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CONTINUING EDUCATION
Totally Endoscopic Robotic Mitral
Valve Surgery 2.3
www.aornjournal.org/content/cme
JAMES R. McCARTHY, RN, AS, CNOR, CRNFA; T. SLOANE GUY, MD, MBA
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Purpose/Goal
To provide the learner with knowledge of best practices related
to totally endoscopic robotic mitral valve surgery.
Objectives
1.
2.
3.
4.
Describe the anatomy of the mitral valve.
Discuss the consequences of mitral valve dysfunction.
Discuss how mitral valve pathology is diagnosed.
Describe the types of mitral valve surgery.
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Conflict-of-Interest Disclosures
James R. McCarthy, RN, AS, CNOR, CRNFA, has no
declared affiliation that could be perceived as posing a
potential conflict of interest in the publication of this article.
As a consultant for Medtronics and Edwards Lifesciences
Corporation and a grant recipient from Biomet, Inc, T. Sloane
Guy, MD, MBA, has declared affiliations that could be
perceived as posing potential conflicts of interest in the publication of this article.
The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Starbuck Pashley and Ms Bakewell
have no declared affiliations that could be perceived as posing
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mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2016.07.013
ª AORN, Inc, 2016
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AORN Journal j 293
Totally Endoscopic Robotic Mitral
Valve Surgery 2.3
www.aornjournal.org/content/cme
JAMES R. McCARTHY, RN, AS, CNOR, CRNFA; T. SLOANE GUY, MD, MBA
ABSTRACT
Mitral valve dysfunction can seriously impair patients’ lives and may require valve repair or replacement. Surgery can be performed using techniques including sternotomy; right thoracotomy with or
without robot assistance; and the totally endoscopic robotic technique, which requires percutaneous
techniques, femoral cannulation, and endovascular aortic cross-clamping. The totally endoscopic
robotic technique has been facilitated by minimally invasive surgical techniques, the evolution of
endoscopic techniques, and the development of surgical robots. These advances have enhanced the
view of the surgical field and provide better exposure for the repair or replacement of the mitral valve
and subvalvular apparatus. This article describes the totally endoscopic robotic approach to mitral
valve surgery as performed at Temple University Hospital, Philadelphia, Pennsylvania. AORN J 104
(October 2016) 293-306. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.07.013
Key words: endoscopic mitral valve, robotic mitral surgery, mitral repair, endoclamp.
E
ver since Carpentier1,2 described the surgical treatment of mitral valve prolapse in 1978 and the
treatment of different types of mitral valve disease in
1983, mitral valve repair has been a primary goal for cardiac
surgeons. Successful mitral valve repair can produce long-term
relief of symptoms of congestive heart failure, improve quality
of life, and help patients avoid the chronic use of heart failure
and anticoagulation medications.3,4 Historically, surgeons
have performed mitral valve surgery (MVS) through sternotomy, which remains the most common surgical approach
(ie, 84.6% in 2010).5 However, the development of minimally
invasive techniques and instruments has allowed cardiac
surgeons to repair or replace mitral valves using less invasive
techniques; these include right thoracotomy incisions with
direct cannulation of the aorta and heart or a minithoracotomy with remote or direct cannulation and totally
endoscopic robotic MVS with remote cannulation of the
femoral artery and vein for cardiopulmonary bypass. These
techniques avoid the need for sternotomy and reduce the
development of mediastinal adhesions, which pose significant
risk of injury to the heart or aorta should a sternotomy be
required in the future.6-8 The surgical robot has expanded the
application of minimally invasive techniques to many procedures (eg, MVS, pelvic surgery) by providing minimal incisions and hand-like instruments with multiple degrees of
motion (Table 1).
Totally endoscopic robotic MVS is a more advanced surgical
technique than robot-assisted MVS and can be performed for
any mitral pathology that historically has been treated using an
open technique. The endoscope used for robotic MVS is
designed to provide the surgeon with three-dimensional vision
via two lenses and provides the same depth perception as
native binocular vision, thus improving the view of the surgical
field. This enhanced view of the surgical field, along with the
use of robotic instrumentation, has improved morbidity,
reduced hospital stays, helped patients return to normal
activities more quickly, and may be superior for minimally
invasive access because of the right lateral thoracic
approach.6,9-12
MITRAL VALVE ANATOMY
The mitral valve is a complex structure with two asymmetric
leaflets that permit blood flow from the left atrium to the left
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ª AORN, Inc, 2016
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Endoscopic Mitral Valve Surgery
Table 1. History of Robotic Mitral Valve Surgery
Year
Event
1
1998
Carpentier performs the first mitral repair using
the da Vinci robotic system from Intuitive
Surgical, Inc.
1998
Mohr2 performs 5 endoscopic mitral valve
surgeries and 1 coronary revascularization
procedure.
2000
Chitwood3 performs the first robotic mitral
surgery in North America.
2002
The US Food and Drug Administration approves
the da Vinci surgical robot for mitral surgery
in the United States.4,5
Editor’s note: da Vinci is a trademark of Intuitive Surgical, Inc,
Sunnyvale, CA.
References
1. Carpentier A, Loulmet D, Aup
ecle B, et al. Computer assisted
open heart surgery. First case operated on with success [in
French]. C R Acad Sci III. 1998;321(5):437-442.
2. Mohr FW, Falk V, Diegeler A, Autschback R. Computerenhanced coronary artery bypass surgery. J Thorac
Cardiovasc Surg. 1999;117(6):1212-1214.
3. Chitwood WR Jr, Nifong LW, Elbeery JE, et al. Robotic mitral
valve repair: trapezoidal resection and prosthetic annuloplasty
with the da Vinci surgical system. J Thorac Cardiovasc Surg.
2000;120(6):1171-1172.
