Endoscopic Robotic Aortic Valve Surgery
Although a much newer procedure than for the mitral valve, robotic aortic valve surgery is emerging as another minimally invasive technique. A valve repair or replacement along with aortic valve tumor removal (usually fibroelastoma) can be done endoscopically with the robot by Dr. Guy and the team at Thomas Jefferson University Hospital. The “working port” is around 30-35 mm in order to fit the prosthetic valve (tissue or mechanical) into the chest. There is absolutely no rib spreading involved (rib spreading done in other methods often causes pain). Either tissue or mechanical valves can be implanted depending on the patient’s characteristics and wishes.
Totally endoscopic aortic valve surgery with the robot requires advanced catheter-based techniques used for heart-lung bypass and stopping the heart as illustrated below. Many patients are frightened by the phrase “stopping the heart”. However, a better way to think of it is that we are giving the heart medicine (cardioplegia) to the heart which allows it to “sleep”. The heart then “wakes up” when we restore normal blood flow to it! The terms Heartport, Thruport, or Port Access have all been used to refer to this technology which is very powerful when combined with robotic technology and an endoscopic approach.
In traditional surgery, the heart is bypassed and stopped during surgery using tubes (cannulae) placed directly in the heart. With our endoscopic robotic approach, this is usually done through blood vessels in the leg (femoral artery and vein) using catheter-based approaches and a small incision. One additional difference between totally endoscopic robotic mitral valve surgery and other techniques is that it requires much more teamwork in the operating room than most programs can muster. The era of the “superstar” surgeon is over and the era of the “superstar” surgical team has arrived!
The anesthesiology team will place some of these catheters. Others will be placed by the surgeon and surgical team. The placement of these catheters
requires advanced skills which is why these procedures are performed by a dedicated, highly specialized team. Some of the catheters are placed with the assistance of fluoroscopy (x-ray) and echocardiography (ultrasound to see the heart and blood vessels). All of the catheters are placed percutaneously, meaning without open incisions. We usually only have to make a small stab incision to place the cannula through the skin. Most programs make larger open incisions so they can see the vessel and insert a cannula directly into it. We use ultrasound to “see” the vessel instead, saving the patient an open incision.
Mechanical versus Tissue Aortic Valve Replacement
The choice of a mechanical or tissue valve depends on several factors. These days most patients are receiving tissue valves (pig or cow usually) because of patients’ desires not to be on blood thinners (Coumadin) that may lead to bleeding or stroke if not closely managed. Mechanical valves are generally placed with the goal of never having to re-operate onthe valve although there is an incidence of re-operation even with mechanical valves. Mechanical valves are preferred for younger patients (age <60) because of the reality that tissue valves fail faster in young people. I have seen them fail as early as 5 years although 10 years would not be an unreasonable estimate. Each subsequent operation has risks and these risks increase with each operation because of the formation of scar tissue. Reasons to select a tissue valve include older age (the valve may last longer and perhaps the lifetime of the patient) and the patients’ opposition to blood thinners or other contraindications to coumadin. Mechanical valves are appropriate for young patients who can manage coumadin (are compliant with medication regimen) and those who are already on blood thinners.