Fig 3. Coronary angiography: (A) left ante-rior oblique view and (B) right anterior obli-que view. Coronary angiography 22 monthsafter coiling showed no flow in the aneu-rysmal sac and contraction of the aneurysmalcavity (arrowheads).

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however, the patient will still need further close follow-up.To our knowledge, this is the first reported case of a suc-cessfully coiled postoperative coronary aneurysm withan almost 2-year follow-up.

References

1. Syed M, Lesch M. Coronary artery aneurysm: a review. ProgCardiovasc Dis 1997;40:77–84.

2. Mishra I, Sirasena M, Slaughter R, Pohlner P, Walters DL.Percutaneous treatment of an occlusive left main pseudoa-neurysm: a role for multimodality imaging. Cardiovasc RevascMed 2011;12:133.e7–133.e10.

3. Goel P. Coil embolization of left coronary artery pseu-doaneurysm arising as a complication of percutaneouscoronary intervention. Catheter Cardiovasc Interv 2013;82:426.

4. Ferns SP, Sprengers ME, van Rooij WJ, et al. Coiling ofintracranial aneurysms: a systematic review on initial occlu-sion and reopening and retreatment rates. Stroke 2009;40:e523–9.

Successful Robot-Assisted Repairof Congenital Mitral ValveRegurgitationVijayakumar Raju, MD, Harold M. Burkhart, MD,Frank Cetta, Jr, MD, and Rakesh M. Suri, MD, DPhil

Divisions of Cardiovascular Surgery and Pediatric Cardiology,Mayo Clinic and Foundation, Rochester, Minnesota

Congenital mitral valve regurgitation (CMR) is veryuncommon in adults and is usually associated with othercongenital malformations. Repair of the mitral valve

Accepted for publication Oct 11, 2013.

Presented at the Surgical Motion Picture Session of the Forty-ninthAnnual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA,Jan 26–30, 2013.

Address correspondence to Dr Burkhart, Division of CardiovascularSurgery, Mayo Clinic College of Medicine, 200 First St SW, Rochester,MN 55905; e-mail: burkhart.harold@mayo.edu.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

remains the standard of care. Very limited reports areavailable on minimally invasive surgical approaches intreating CMR. This report represents the first case seriesof the successful application of robotics in correctingCMR and associated anomalies, including a partialatrioventricular canal defect.

(Ann Thorac Surg 2014;98:1085–7)� 2014 by The Society of Thoracic Surgeons

obotic techniques have been used successfully in

Rolder children and adults with extracardiac lesionssuch as patent ductus arteriosus and vascular rings [1].The use of robotics in treating congenital cardiac lesionsin children is limited by body surface area, complexity ofthe lesion, and the need for larger ports to manipulatethe instruments [2]. Congenital mitral valve regurgita-tion (CMR) is uncommon, with an incidence of about 2%in all adults undergoing mitral valve operations, withleaflet prolapse being the predominant cause [3, 4]. Eventhough robot-assisted mitral valve intervention is usedwidely in treating acquired mitral valve disease, verylittle has been reported of this technology being used inthe treatment of congenital mitral valve disease. Wereport the successful use of robotic assistance in treatingCMR with and without associated heart defects in 3consecutive patients.

Case Reports

Patient 1A 54-year-old man with a known partial atrioventricularcanal defect (PAVC) was referred for surgical evaluation.Transthoracic two-dimensional echocardiography con-firmed a PAVC with a 20-mm ostium primum defect,dilated right-sided cardiac chambers, and a zone ofapposition (ZOA) in the anterior mitral valve with severemitral valve regurgitation. Cardiac catheterizationshowed a significant intracardiac shunt, with a Qp/Qsratio of 1.8:1 and normal coronary arteries. Preoperativecomputed tomography of the chest, abdomen, and pelvis

0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2013.10.100

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demonstrated normal arterial and venous vasculature.Given the dilated cardiac chambers and significantintracardiac shunt, surgical repair was advised.

Surgical preparation was performed according to thepublished Mayo Clinic robot-assisted mitral valve pro-tocol [5]. Once the heart was arrested, small vascularclamps were applied to the superior vena cava and theinferior vena cava. Through a right atriotomy, the ostiumprimum atrial septal defect (ASD) was closed with abovine pericardial patch (Supple Peri-Guard, Synovis,MN) leaving the coronary sinus on the right atrial side.To avoid interference with the conduction tissue, theinferior edge of the patch was sutured along the annularedge of the anterior mitral leaflets with 4-0 poly-propylene suture, the remainder of the patch beinganchored to the ASD margin. The right atrium wasclosed in two layers. The left atrium was opened with anincision posterior to the interatrial groove. The ZOA inthe anterior mitral leaflet was identified, and its marginswere confirmed by the attachment of primary chordae.The ZOA was closed along its entire length in two layerswith 3-0 polypropylene suture in a continuous manner.A posterior annuloplasty was then performed with use ofa 63-mm annuloplasty band (Medtronic, Minneapolis,MN). Valve competency was inspected with salineinsufflation. The aortic cross-clamp was removed after

Fig 1. (A, B) Preoperative echocardiogram showing large ostium primum azone of apposition (ZOA) in the anterior mitral leaflet. (C) Intraoperative phASD and closure of ZOA in the anterior mitral leaflet. (E) Mitral valve repaishowing good surgical result.

104 minutes, and cardiopulmonary bypass was weaned.The integrity of the repair (mild regurgitation) andadequacy of deairing were confirmed with two-dimensional echocardiography (Fig 1). The patient wasextubated in the operating room. Brief episodes of atrialarrhythmias prolonged his hospital stay from 3 to 5 days.He returned to his normal activities within 2 weeksafter hospital dismissal and is doing well at the 2-yearfollow-up.

