Robotic mitral valve repair for papillary muscle rupture

Skin incisions were made on the third (left arm, 1 cm), fourth (working port, –3 cm), and sixth (right arm, 1 cm) intercostal spaces on the right anterior axillary line (Figure 1). A 1-cm port for the atrial retractor was placed slightly medial to the midclavicle line in the fourth intercostal space. The camera was then placed through a working port. The patient-side cart of the da Vinci Xi surgical system (Intuitive Inc) was docked from the patient's left side, and cardiopulmonary bypass was initiated from the right jugular vein and femoral cannulation. An aortic root cannula was then inserted into the ascending aorta for cardioplegia. The aorta was clamped, and cardioplegia was introduced.

MVr included papillary muscle reimplantation with artificial chordae (Video 2). After left atriotomy, the atrial retractor provided an excellent view for MVr (Figure 2, A). One of the anterior papillary muscle heads was completely ruptured and was connected to the lateral side of the posterior MV leaflet (Figure 2, B). The robot camera showed an intact anterior papillary muscle with no obvious ischemic changes where the ruptured papillary muscle head could be reimplanted (Figure 2, C). Reimplantation was performed using sandwiched pledget-reinforced polytetrafluoroethylene sutures (Figure 2, D). Both sides of the sandwiched sutures were left to be used as artificial chordae to reinforce the connection between the new papillary muscle and the targeted leaflet of the MV (Figure 2, E). Mitral annuloplasty using a semirigid partial band (CG Future Annuloplasty Ring and Band; Medtronic) was then performed using nonabsorbable 3-0 V-Loc (Covidien) continuous sutures (Figure 2, F). Continuous sutures were applied from both sides of the trigon to the bottom of the mitral annulus. Finally, the artificial chordae were placed on the target leaflet. In this case, only 1 side of the artificial chordae of the sandwiched sutures facing the posterior leaflet was used as an artificial chordae. The artificial chordae were attached to the lateral side of the posterior mitral MV leaflet (Figure 2, G), adjusted to the optimal length, and tied (Figure 2, H). The water test showed excellent coaptation of the MV, with no major leak (Figure 2, I).

After closing the left atrium, the aortic crossclamp was released. MV function evaluated using transesophageal echocardiography showed excellent coaptation and no residual mitral regurgitation (Video 3). The remaining procedure was uneventful. The operation and cardiopulmonary bypass times were 205 minutes and 138 minutes, respectively.

The patient was discharged with no residual mitral regurgitation on postoperative day 7, without complications. A follow-up visit at the clinic 1 year postoperatively showed excellent condition with no recurrence of mitral insufficiency.