Combining robotic mitral valve repair and microwave atrial fibrillation ablation: techniques and initial results.

BACKGROUND: Left atrial microwave ablation for atrial fibrillation has become popular for isolating autonomous atrial foci. Previously, mitral valve repairs (MVP) with atrial fibrillation ablation have been performed through sternotomy. We present a technique that combines robotic MVP with left atrial fibrillation ablation. METHODS: Through a 4-cm right minithoracotomy and using cardiopulmonary bypass, the transverse and oblique sinuses are accessed. A Flex-10 microwave catheter is passed around the pulmonary veins, and after weaning from cardiopulmonary bypass, peripulmonary vein microwave ablations are performed. After cardioplegic arrest, the da Vinci system is used to manipulate the catheter to create endocardial lesions around the left atrial appendage. Another endocardial lesion is made connecting the pulmonary venous line with the mitral annulus near P3. The left atrial appendage is closed, and the MVP performed robotically. Data are expressed as mean +/- standard deviation. RESULTS: Sixteen patients underwent this combined procedure, with 80% returning to a normal sinus rhythm at 6 weeks and 73% remaining in normal sinus rhythm at 6 months. Only 1 patient was in atrial fibrillation at 6 months. The ablation procedure added 42 +/- 16.1 minutes to a robotic MVP. The average length of hospital stay was 6.3 +/- 2.2 days, 1.3 days longer than the mean of the prior 50 consecutive robotic MVP patients without a concomitant ablation. CONCLUSIONS: Robotic microwave ablation during robotic MVP is a safe, effective way to resolve atrial fibrillation. These methods offer a promising prelude to the combined totally endoscopic treatment of atrial arrhythmias and mitral insufficiency.

Should a video-assisted mini-thoracotomy be the approach of choice for reoperative mitral valve surgery?

BACKGROUND AND AIM OF THE STUDY: Reoperative cardiac surgery carries a greater morbidity and mortality than primary cardiac surgery. The study aim was to compare perioperative outcomes in patients undergoing mitral valve surgery who had already undergone a previous cardiac operation using either a minimally invasive video-assisted (MIVA) mini-thoracotomy or a redo median sternotomy (MS). METHODS: Between January 1996 and June 2003, 71 consecutive patients with prior cardiac surgery underwent mitral valve surgery. Of these operations, 38 were MIVA procedures, performed through a 5-cm right anterior thoracotomy using voice-activated robotic camera control (AESOP 3000). Outcome was compared with results in 33 consecutive patients who underwent a standard redo MS. RESULTS: The MIVA and redo MS cohorts differed in preoperative ejection fraction (46 +/- 2% versus 55 +/- 2%; p = 0.004) and percentage of urgent operations (33 versus 8.3%; p = 0.01). Operative mortality was similar in both groups (5.7% and 5.9% respectively; p = 0.976), as were cardiopulmonary bypass, operating room, and ICU times. Postoperative intubation time was shorter in the MIVA group than in the redo MS group (29.1 +/- 8.9 versus 38.0 +/- 9.9 h; p = 0.008), and blood transfusion requirements were also reduced (2.9 +/- 0.6 versus 5.5 +/- 0.7 units; p = 0.001) respectively. Length of hospital stay was significantly less in the MIVA group (7.1 +/- 1.3 versus 11.2 +/- 1.1 days; p = 0.001). CONCLUSION: Minimally invasive video-assisted mitral valve operations may be performed safely and efficiently in patients with prior cardiac surgery. Demonstrated advantages include fewer red blood cell and blood product transfusions, as well as decreased intubation time and length of hospital stay.