4. Nifong LW, Chu VF, Bailey BM, et al. Robotic mitral valve repair:
experience with the da Vinci system. Ann Thorac Surg.
2003;75(2):438-443.
5. Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve
surgery: a United States multicenter trial. J Thorac Cardiovasc
Surg. 2005;129(6):1395-1404.
ventricle. At their free edges, the leaflets are attached to the left
endoventricular walls by chordae tendineae and papillary
muscles. During diastole, the ventricle is relaxed and the
leaflets are under no tension, allowing free flow of atrial blood
into the left ventricle; the volume of blood increases after the
atrium contracts just before ventricular contraction. During
systole, the left and right ventricles contract. The blood volume is forced through the aortic valve by the left ventricle and
simultaneously through the pulmonary valve by the right
ventricle. During left ventricular contraction, the papillary
muscles contract, tightening the chordae tendineae and pulling
the leaflets to the middle of the annulus. This produces
coaptation (ie, the drawing together of the separated tissue of
the leaflets) and results in unidirectional blood flow through
the aortic valve.13 Depending on the type of mitral valve
dysfunction, the patient may experience mitral regurgitation,
mitral stenosis, or a combination of both. Physicians can
manage the early stages of mitral valve dysfunction medically
until it results in shortness of breath or symptomatic
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congestive heart failure that affects daily activities. When this
occurs, surgical treatment may be required.
SURGICAL REPAIR OR REPLACEMENT
Mitral valve surgical repair is based on the type of valvular
deformity described by Carpentier1 (ie, types I through IIIa
and b; [Table 2]). Correct assessment of disease type is crucial
to obtaining the best surgical outcome. A type I defect is a
result of annular dilation. It also may be caused by endocarditis or trauma, which almost always requires replacement.1
If the mitral defect is a result of annular dilation from cardiomyopathy, a ring annuloplasty generally provides a good
result.1 Type II defects result from mitral regurgitation
with leaflet prolapse and can present with a variety of leaflet
anomalies, ruptured chordae tendineae with or without
annular dilation, or any combination of these. Repair may
require an annular ring, anterior or posterior leaflet resection,
or any combination of these techniques.1 Type III defects
include the less severe type IIIa, which may be repaired if
no significant subvalvular changes are present that prevent
restoration of leaflet function.1,14 Severe type IIIa, such as
rheumatic stenosis with leaflet restriction, is most often
corrected by valve replacement. Mitral annular calcification
increases the risk of replacement or repair, which can lead to
repair failure.15 Type IIIb pathology, which is commonly
associated with coronary artery disease, is usually repaired with
a ring annuloplasty and may be performed in combination
with coronary artery bypass grafting via a traditional sternotomy approach.1
1
Table 2. Carpentier’s Surgical Classification of
Mitral Valve Pathology
Classification
Description
Type I
Normal leaflet motion
Annular dilation (eg, cardiomyopathy)
Leaflet perforation (ie, trauma, endocarditis)
Type II
Leaflet prolapse (eg, myxomatous, Barlow’s
syndrome)
Chordal rupture, elongation
Papillary muscle rupture, elongation
Type III
Type IIIa
o Restricted leaflet motion during diastole
and systole (eg, rheumatic valve disease)
Type IIIb
o Ischemic mitral regurgitation during
systole only
Reference
1. Carpentier A. Cardiac valve surgerydthe “French Correction”.
J Thorac Cardiovasc Surg. 1983;86(3):323-337.
AORN Journal j 295
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To assess valve and heart function and determine the type of
mitral valve repair needed, the cardiac surgeon requires
the following:
a transthoracic echocardiogram or transesophageal echocardiogram (TEE),
right and left heart catheterization,
a comprehensive history and physical examination,
a functional assessment of the valve leaflets and subvalvular
components, and
an evaluation of the severity of the mitral regurgitation.16,17
A TEE is the most reliable diagnostic procedure for cardiac
assessment, but it is invasive and requires sedation to enable
patients to tolerate placement of the echo probe. If preliminary
studies have provided adequate findings for a diagnosis, the
surgeon may delay TEE until after induction of general
anesthesia for surgery.18
The transthoracic echocardiogram and review of TEE studies
are only part of the overall assessment for endoscopic robotic
mitral surgery. A preoperative ultrasound assessment of the
carotid arteries is required to assess any increased risk of cerebrovascular accident during surgery or the need for vascular
intervention, such as endarterectomy. Computed tomography
with contrast to evaluate vessels from the neck to the femoral
vessels is vital to determine the ability to use a remote cannulation technique.19 Other studies typical of most cardiac
surgeries include
a complete metabolic panel,
pulmonary function tests,
chest x-rays, and
a coronary angiogram.
MITRAL VALVE SURGICAL PREPARATION
Most patients undergoing MVS can be admitted the day of
surgery. However, patients who experience worsening of
symptoms as a result of heart failure or have developed acute
heart failure from endocarditis or a myocardial infarction are at
higher risk and may not qualify for same-day admissions.
In the preoperative area, the anesthesia professional and
members of the nursing team introduce themselves to the
patient and perform their preoperative assessments. If there are
no unexpected findings (eg, a new cough or fever), the team
prepares the patient for surgery, confirming the patient’s
identity, procedure, operative site, and consent. The RN
circulator performs a thorough nursing assessment and
provides any recommended comfort or safety measures
(eg, preoperative warming, special positioning requirements).
