Transcript Totally Endoscopic Robotic Treatment of Hypertrophic Obstructive

TOTALLY ENDOSCOPIC ROBOTIC
TREATMENT OF HYPERTROPHIC
OBSTRUCTIVE CARDIOMYOPATHY
WITH SEPTAL MYOMECTOMY AND
ANTERIOR MITRAL VALVE LEAFLET
AUGMENTATION.
Thomas Kelley, Jr., T. Sloane Guy, Abul Kashem,
Sheela Pai, Yanfu Shao, Yoshiya Toyoda, Mohamad
Alkhouli, James McCarthy, Kaiser Larry R., Shiose
Akira.
Temple University School of Medicine, Philadelphia,
PA, USA,
BACKGROUND
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The common surgical treatment for hypertrophic cariomyopathy causing left
ventricular outflow tract obstruction is a septal myomectomy developed by Morrow
et al or mitral valve replacement.
Current studies have demonstrated that in many cases, septal hypertrophy is not the
sole cause of outflow obstruction, there is also concurrent mitral valve dysfunction.
These two factors create obstruction of the Left Ventricular Outflow Tract (LVOT).
With poor coaptation there can be systolic anterior wall motion causing further
LVOT obstruction along with mitral regurgitation.
The use of leaflet augmentation with myomectomy via a sternotomy was first
demonstrated by Aubert et al.
In this case report we demonstrate the feasibility of combining mitral valve
augmentation and a minimal myomectomy while utilizing the minimally invasive
advantages conferred by the Da Vinci Surgical System.
METHODS
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2 patients with HOCM, SAM and LVOT gradients of greater than 50mm
Hg consented to undergo robotic myomectomy and leaflet augmentation
with the Da Vinci Robotic System.
Ports were placed in the right chest (3 8mm ports, a 15mm working port
and a 12 mm camera port) and bypass initiated through femoral
cannulation and the heart was arrested with an endoclamp catheter.
The anterior leaflet was detached at the base with a knife and a septal
myomectomy performed through the hole created in the anterior mitral
leaflet. A patch of CorMatrix ECM was then sutured into the leaflet hole
to dramatically augment the anterior leaflet to bring it out of the LVOT.
IMAGING
Preoperative TEE
Postoperative TEE
RESULTS
Both patients had an immediate and dramatic
reduction in the LVOT gradient (<10mm Hg).
 2D echocardiogram demonstrated coaptation of
the mitral leaflets to occur in a much more
posterior location, thus taking the anterior leaflet
out of the LVOT.
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CONCLUSIONS
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Enlargement of the LVOT can be done with totally endoscopic robotic
techniques using both septal myomectomy and perhaps more importantly,
anterior leaflet mitral valve augmentation.
The leaflet augmentation removes the anterior leaflet from the outflow
tract and dramatically decreases regurgitation without the requirement of
total valve replacement.
All the benefits of minimally invasive surgery are still conferred to the
patient.
SOURCES
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F. Delahaye, O. Jegaden, G. De Gevigney, J. L. Genoud, M. Perinetti, P.
Montagna, J. Delaye, and P. Mikaeloff Postoperative and long-term prognosis of
myotomy-myomectomy for obstructive hypertrophic cardiomyopathy: influence of
associated mitral valve replacement. Eur Heart J (1993) 14 (9): 12291237 doi:10.1093/eurheartj/14.9.1229
Ruth K. Petrone, Heinrich G. Klues, Julio A. Panza, Elfriede E. Peterson, Barry J.
Maron, Coexistence of mitral valve prolapse in a consecutive group of 528 patients
with hypertrophic cardiomyopathy assessed with echocardiography, Journal of the
American College of Cardiology, Volume 20, Issue 1, July 1992, Pages 55-61, ISSN
0735-1097.
Stéphane Aubert, Erwan Flecher, Sylvain Rubin, Christophe Acar, Iradj
Gandjbakhch, Anterior Mitral Leaflet Augmentation With Autologous Pericardium,
The Annals of Thoracic Surgery, Volume 83, Issue 4, April 2007, Pages 1560-1561,
ISSN 0003-4975.
The Mitral Valve in Hypertrophic Cardiomyopathy: It's a Long StoryAnna
Woo and Sean Jedrzkiewicz. Circulation. 2011;124:9-12, doi:10.1161/CIRCULATION
AHA.111.035568