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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 Continuing Education Contact Hours Approvals indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. Event: #16535 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme. The contact hours for this article expire October 31, 2019. Pricing is subject to change. 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. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. 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 potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2016.07.013 ª AORN, Inc, 2016 www.aornjournal.org 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 http://dx.doi.org/10.1016/j.aorn.2016.07.013 ª AORN, Inc, 2016 294 j AORN Journal www.aornjournal.org October 2016, Vol. 104, No. 4 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 www.aornjournal.org 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 McCarthydGuy 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). 296 j AORN Journal October 2016, Vol. 104, No. 4 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 www.aornjournal.org October 2016, Vol. 104, No. 4 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. print & web 4C=FPO 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 www.aornjournal.org 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, AORN Journal j 297 McCarthydGuy 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, 298 j AORN Journal print & web 4C=FPO 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 www.aornjournal.org Endoscopic Mitral Valve Surgery print & web 4C=FPO October 2016, Vol. 104, No. 4 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 www.aornjournal.org 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 AORN Journal j 299 McCarthydGuy October 2016, Vol. 104, No. 4 print & web 4C=FPO 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 300 j AORN Journal 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 www.aornjournal.org October 2016, Vol. 104, No. 4 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 www.aornjournal.org print & web 4C=FPO 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 AORN Journal j 301 McCarthydGuy 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 302 j AORN Journal print & web 4C=FPO 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. www.aornjournal.org 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. www.aornjournal.org Endoscopic Mitral Valve Surgery 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 www.aornjournal.org 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. www.aornjournal.org 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 306 j AORN Journal www.aornjournal.org