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Successful totally endoscopic robotic MVS requires a variety of
invasive monitoring methods. The anesthesia team uses invasive and noninvasive monitoring methods, including inserting
large-bore peripheral IV lines and bilateral brachial arterial
lines and initiating electrocardiography, pulse oximetry, and
TEE monitoring. Bilateral brachial arterial lines are required to
monitor the position of the balloon endoclamp (ie, an endovascular cross-clamp) used after the heart is arrested during
cardiopulmonary bypass. It is crucial for the surgical team to
detect any migration of the balloon into the aortic arch, where
it can occlude the brachiocephalic and left carotid arteries,
resulting in obstructed cerebral flow and cerebrovascular
accident.20,21
While the anesthesia team places the lines, the nursing team
prepares the robot, robotic instrumentation, and specialty
supplies required by the anesthesia and surgical teams. Room
setup includes opening supplies and instruments; preparing,
draping, and covering the robotic instrument cart; and having
the supplies and instruments available for sternotomy if
needed. The RN circulator and scrub person are responsible
for preparing the robotic endoscope. Because the robot has a
relatively large footprint and is not part of the surgical field
during the initial phases of the procedure, the scrub person
drapes the robot, contracts the arms, and covers the draped
robot with sterile drapes. This helps to prevent accidental
contamination and allows the RN circulator to remove the
cover without contaminating the draped robot when it is
needed at the surgical field.
The scrub person prepares an anesthesia procedure table,
which contains the following items:
a percutaneous catheter to be inserted into the coronary
sinus,
a pulmonary artery catheter as a vent to keep the heart
decompressed, and
a superior vena cava angiocatheter for cardiopulmonary
bypass cannulation.
The coronary sinus catheter (Figure 1a) is used to deliver
cardioplegia to arrest the heart and limit oxygen demand
during the procedure. This catheter is only required when
more than mild aortic insufficiency is diagnosed by echocardiogram that prevents delivery of antegrade cardioplegia via
the coronary arteries.
The pulmonary artery venting catheter (Figure 1b) is used to
collect any pulmonary and noncoronary blood flow that may
obscure the minimally invasive surgical field or prevent
warmer systemic blood from collecting in the heart. The third
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Endoscopic Mitral Valve Surgery
properly interfaced. This requires ensuring that the fiber-optic
cables, video tower, robot, and control (and observer console,
if used) are properly connected. If these cables are not integrated into the OR suite, the team should position them so
they do not pose a risk to staff members and are not in
jeopardy of being disrupted.
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The surgical team must interface the hemodynamic and TEE
monitoring feedback into the robot control console to ensure
the surgeon can see the surgical field and patient monitoring
signals at the control console. After positioning the robot,
video cart, and OR bed, the anesthesia team often has a
limited view of the surgical field. The RNFA can interface an
additional monitor to provide a view of the surgical field for
the anesthesia team as needed.
Figure 1. Percutaneous pulmonary artery venting
catheter (white cap) (a), percutaneous coronary sinus
catheter (yellow cap) (b), and the angiocatheter for
cannulation of the superior vena cava (c).
percutaneous line inserted by the anesthesia professional
(Figure 1c) provides access for the surgeon to cannulate the
superior vena cava for cardiopulmonary bypass.
Preoperative Duties of the RN First
Assistant
The RN first assistant (RNFA) serves as the surgical assistant
and collaborates with the surgeon to develop and convey the
surgical plan to the surgical team. While the nursing and
anesthesia teams are conducting their preoperative preparations,
the RNFA ensures that the OR bed is a correctly positioned
sliding bed that supports fluoroscopic line placement and is in
a position that facilitates the robot docking and deployment,
and checks that positioning supplies are available. The RNFA
also answers preoperative questions that staff members may
have about the procedure, instrumentation, and surgical plan.
Proper bed and robot location and orientation and patient
positioning related to static room landmarks that are consistent with final patient positioning require preliminary preparation. Identifying bed and robot position provides a guide for
setup and eliminates unnecessary robotic manipulation to
engage the surgical field. The correct positioning and docking
location allows the surgeon and staff members to drive and
dock the robot without difficulty.
Although not required, it is prudent for the RNFA to perform
a video and robot check and understand the relationships
between the robot, video camera, and patient monitoring
equipment. Before the patient’s arrival in the OR, the RNFA
should ensure that the robot and all its digital signals are
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Patient Preparation
After preliminary robot and room preparation, placement of
arterial lines, and patient transport to the OR suite, the entire
surgical team, with patient participation, performs a time out
to identify the patient and confirm the planned surgical
procedure. The surgical team safely secures the patient and
connects the patient monitoring equipment, including the
transdermal defibrillator and pacing pads. In addition, the RN
circulator or RNFA applies a deep vein thrombosis prophylaxis
device to the patient’s lower legs and makes the patient as
comfortable as possible.
The anesthesia professional induces general endotracheal
anesthesia and prepares for providing single-lung ventilation
while endoscopic surgery is performed through the right
thorax. This is achieved by placing a right bronchial blocker
(ie, a semirigid balloon catheter) using video-assisted flexible
bronchoscopy and positioning the bronchial blocker catheter
into the patient’s right main stem bronchus. This isolates the
right lung from ventilation during port placement and robotic
exposure of the pericardium.20,21 During this period, the RN
circulator and scrub person complete back table preparation;
count instruments, equipment, and disposables; and prepare
for an electively or urgently aborted robotic approach.
Vessel Preparation for Cardiopulmonary
Bypass
After the patient’s airway is secured, the team places the
patient in the Trendelenburg position to produce venous
distention of the neck veins. Using sterile techniques and
ultrasound guidance, the anesthesia professional
1.
uses a small-bore access needle to enter the right internal
jugular vein,
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2.
3.
4.
5.
October 2016, Vol. 104, No. 4
introduces a guidewire through the access needle,
removes the needle,
inserts a specialized catheter over the guidewire, and
threads the catheter to the desired position (ie, the
Seldinger technique).
