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LETTERS TO THE EDITOR
Concomitant Atrial Septal Defect Closure and Tricuspid Repair Using the da Vinci Robotic System To the Editor, A 33-year-old female patient presented with exertional dyspnea. Physical examination revealed
doi:10.1111/aor.12270
903
3/6 grade systolic murmur over the pulmonary area. Transthoracic echocardiography revealed large secundum atrial septal defect (ASD) with extension toward the superior vena cava, moderate (3+) tricuspid regurgitation, and dilated right cardiac chambers. Tricuspid valve annulus was 42 mm. Transesophageal echocardiography confirmed secundum ASD with a deficient rim superiorly and tricuspid regurgitation. The operation was performed under general anesthesia and using the da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Cardiopulmonary bypass was established through the femoral artery, femoral vein, and jugular vein. Cardiac arrest was established using antegrade blood cardioplegia. After right atriotomy, the tricuspid valve was exposed using the Endowrist atrial retractor (Intuitive Surgical, Inc.). Annuloplasty to the tricuspid valve (Kay annuloplasty) was performed using Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) sutures (Fig. 1). The ASD was closed primarily using 4–0 Gore-Tex in double-running fashion. The operation was completed uneventfully. Intraoperative transesophageal echocardiography showed trivial tricuspid regurgitation without a residual septal defect. The patient was discharged with a good outcome on postoperative day 5. At 1-month follow-up, the patient was back to full activity. Totally endoscopic robotic surgery has been performed successfully for ASD closure. However, the number of concomitant tricuspid procedures is still limited. In older patients with large ASDs, secondary tricuspid regurgitation can develop due to right ventricular enlargement and associated annular dilatation. Annuloplasty of the tricuspid valve is therefore recommended to improve functional status irrespective of the grade of regurgitation (1,2). Annular dilatation above 40 mm in the four-chamber view on echocardiography is considered as an indication for surgery (2). In secundum ASDs, transcatheter closure has been accepted as an alternative to surgery. The size of the defect and adequacy of rims are the major factors determining suitability for nonsurgical closure (3). The presence of a large ASD with deficient rim to anchor the closure device and concomitant pathologies requires surgical intervention. Robotic surgery allows closure of ASDs, which are located next to the inferior or superior vena cava. The deficiency of superior or inferior rims is not a limitation for robotic surgery. Specifically, the introduction of a robotic atrial retractor has allowed dynamic atrial retraction and facilitated the exposure of the mitral and tricuspid valves. It provides superior exposure of Artif Organs, Vol. 38, No. 10, 2014
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904
LETTERS TO THE EDITOR
A
B
C
D
the intracardiac anatomy. In this case, we showed the feasibility of ASD closure and tricuspid valve repair using a robotic atrial retractor. Previously, Smith et al. (4) reported a successful concomitant tricuspid valve repair using an annular band in a mitral valve repair procedure with the aid of an atrial retractor. In conclusion, ASD closure and concomitant tricuspid annuloplasty is feasible with the aid of robotic instruments. The use of an atrial retractor facilitates the exposure of intracardiac structures including the tricuspid valve.
FIG. 1. Endoscopic camera views show tricuspid valve annuloplasty with GoreTex sutures (A and B), fluid injection test with an acceptable coaptation (C), and atrial septal defect closure with a doublerunning Gore-Tex suture (D).
4. Smith JM, Stein H, Engel AM, et al. Totally endoscopic mitral valve repair using a robotic-controlled atrial retractor. Ann Thorac Surg 2007;84:633–7.