Patients 2 and 3Two other patients underwent closure of ZOA in theanterior mitral valve with the use of robotic assistance(Table 1). A mitral annuloplasty band was placed for thesecond patient in view of a dilated annulus; it was notused for the third patient, who had a normal annulus.

Comment

Congenital cleft malformation (ZOA) in an otherwisenormal mitral valve usually present with other concomi-tant cardiac defects, mainly the primum type of ASD [6].Isolated mitral valve cleft / isolated mitral valve ZOAwithout other cardiac lesions is very rare (incidence1:1340). Isolated mitral valve cleft is defined as cleft/ZOA

trial septal defect (ASD) with significant mitral regurgitation throughotograph is consistent with partial AV canal defect. (D) Closure of ther supported with ring annuloplasty and postoperative echocardiogram

Table 1. Patient Details

Age/Sex Pt 1: 54/M Pt 2: 18/F Pt 3: 14/M

NYHA symptoms II II IGrade of MR Moderate to severe Severe Moderate to severeAssociated defect Ostium primum defect None PFOZOA AML AML AMLDiagnosis Partial AV canal defect Isolated mitral ZOA Mitral valve ZOA with PFOProcedure Closure ZOA, closure of

ostium primum ASD,posterior ring annuloplasty

Closure of ZOA, posteriorring annuloplasty

Closure of ZOA, PFO closure

Aortic cross-clamp time (min) 104 54 27Hospital stay (days) 5 3 3Follow-up echocardiography Trivial MR

Gradient 4 mm HgTrivial MRGradient 4 mm Hg

Trivial MRGradient 2 mm Hg

AML ¼ Anterior mitral leaflet; AV ¼ atrioventricular; F ¼ female; M ¼ male; MR ¼ mitral regurgitation; NYHA ¼ New York HeartAssociation; PFO ¼ patent foramen ovale; ZOA ¼ zone of apposition.

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of the anterior mitral valve leaflet not associated with

ostium primum defect or other features of ASD [7].Mitral valve regurgitation and left ventricular outflow

tract obstruction resulting from abnormal chordal at-tachments are the two main clinical sequelae in patientswith a mitral valve cleft [8]. The mechanism of mitralregurgitation in isolated ZOA results from a combinationof factors. It may be due to the ZOA, annular dilatation,and retraction of edges of ZOA, or it may result fromabnormal attachment of the subvalvular apparatus. Thedegree of mitral valve regurgitation may increase as thepatient advances in age. It is usually asymptomaticduring childhood in the absence of left ventricularoutflow tract obstruction or other associated cardiaclesions.

The surgical options include direct suturing of the ZOAif the edges are pliable without much retraction or the useof a patch to close the ZOA if the edges are retracted.Mitral valve annuloplasty is typically performed in adultpatients with annular dilatation.

To the best of our knowledge, this is the first caseseries of the successful use of robotics in treatingcongenital mitral valve regurgitation and other associ-ated defects including a partial atrioventricular canaldefect. A few technical points should be highlighted.First, we find that the biatrial approach for the partialAV canal defect is preferred because closing the mitralvalve cleft and placing the ring annuloplasty through theinteratrial defect is difficult in view of the angle neededto use the robotic atrial retractor and arm instruments.A partial ring annuloplasty is best performed by a leftatrial approach and should be included as part of themitral valve ZOA repair in adults with a dilated annulus.Care should be taken to rotate away from the rightfibrous trigone because the AV node is situated in thenodal triangle and hence is at risk for trauma. Inasmuchas patients with a mitral valve ZOA are prone to leftventricular outflow tract obstruction, one must take careto ensure the absence of that obstruction after placing

the posterior ring annuloplasty before leaving the oper-ating room.

ConclusionIn conclusion, we present the successful application ofrobot-assisted mitral valve repair in three cases of CMRand associated intracardiac defects, including one in thesetting of PAVC. Although this is a unique series, thesepatients received the benefits of minimally invasive op-erations including safe successful repair, early extubation,and shortened hospital stay. As technology improves, thebenefits of robot-assisted cardiac operations will likely beincreasingly applicable to more forms of congenitalcardiac operations.

References

1. Chakraborty B, Burkhart HM, Warnes CA, Suri R. Successfulrobotic-assisted division of symptomatic vascular ring. HeartSurg Forum 2012;15:E306.

2. del Nido PJ. Minimal incision congenital cardiac surgery.Semin Thorac Cardiovasc Surg 2007;19:319–24.

3. Zegdi R, Amahzoune B, Ladjali M, et al. Congenital mitralvalve regurgitation in adult patients: a rare, often mis-diagnosed but repairable, valve disease. Eur J CardiothoracSurg 2008;34:751–4.

4. Jiang SL, Gao CQ, Li BJ, et al. Congenital mitral valveregurgitation in adult patients. Heart Surg Forum 2011;14:E114–6.

5. Suri RM, Burkhart HM, Rehfeldt KH, et al. Robotic mitralvalve repair for all categories of leaflet prolapse: improvingpatient appeal and advancing standard of care. Mayo ClinProc 2011;86:838–44.

6. McDonald RW, Ott GY, Pantely GA. Cleft in the anterior andposterior leaflet of the mitral valve: a rare anomaly. J Am SocEchocardiogr 1994;7:422–4.

7. Sulafa AKM, Tamimi O, Najm HK, Godman MJ. Echocar-diographic differentiation of atrioventricular septal defectsfrom inlet ventricular septal defects and mitral valve clefts.Am J Cardiol 2005;95:607–10.

8. Mohammadi S, Bergeron S, Voisine P, Desaulniers D. Mitralvalve cleft in both anterior and posterior leaflet: an extremelyrare anomaly. Ann Thorac Surg 2006;82:2287–9.