He or she places three wires into the internal jugular and
threads them into the superior vena cava. He or she uses these
wires for placement of the coronary sinus and pulmonary
artery venting catheters and an angiocatheter for superior vena
cava cannulation for cardiopulmonary bypass, which occurs
preoperatively.
Remote cannulation for robotic surgery (Figure 2) requires a
specialized arterial cannula with a side port for introduction of
the balloon endoclamp; the cannula size used is based on the
patient’s body surface area and femoral artery diameter.
The endoclamp is a specialized device with a large balloon near
the end of the catheter for aortic occlusion. It also has a lumen
that extends to the tip of the catheter proximal to the balloon
to deliver antegrade cardioplegia through the coronary arteries
and is used after cardiac arrest to suction blood from the aorta
and heart during aortic occlusion. Another lumen extends into
the ascending aorta distal to the balloon and is used to monitor
blood pressure and cardiopulmonary bypass status.
The RNFA assesses and prepares the patient for positioning
and cannulation. He or she performs an initial ultrasound
examination of the right and left femoral vessels in preparation
for cannulation and compares the findings with computed
tomographic angiography findings to determine the size and
location of the common femoral artery and femoral vein. The
team positions the patient with the right thorax slightly
elevated and the pelvis rotated slightly to the right to
approximate a supine position for femoral exposure. The right
femoral vessels are preferred for cannulation. This slightly
lateral position does not preclude the use of the left common
femoral artery and femoral vein for cannulation if there is a
contraindication to cannulating the right side (eg, the patient
is post right femoral endarterectomy). After completion of the
ultrasound and confirmation of the planned cannulation sites,
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Endoscopic mitral surgery requires several steps and preparation for bypass and the surgery. Because bypass during surgery
is achieved through cannulation sites remote to the surgical
site, the bypass lines require unique preparation and positioning in a separate procedural step. The anesthesia professional uses percutaneous internal jugular wires for placement
of the coronary sinus and pulmonary artery venting catheters
and an angiocatheter for superior vena cava cannulation for
cardiopulmonary bypass, which occurs preoperatively.
Figure 2. Percutaneous coronary sinus catheter (a),
percutaneous pulmonary artery venting catheter (b),
endoballoon with antegrade coronary and aortic
monitoring lumens (c), working port tissue retractor (d),
femoral artery and vein cannulation (e). Reprinted with
permission from Edwards Lifesciences Corporation,
Irvine, CA.
the RNFA inserts a urinary drainage catheter with a thermocouple to measure the patient’s core temperature.
Although cerebral oximetry monitoring has not yet become a
standard of care for cardiac surgery, it is increasingly recognized
as an additional, noninvasive monitoring technique for
improving cerebral outcomes in cardiac surgery and is a standard of care at our institution for robotic cardiac surgery.22 We
have used this technique to monitor for lower leg ischemia
(eg, as a result of femoral cannulation) by placing oximetry pads
on the muscular portion of the patient’s calves, under the deep
vein thrombosis prophylaxis device, and attaching them to each
leg. After the clinician ensures that the monitoring system is
showing accurate laterality and adequate signals, reinforcing
tape should be applied to reduce the risk of a lost signal.
Final Patient Positioning
After the anesthesia team has completed and confirmed the
position of the percutaneous internal jugular catheters, and
before final positioning for surgery, the surgeon marks a
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Figure 3. Final patient and OR bed position.
sternal incision line for a conversion to sternotomy should
sternotomy be required as a result of pleural adhesions or
percutaneous injury to the heart from anesthesia lines. If the
patient is female, the surgeon retracts the right breast superiorly and marks a high right inframammary crease to avoid
injury to the breast.
The RNFA or RN circulator attaches a thoracic arm support
to the OR bed rail at the patient’s head and extends the
support caudally, securing it in a neutral position. He or she
assists the team with moving the patient to the right edge of
the OR bed so the patient’s right arm is past the border of the
bed; the movement is performed in conjunction with the
anesthesia professional, who protects the patient’s head, neck,
and IV lines during the positioning.
The team then
rolls the patient to the left,
elevates the right chest and hips,
places a gel roll under the thorax,
places the patient’s right arm on the thoracic arm support in
a position level with the OR bed to provide posterior
extension of the shoulder, and
rotates the hips slightly to approximate a supine position.
These positioning techniques expose the anterior and midaxillary lines at the level of thoracic interspace 4 to provide
access for the left robotic arm. The team secures the patient’s
right arm safely in the arm support, avoiding dampening of the
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arterial trace of the brachial artery catheter, and tucks and
secures the left arm at the patient’s side. The team rotates the
patient’s pelvis toward a neutral line for better femoral site
exposure and supports the patient’s legs in a frog leg position
to facilitate anatomic positioning and femoral exposure. The
RNFA applies a forced-air warming blanket and ensures the
best surface area coverage for facilitating temperature management. The team slides the bed in a caudal direction until
the patient’s nipple line is aligned with the center post of the
robot for robot docking (Figure 3). Finally, the RN circulator
preps the patient.
THE SURGICAL PROCEDURE
After draping the patient from the chin to the knees, including
the chest, lower neck, and bilateral groin areas, the surgeon
places an iodine-impregnated adhesive drape on the incision
site before the final layer of cardiovascular drapes is placed.
The scrub person delivers the cardiopulmonary bypass circuit
to the surgical field, and the RN circulator positions the video
tower. The scrub team positions the cardiopulmonary bypass
arterial and venous lines and attaches them to the patient
drapes in preparation for cannulation; positioning these lines
also includes delivering tubing to the anesthesia professionals
for the coronary sinus and pulmonary artery vent catheters and
for monitoring the central aortic pressure.