*Burak Onan, MD, †Mustafa Guden, MD, and *Ihsan Bakir, MD *Department of Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center; †Department of Cardiovascular Surgery, Fatih University, Istanbul, Turkey E-mail: [email protected] REFERENCES 1. Dreyfus GD, Corbi PJ, Chan KM, et al. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127–32. 2. Benedetto U, Melina G, Angeloni E, et al. Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg 2012;143:632–8. 3. Mathewson JW, Bichell D, Rothman A, et al. Absent posteroinferior and anterosuperior atrial septal defect rims: factors affecting nonsurgical closure of large secundum defects using the Amplatzer occluder. J Am Soc Echocardiogr 2004; 17:62–9. Artif Organs, Vol. 38, No. 10, 2014
and
Copyright of Artificial Organs is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
LETTERS TO THE EDITOR
Concomitant Atrial Septal Defect Closure and Tricuspid Repair Using the da Vinci Robotic System To the Editor, A 33-year-old female patient presented with exertional dyspnea. Physical examination revealed
doi:10.1111/aor.12270
903
3/6 grade systolic murmur over the pulmonary area. Transthoracic echocardiography revealed large secundum atrial septal defect (ASD) with extension toward the superior vena cava, moderate (3+) tricuspid regurgitation, and dilated right cardiac chambers. Tricuspid valve annulus was 42 mm. Transesophageal echocardiography confirmed secundum ASD with a deficient rim superiorly and tricuspid regurgitation. The operation was performed under general anesthesia and using the da Vinci system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Cardiopulmonary bypass was established through the femoral artery, femoral vein, and jugular vein. Cardiac arrest was established using antegrade blood cardioplegia. After right atriotomy, the tricuspid valve was exposed using the Endowrist atrial retractor (Intuitive Surgical, Inc.). Annuloplasty to the tricuspid valve (Kay annuloplasty) was performed using Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) sutures (Fig. 1). The ASD was closed primarily using 4–0 Gore-Tex in double-running fashion. The operation was completed uneventfully. Intraoperative transesophageal echocardiography showed trivial tricuspid regurgitation without a residual septal defect. The patient was discharged with a good outcome on postoperative day 5. At 1-month follow-up, the patient was back to full activity. Totally endoscopic robotic surgery has been performed successfully for ASD closure. However, the number of concomitant tricuspid procedures is still limited. In older patients with large ASDs, secondary tricuspid regurgitation can develop due to right ventricular enlargement and associated annular dilatation. Annuloplasty of the tricuspid valve is therefore recommended to improve functional status irrespective of the grade of regurgitation (1,2). Annular dilatation above 40 mm in the four-chamber view on echocardiography is considered as an indication for surgery (2). In secundum ASDs, transcatheter closure has been accepted as an alternative to surgery. The size of the defect and adequacy of rims are the major factors determining suitability for nonsurgical closure (3). The presence of a large ASD with deficient rim to anchor the closure device and concomitant pathologies requires surgical intervention. Robotic surgery allows closure of ASDs, which are located next to the inferior or superior vena cava. The deficiency of superior or inferior rims is not a limitation for robotic surgery. Specifically, the introduction of a robotic atrial retractor has allowed dynamic atrial retraction and facilitated the exposure of the mitral and tricuspid valves. It provides superior exposure of Artif Organs, Vol. 38, No. 10, 2014
bs_bs_banner
904
LETTERS TO THE EDITOR
A
B
C
D
the intracardiac anatomy. In this case, we showed the feasibility of ASD closure and tricuspid valve repair using a robotic atrial retractor. Previously, Smith et al. (4) reported a successful concomitant tricuspid valve repair using an annular band in a mitral valve repair procedure with the aid of an atrial retractor. In conclusion, ASD closure and concomitant tricuspid annuloplasty is feasible with the aid of robotic instruments. The use of an atrial retractor facilitates the exposure of intracardiac structures including the tricuspid valve.
FIG. 1. Endoscopic camera views show tricuspid valve annuloplasty with GoreTex sutures (A and B), fluid injection test with an acceptable coaptation (C), and atrial septal defect closure with a doublerunning Gore-Tex suture (D).
4. Smith JM, Stein H, Engel AM, et al. Totally endoscopic mitral valve repair using a robotic-controlled atrial retractor. Ann Thorac Surg 2007;84:633–7.
*Burak Onan, MD, †Mustafa Guden, MD, and *Ihsan Bakir, MD *Department of Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center; †Department of Cardiovascular Surgery, Fatih University, Istanbul, Turkey E-mail: [email protected] REFERENCES 1. Dreyfus GD, Corbi PJ, Chan KM, et al. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127–32. 2. Benedetto U, Melina G, Angeloni E, et al. Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg 2012;143:632–8. 3. Mathewson JW, Bichell D, Rothman A, et al. Absent posteroinferior and anterosuperior atrial septal defect rims: factors affecting nonsurgical closure of large secundum defects using the Amplatzer occluder. J Am Soc Echocardiogr 2004; 17:62–9. Artif Organs, Vol. 38, No. 10, 2014
and
Copyright of Artificial Organs is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
