. Finally, a
safe technique for exchanging the DLT required during the operation with a single-lumen tube for postoperative ventilation must be used because of the
significant facial edema associated with this surgical
technique.
References
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2. Vanermen H, Wellens F, De Geest R, et al. Video-assisted PortAccess mitral valve surgery: from debut to routine surgery. Semin Thorac Cardiovasc Surg 1999;11:223– 4.
3. Kappert U, Schneider J, Cichon R, et al. Closed chest totally
endoscopic coronary artery bypass surgery: fantasy or reality?
Curr Cardiol Rep 2000;2:558 – 63.
4. Shapiro BA, Lichtenthal PR. Postoperative respiratory management. In: Kaplan JA, Reich DL, Konstadt SN, eds. Cardiac anesthesia. 4th ed. Philadelphia: Saunders, 1999:1215–32.
5. Larsen CE, Gasior TA. A device for endobronchial blocker placement during one-lung anesthesia. Anesth Analg 1990;71:311–2.
6. Hall RI. Anesthesia for coronary artery surgery. Can J Anaesth
1993;40:1178 –94.
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