Having assessed the femoral vessels by ultrasound and marked
the general location of the femoral pulse, the surgeon or
RNFA dissects and exposes the proximal and distal common
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be present, he or she inserts a 15-mm working port first if
planning a repair or a 30-mm working port if mitral replacement is required. The surgeon attaches the carbon dioxide
(CO2) insufflator to the endoscope port and infuses it at 5 L
per minute at a pressure of 8 mm Hg. This encourages the
diaphragm to move caudally and presses the deflated lung
posteriorly out of the visual and operative field.
Figure 4. Final endoscopic port placement: right and
left arm ports (blue caps), telescope port (white cap),
15-mm metal working port, angiocatheters for exposure retraction suture (below right arm and working
ports), and atrial retractor port (anterior chest wall).
femoral artery and femoral vein, secures them with vascular
tape, and applies a purse-string suture to the femoral vein,
securing it with a Rummel tourniquet. At this point, the
anesthesia professional isolates the patient’s right lung and
begins left single-lung ventilation.
Although femoral dissection and cannulation are less invasive
with lower morbidity than sternotomy and central cannulation, they are not without risks. The most serious complications from retrograde aortic perfusion are stroke and aortic
dissection, which have been reported to occur in 0.3% of
patients.15,23 Leg wound infection rates have been reported to
occur in 0.4% of patients.23 The most commonly reported
complication is groin lymphocele, occurring in as many as
4.6% of patients.15 Although not life threatening, lymphocele
can be chronic and adversely affect the patient’s quality of life.
Surgical Port Placement
To provide adequate exposure for operating instrumentation
and an endoscopic view of the surgical field, five endoscopic
ports and three angiocatheters are required. The surgeon uses
one 12-mm port for the endoscope,
two 8-mm ports for the right and left robotic arms,
one 8-mm port for the atrial retractor, and
three angiocatheters for suture retraction (Figure 4).24
The surgeon first places the endoscope port in the fourth
intercostal space. If the patient has previously undergone right
thoracic surgery, or the surgeon believes lung adhesions may
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Next, the surgeon inserts the 8-mm atrial retractor port into the
patient’s anterior left chest wall using direct endoscopic vision.
He or she determines the precise location for insertion using the
orientation of the patient’s atrium and diaphragm and inserts
the next 8-mm ports for the right robotic arm, one intercostal
space inferior to the working port, along the same anatomic
line. The surgeon then inserts three angiocathetersdone just
below the right arm port and two in the posterior pericardiotomy margindand uses them to place a suture in the
diaphragm one rib space below the right arm port. The surgeon
inserts a final angiocatheter just below the working port. He or
she inserts the left arm port one rib space superior to the
working port along the same anatomic line. The CO2 insufflation cannula can now be changed from the endoscope cannula to the left arm port, with the working port left open to
prevent excessive intrathoracic pressure, which could lead to
tension pneumothorax. After successful insertion of all ports,
the anesthesia professional administers IV heparin in a weightcalculated dose to produce an actuated coagulation time of
more than 480 seconds to prevent blood clotting and enable
safe cannulation and initiation of cardiopulmonary bypass.
Cannulation, Cardiopulmonary Bypass,
and Cardiac Arrest
The totally endoscopic approach requires remote cannulation
for cardiopulmonary bypass and is routinely performed by the
surgeon via an incision and dissection of the right femoral vein
and artery and percutaneous cannulation of the right superior
vena cava. This procedure involves specially designed cannulae
that require specific training to insert.
After exposure and isolation of the femoral vessels, the surgeon
ensures that the anticoagulation levels are adequate and
prepares to insert the inferior vena cava cannulae. He or she
inserts the inferior vena cava cannula first via the femoral vein,
estimating the length of the guidewire and cannula from the
angle of Louis (ie, where the manubrium meets the body of
the sternum) to the exposed femoral vein. Under TEE guidance using the Seldinger technique, the surgeon watches as the
wire passes from the inferior vena cava into the superior vena
cava. The surgeon serially enlarges the femoral venotomy to
the appropriate cannula size with dilators and inserts the
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Endoscopic Mitral Valve Surgery
The surgeon places a suture with an attached pledget in the
proximal segment of the exposed common femoral artery and
attaches a Rummel tourniquet using the Seldinger technique
and TEE to see its position in the descending thoracic aorta.
The surgeon serially dilates the arteriotomy to the size of the
dual-port arterial cannula and then inserts and secures the
cannula. The surgeon and perfusionist coordinate connection
of the cannula to the arterial arm of the cardiopulmonary
bypass circuit to evacuate air from the perfusion circuit. The
surgeon secures the cannula with a silk tie stitched to the skin.
The distal perfusion catheter is now connected to the arterial
perfusion catheter for distal limb perfusion during cardiopulmonary bypass. As a prophylactic measure to prevent lower
limb ischemia secondary to large arterial cannulation of the
common femoral artery, our cardiac team places a distal
perfusion catheter to shunt blood flow from the arterial
cannula to the femoral artery distal to the arterial bypass
cannula to prevent leg ischemia. We believe the minimal risk
of the additional cannula inserted under direct vision using the
Seldinger technique significantly outweighs the risk of limb
ischemia or limb loss.
After purging air from the cardiopulmonary bypass cannulae,
the surgeon prepares to insert and position the endovascular
occlusion device by inserting a long guidewire through the side
port of the arterial cannula and positioning it in the descending
thoracic aorta using TEE guidance, advancing the endoclamp
under echo guidance to a final position in the ascending aorta.
The placement and positioning of the endoballoon is considered a crucial step in the preparation for robotic MVS, and the
surgeon must ensure that the guidewire does not perforate the
aortic valve or left ventricle during catheter endoballoon
advancement. The position of the endoballoon must be high
enough in the ascending aorta to avoid coronary artery
obstruction, but not so high as to obstruct innominate artery
flow, including that of the right carotid artery.
