Robotic Mitral Valve Repair, Biatrial CryoMaze Procedure, Left Atrial Appendage Closure, and PFO Closure

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This case involves a 69-year-old man who presented with symptomatic severe mitral regurgitation. Preoperative investigations demonstrated a flail anterior leaflet. He also had a history of paroxysmal atrial fibrillation, and a small patent foramen ovale was noted. 

Positioning, Preparation, and Peripheral Access 

After the induction of anesthesia and double lumen intubation, the right internal jugular vein was cannulated by the cardiac anesthetist as part of the peripheral cannulation strategy. 
 
The patient was positioned supine with a wedge under the right paraspinal muscles, displacing the right hemithorax upward to provide a direct view of the mitral valve. The right upper limb was slightly dropped backward to enhance exposure of the axilla. Standard preparation and draping were performed. 
 
A 3 cm oblique incision was performed in the right groin. The anterior aspects of the femoral vessels were exposed. 5-0 polypropylene purse-string sutures were placed in the common femoral artery and vein. After systemic heparinization, the femoral vessels were cannulated using the Seldinger technique. 
 
Working Port Entry, Exposure, and Cannulation 

A 4 cm working port was performed through the fourth intercostal space. Single lung ventilation was commenced, and an Alexis wound retractor was placed. A port was formed in the fourth intercoastal space (ICS) with an 8 mm trocar, anterior to the 4 cm working port, to accommodate the left atrial lift retractor. Additional two ports using trocars in the third ICS (left hand) and fifth ICS (right hand), and the robotic arms were docked. The thorax was insufflated with CO2 via the sideline connection of the left-hand trocar. 

The pericardium was opened anterior to the phrenic nerve, and cardiopulmonary bypass was initiated using right internal jugular venous, right femoral venous, and right femoral arterial cannulation. 
 
Cooling, Cross-Clamp, and Early CryoMaze 

The patient was cooled to 32 degrees Celsius. A Chitwood aortic cross-clamp was applied, and custodiol cardioplegia was delivered to achieve myocardial protection. The right atrial CryoMaze lesions were then completed on bypass with the heart beating. 

Left Atrial Exposure 

The left atrium was entered through Waterston’s groove. 

Left Atrial CryoMaze 

Following the opening of the left atrium, the left-sided CryoMaze lesions were completed to establish a full biatrial ablation pattern for atrial fibrillation. 
 
The robotic left atrial retractor was positioned to obtain excellent exposure of the mitral valve. Inspection confirmed a flail anterior leaflet consistent with ruptured chordae, along with a cleft between P2 and P3. 

Anterior Leaflet Repair with Gore-Tex Neochordae 

Attention was then directed to the mitral valve repair. Using a CV4 Gore-Tex suture, a figure-of-eight stitch was passed through the fibrous component of the papillary muscle. The same needle was then passed twice through the prolapsing edge of the anterior leaflet to resuspend the flail leaflet. The same steps were repeated with the second needle of the suture. The chordal length was adjusted under direct vision to achieve an appropriate and stable line of coaptation. A titanium ligating clip was temporarily placed on the Gore-Tex suture to adjust the exact chordae length once the annuloplasty ring was implanted. The P2/P3 cleft and noncommissural leaflet cleft were closed with simple interrupted sutures to restore normal coaptation and prevent residual or recurrent mitral regurgitation (MR). 
 
Annuloplasty Ring Implantation 

A 38 mm Memo 4D annuloplasty ring was selected based on annular sizing. The ring was secured to the annulus using a series of 2-0 sutures, which were anchored with the Cor-Knot device to achieve consistent tension and a uniform annular profile. The previously placed Gore-Tex suture was adjusted according to the saline test and then tied. After that, the valve was tested again. 

Final Valve Testing 

The mitral valve was tested again and demonstrated an excellent line of coaptation with no residual leaflet flail and no significant regurgitation. 

Left Atrial Appendage Closure 

The left atrial appendage was then closed using interrupted 4-0 sutures. 
 
PFO Closure 

An 8 mm patent foramen ovale was identified and closed with interrupted 4-0 sutures. 
 
Left Atriotomy Closure 

The left atrium was closed using a continuous 4-0 Prolene suture, and standard deairing maneuvers were performed. 

Reperfusion 

The aortic cross-clamp was removed, and the heart resumed a stable sinus rhythm. Atrial and ventricular epicardial pacing wires were applied. 

Weaning From Bypass 

The patient was weaned from cardiopulmonary bypass without difficulty. Decannulation was performed, and meticulous hemostasis was achieved. The total cross-clamp time was 88 minutes, and the total bypass time was 134 minutes.  
 
Final Steps and Working Port Site Closure 

The pericardium was closed, and two chest drains were inserted. The wounds were closed in a standard layered fashion. 

Postoperative Result 

Postoperative transesophageal echocardiography demonstrated an excellent mitral valve repair with only trivial residual regurgitation. The mean transmitral gradient was 3 mm of mercury, and the coaptation depth measured 12 mm. The patient was transferred to the intensive care unit in stable condition. 

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