The final cannulation involves the percutaneous insertion of
the superior vena cava cannula. Using the Seldinger technique,
the surgeon serially dilates the percutaneous venotomy and
inserts a 16-Fr flexible cannula into the superior vena cava,
securing it with a silk purse-string skin suture with a Rummel
tourniquet.
The RN circulator moves the robot to the surgical field for
docking and, if the room is properly prepared, positions the
robot without issue. The surgeon connects the endoscope arm
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superior vena cava cannula with TEE guidance. The surgeon
connects the venous cannula to the venous drainage arm of the
cardiopulmonary bypass circuit and evacuates excess air.
Figure 5. Robot docked for mitral surgery with instruments attached.
to the endoscope port and visually examines the heart and
thorax. With the endoscope attached, the surgeon connects
the retractor arm and right and left robotic arms to the
endoscopic ports, inserts the right and left arm instruments
into the ports, positions the robotic arms under video assistance, and views the heart anatomy (Figure 5).
After all preparatory procedures are completed and adequate
cardiopulmonary bypass is achieved, the surgeon proceeds to
the robot control console. From there, the surgeon takes
control of the robot, leaving the RNFA and scrub person to
manage the surgical field and provide assistance as needed. The
surgeon provides exposure of the left atrium by placing one
percutaneous retraction suture in the diaphragm and two in
the pericardium, which are held taut with extracorporeal
hemostats. The RNFA retrieves the sutures through the
angiocatheters with a specialized percutaneous hook. This
provides exposure from the inferior vena cava to the ascending
aorta. A patient may not tolerate an extended period of singlelung ventilation or the increased thoracic pressure of CO2
insufflation for this phase of the procedure. In this situation,
the surgeon may decide to initiate cardiopulmonary bypass
early and complete the pericardial exposure while the patient is
on the cardiopulmonary bypass pump. This alleviates the need
for ventilation, which allows the lung to deflate and clear the
visual and operative field, and the surgeon can reduce the
infusion of CO2; otherwise, the surgeon initiates cardiopulmonary bypass after completing the atrial exposure.
The surgeon scrubs, gowns, and gloves again and returns to
the surgical field to deploy the endoballoon and achieve cardiac arrest. If cardiopulmonary bypass was not required early
to facilitate access to the heart, the surgeon will direct the
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October 2016, Vol. 104, No. 4
A pressure gradient between brachial lines indicates that the
balloon has migrated into the aortic arch and blood flow to the
brachiocephalic and right carotid arteries and head are being
compromised. This requires the surgeon to quickly advance
the balloon proximally out of the arch until the brachial
pressures equalize.
The surgeon purges the cannula of air and connects it to the
second venous arm for cardiopulmonary bypass. Adequate
flow is verified by the perfusionist. The surgeon inflates the
endoballoon to produce aortic occlusion and delivers cardioplegia to produce cardiac arrest. After cardiac arrest, a vital
component to preventing ischemia and myocardial damage is
keeping the heart cold, which reduces metabolic activity and
oxygen demand, allowing the heart to be arrested for a sustained period. This is accomplished initially with the cold
cardioplegia solution and maintained by keeping noncoronary
and systemic blood out of the heart via the pulmonary vent
catheter and the tip of the endoballoon catheter. If all has
proceeded correctly, after occlusion is achieved, the scrub
person infuses adenosine into the proximal endoclamp port for
coronary infusion to achieve rapid asystole, and then the
perfusionist infuses cardioplegia to maintain arrest.
Mitral Valve Repair or Replacement
After cardiopulmonary bypass and arrest are achieved, the
surgeon returns to the robotic console to open the patient’s left
atrium, evaluate the valve pathology, and begin repair or
replacement of the mitral valve. The surgeon incises the left
atrium below Waterston’s groove anterior to the right pulmonary veins, drains excess blood with extracorporeal suction,
and places a static extracorporeal vent into the left superior
vein to maintain a bloodless surgical field. The surgeon inserts
a left atrial retractor and positions it to provide mitral valve
exposure. Often the surgeon will perform a static test of mitral
function by filling the left ventricle with a laparoscopic suction
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perfusionist to initiate bypass as he or she prepares to rejoin
the surgical field. After the surgeon has measured the
ascending aortic diameter, the scrub person, under the direction of the surgeon, infuses the prescribed volume of heparinized saline into the endoballoon. The surgeon directs the
perfusionist to reduce bypass flow to lower the risk of balloon
migration and injury and ensures proper positioning of the
balloon while observing the TEE images. The RNFA is
responsible for monitoring the bilateral brachial arterial lines
and aortic root pressures. After the arterial blood pressures are
sufficiently reduced to prevent injury to the aortic wall during
inflation of the endoclamp, the surgeon inflates the balloon to
occlude the aorta.
Figure 6. The RN first assistant and scrub person tying
the annuloplasty ring in place while viewing the
surgical field on the video screen (inset).
irrigator and distending the valve leaflets for assessment. This
helps to further identify the valve defects and determine the
most appropriate surgical repair. The selection of mitral valve
repair or replacement depends on the type of valvular defect.
Although an intraoperative TEE is the standard for diagnosing
the type and severity of mitral valve disease, severe regurgitation can mask the specific valve defects. Repair of the mitral
valve is a complex surgical procedure. The variety of testing
studies provide much of the data to develop a surgical plan,
but ultimately the outcome depends on the sound intraoperative judgment and technique of the experienced mitral
surgeon when undertaking a repair.14,25,26
Surgeon and RNFA Collaboration
In our robotic cardiac program, the RNFA has a strong
collaborative relationship with the surgeons who perform
robotic procedures. The RNFA’s responsibilities include
preoperative review of diagnostic studies, which may be performed with the surgeon the day before surgery or the
morning of surgery. During a totally endoscopic procedure,
the RNFA must coordinate his or her activities in conjunction
with the surgeon and the scrub person to effectively conduct
these procedures (Figure 6).
CONCLUSION
Totally endoscopic robotic MVS is a uniquely complex
surgery that requires exceptional focus and coordination
between the anesthesia team, the RN circulator, the surgeon,
the RNFA, and the scrub person. In addition, it requires the
surgeon and team members to have confidence in each other.
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October 2016, Vol. 104, No. 4
It is this trust, confidence, teamwork, and collaboration that
has allowed our program to progress and provide outstanding
patient care and outcomes.
References
1. Carpentier A. Cardiac valve surgerydthe “French Correction”.
J Thorac Cardiovasc Surg. 1983;86(3):323-337.
2. Carpentier A, Relland J, Deloche A, et al. Conservative management of the prolapsed mitral valve. Ann Thorac Surg. 1978;26(4):
294-302.
3. Sheikh AM, Livesey SA. Surgical management of valve disease in
the early 21st century. Clin Med (Lond). 2010;10(2):177-187.
4. Vahanian A, Baumgartner H, Bax J, et al; Task Force on the
Management of Valvular Heart Disease of the European Society of
Cardiology; ESC Committee for Practice Guidelines. Guidelines on
the management of valvular heart disease: The Task Force on the
Management of Valvular Heart Disease of the European Society of
Cardiology. Eur Heart J. 2007;28(2):230-268.
5. Gammie JS, Zhao Y, Peterson ED, O’Brien SM, Rankin JS,
Griffith BP. J. Maxwell Chamberlain Memorial Paper for adult
cardiac surgery. Less-invasive mitral valve operations: trends and
outcomes from the Society of Thoracic Surgeons Adult Cardiac
Surgery Database. Ann Thorac Surg. 2010;90(5):1401-1410.e1.
6. Welp H, Martens S. Minimally invasive mitral valve repair. Curr
Opin Anaesthesiol. 2014;27(1):65-71.
7. Holzhey DM, Shi W, Borger MA, et al. Minimally invasive versus
sternotomy approach for mitral valve surgery in patients greater
than 70 years old: a propensity-matched comparison. Ann Thorac
Surg. 2011;91(2):401-405.
8. Falk V, Cheng DC, Martin J, et al. Minimally invasive versus open
mitral valve surgery: a consensus statement of the International
Society of Minimally Invasive Coronary Surgery (ISMICS) 2010.
Innovations (Phila). 2011;6(2):66-76.
9. Suri RM, Taggarse A, Burkhart HM, et al. Robotic mitral valve
repair for simple and complex degenerative disease: mid-term
clinical and echocardiographic quality outcomes. Circulation.
2015;132(21):1961-1968.
10. Yaffee DW, Loulmet DF, Kelly LA, et al. Can the learning curve of
totally endoscopic robotic mitral valve repair be short-circuited?
Innovations (Phila). 2014;9(1):43-48.
11. Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve
surgery: a United States multicenter trial. J Thorac Cardiovasc
Surg. 2005;129(6):1395-1404.
12. Bush B, Nifong LW, Alwair H, Chitwood WR Jr. Robotic mitral valve
surgerydcurrent status and future directions. Ann Cardiothorac
Surg. 2013;2(6):814-817.
13. McCarthy KP, Ring L, Rana BS. Anatomy of the mitral valve:
understanding the mitral valve complex in mitral regurgitation. Eur
J Echocardiogr. 2010;11(10):i3-i9.
14. Perloff JK, Roberts WC. The mitral apparatus: functional anatomy
of mitral regurgitation. Circulation. 1972;46(2):227-239.
15. Casselman FP, Van Slycke S, Wellens F, et al. Mitral valve surgery
can now routinely be performed endoscopically. Circulation. 2003;
108(suppl 1):II48-II54.
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16. Topilsky Y, Grigioni F, Enriquez-Sarano M. Quantitation of mitral
regurgitation. Semin Thorac Cardiovasc Surg. 2011;23(2):106-114.
17. Joint Task Force on the Management of Valvular Heart Disease of
the European Society of Cardiology (ESC); European Association
for Cardio-Thoracic Surgery (EACTS); Vahanian A, Alfieri O,
Andreotti F, et al. Guidelines on the management of valvular heart
disease (version 2012). Eur Heart J. 2012;33(19):2451-2496.
18. Mahmood F, Matyal R. A quantitative approach to the intraoperative echocardiographic assessment of the mitral valve for
repair. Anesth Analg. 2015;121(1):34-58.
19. Dass C, Simpson SA, Steiner RM, Guy TS. Preprocedural
computed tomography evaluation for minimally invasive mitral
valve surgery: what the surgeon needs to know. J Thorac Imaging.
2015;30(6):386-396.
20. Wang G, Gao C. Robotic cardiac surgery: an anaesthetic
challenge. Postgrad Med J. 2014;90(1066):467-474.
21. Lehr EJ, Rodriguez E, Chitwood WR. Robotic cardiac surgery.
Curr Opin Anaesthesiol. 2011;24(1):77-85.
22. Moerman A, De Hert S. Cerebral oximetry: the standard monitor of
the future? Curr Opin Anaesthesiol. 2015;28(6):703-709.
23. Grossi EA, Galloway AC, LaPietra A, et al. Minimally invasive mitral
valve surgery: a 6-year experience with 714 patients. Ann Thorac
Surg. 2002;74(3):660-664.
24. Maslow AD, Regan MM, Haering JM, Johnson RG, Levine RA.
Echocardiographic predictors of left ventricular outflow tract
obstruction and systolic anterior motion of the mitral valve after
mitral valve reconstruction for myxomatous valve disease. J Am
Coll Cardiol. 1999;34(7):2096-2104.
25. Lillehei CW, Levy MJ, Bonnabeau RC Jr. Mitral valve replacement
with preservation of papillary muscles and chordae tendineae.
J Thorac Cardiovasc Surg. 1964;47:532-543.
26. Lillehei CW. New ideas and their acceptance. As it has related to
preservation of chordae tendineae and certain other discoveries.
J Heart Valve Dis. 1995;4(suppl 2):S106-S114.
James R. McCarthy, RN, AS, CNOR, CRNFA, is an
RNFA in cardiovascular surgery at the Heart and Vascular
Institute, Temple University Hospital, Philadelphia, PA.
Mr McCarthy has no declared affiliation that could be
perceived as posing a potential conflict of interest in the
publication of this article.
T. Sloane Guy, MD, MBA, is an associate professor of
cardiothoracic surgery and director of robotic cardiac
surgery at Weill Cornell School of Medicine/New York
Presbyterian Hospital, New York, NY. As a consultant
for Medtronics and Edwards Lifesciences Corporation
and a grant recipient from Biomet, Inc, Dr Guy has
declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this
article.
AORN Journal j 303
EXAMINATION
Continuing Education:
Totally Endoscopic Robotic
Mitral Valve Surgery 2.3
www.aornjournal.org/content/cme
PURPOSE/GOAL
To provide the learner with knowledge of best practices related to totally endoscopic robotic mitral
valve surgery.
OBJECTIVES
1.
2.
3.
4.
Describe the anatomy of the mitral valve.
Discuss the consequences of mitral valve dysfunction.
Discuss how mitral valve pathology is diagnosed.
Describe the types of mitral valve surgery.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aornjournal.org/content/cme.
QUESTIONS
1. The mitral valve is a complex structure with two asymmetric leaflets that permit blood flow from
a. the right atrium into the left ventricle.
b. the left atrium into the left ventricle.
c. the left atrium into the right ventricle.
d. the right atrium into the right ventricle.
2. At their free edges, the leaflets are attached to the left
endoventricular walls by chordae tendineae and papillary
muscles.
a. true
b. false
3. Left ventricular contraction produces coaptation (ie, the
drawing together of the separated tissue of the leaflets) and
results in ____________ blood flow through the
__________ valve.
a. multidirectional/aortic
b. unidirectional/mitral
c. unidirectional/aortic
d. multidirectional/pulmonary
304 j AORN Journal
4. Depending on the type of mitral valve dysfunction, the
patient may experience mitral
1. flaccidity.
2. regurgitation.
3. stenosis.
4. dissection.
a. 1 and 4
b. 2 and 3
c. 1, 2, and 4
d. 1, 2, 3, and 4
5. Physicians can manage the early stages of mitral valve
dysfunction medically until it results in
1. shortness of breath.
2. symptomatic congestive heart failure.
3. symptoms that affect daily activities.
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
6. Mitral valve pathology is classified as types ___________
through ___________.
a. I/IV
b. I/III
c. I/IIIa and b
d. I/IVa and b
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October 2016, Vol. 104, No. 4
7. The tests the cardiac surgeon performs to assess valve and
heart function and determine the type of mitral valve
repair needed include
1. a transthoracic echocardiogram or transesophageal
echocardiogram.
2. right and left heart catheterization.
3. a comprehensive history and physical examination.
4. a functional assessment of the valve leaflets and
subvalvular components.
5. an evaluation of the severity of the mitral
regurgitation.
6. computed tomography with contrast.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
8. A preoperative ________ is required to assess any
increased risk of cerebrovascular accident during surgery
or the need for vascular intervention, such as
endarterectomy.
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Endoscopic Mitral Valve Surgery
a.
b.
c.
d.
ultrasound assessment of the carotid arteries
transthoracic echocardiogram
cardiac stress test
transesophageal echocardiogram
9. Historically, surgeons have performed mitral valve
surgery through sternotomy.
a. true
b. false
10. The development of minimally invasive techniques and
instruments has allowed cardiac surgeons to repair or
replace mitral valves using more advanced surgical techniques, including
1. right thoracotomy incisions.
2. robotic ports with remote cannulation.
3. mini-thoracotomy with remote or direct cannulation.
4. totally endoscopic robotic mitral valve surgery.
a. 1 and 4
b. 2 and 3
c. 1, 3, and 4
d. 1, 2, 3, and 4
AORN Journal j 305
LEARNER EVALUATION
Continuing Education:
Totally Endoscopic Robotic
Mitral Valve Surgery 2.3
www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and
Learner Evaluation at http://www.aornjournal.org/content/cme.
Rate the items as described below.
8.
Will you change your practice as a result of reading this
article? (If yes, answer question #8A. If no, answer
question #8B.)
8A.
How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement
a policy and procedure.
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change.
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: __________________________________
8B.
If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others about the
purpose of the needed change.
3. I do not have management support to make a
change.
4. Other: __________________________________
9.
Our accrediting body requires that we verify the time
you needed to complete the 2.3 continuing education
contact hour (138-minute) program: _____________
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe the anatomy of the mitral valve.
Low
1.
2.
3.
4.
5.
High
2.
Discuss the consequences of mitral valve dysfunction.
Low
1.
2.
3.
4.
5.
High
3.
Discuss how mitral valve pathology is diagnosed.
Low
1.
2.
3.
4.
5.
High
4.
Describe the types of mitral valve surgery.
Low
1.
2.
3.
4.
5.
High
CONTENT
5.
To what extent did this article increase your knowledge
of the subject matter?
Low
1.
2.
3.
4.
5.
High
6.
To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
7.
Will you be able to use the information from this article
in your work setting?
1.
Yes
2.
No
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